Clinical and Research News
M.D.s Tackle Untreated Delirium to Save Lives
Psychiatric News
Volume 36 Number 11 page 18-29

The outcomes for medical patients with delirium can be very serious. "Twenty percent to 25 percent of delirious patients die within one to three months after developing delirium," noted Michael Wise, M.D., a clinical of psychiatry at the University of California, Davis.

By comparison, far less than 20 percent to 25 percent of nondelirious medical patients died within one to three months of developing their illness, Wise told Psychiatric News.

Furthermore, "the diagnosis of delirium is missed about 46 percent of the time," according to Scott Armstrong, M.D., co-medical director of the Tuality Center for Geriatric Psychiatry in Forest Grove, Ore.

But physicians are working hard to improve the outcomes of delirious patients by implementing innovative and practical educational programs.

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José Maldonado, M.D., has developed a program at Stanford to teach nurses how to diagnose delirium accurately.

José Maldonado, M.D., has developed such a program at Stanford University Medical Center, where he is medical director of the consultation-liaison psychiatry service.

The nurses on the ICU and the main medical and surgical wards attend a two-day seminar that consists of lectures, case presentations, and a test at the beginning and end of the seminar. In addition, the subgroup of nurses specializing in caring for patients with delirium participate in a 12- to 16-hour practicum.

Once they complete this practicum, the nurses return to their units, where they present educational programs on delirium to the other nurses on their units.

To educate physicians about delirium, Maldonado presents six grand rounds at the beginning of the academic year. In addition, he educates internal medicine residents about delirium while they rotate through the consultation-liaison psychiatry service.

Maldonado and his colleagues conducted a study on these initiatives and found that before his program was implemented, only about 30 percent of the nurses and 12 percent of physicians at his facility accurately diagnosed and treated delirium. Now, the nurses recognize delirium 100 percent of the time, and the medical staff does so 60 percent of the time. "Consequently, these patients have shorter hospital stays, fewer complications, and require less treatment. This could amount to a projected savings to the hospital of approximately $30 million annually," said Maldonado.

William Breitbart, M.D., has instituted an educational program about delirium at Memorial Sloan-Kettering Cancer Center in New York, where he is chief of the psychiatry service and director of the consultation-liaison psychiatry fellowship program. Brietbart was a member of the panel that drafted APA’s practice guideline for delirium.

Breitbart developed a 20-minute lecture, which was videotaped. It also is being transferred to the hospital’s intranet. Participants receive a small index card listing the common causes of delirium, an algorithm for the pharmacological management of delirium, and other pertinent information. Participants also take a brief test before and after the video.

The course is given to newly hired nurses, nurse practitioners, physician assistants, and physicians (fellows, residents, and interns, but not attending physicians), as well as others working on medical and surgical services.

Breitbart analyzed data from the brief test and found that after they took his course, employees were three time more likely to diagnose delirium than they were previously.

Geriatrician Joseph Flaherty, M.D., oversees another educational program on the 22-bed ACE (Acute Care for the Elderly) unit at St. Louis University Hospital in Missouri. This unit, which includes four beds for delirium patients, treats patients over age 65 with any acute medical illness that can be managed by internal medicine physicians. Flaherty is medical director of the unit and an assistant professor of internal medicine at the hospital and the Veterans Affairs’ Geriatric Research and Education Center in St. Louis.

Every weekday morning on the unit, there is a 45-minute meeting with the resident physicians, nurses, therapists, a dietician, a pharmacist, pastoral staff, and a social worker.

At every meeting, 10 to 15 patients are discussed one at a time. Each treating specialist reports on the same topics for every patient. For example, the resident physician always reports on the patient’s diagnosis and medications; the nurse reports on the patient’s mental status, breathing, incontinence, and so on.

"These meetings don’t take a lot of time, yet they are very effective for determining if a patient has developed delirium—because if there is any slight mental status change, it’s picked up by a team member," noted Flaherty.

Flaherty and his colleagues conducted a study on the impact of their initiatives and found that before the unit was established, medically ill inpatients with delirium spent more days hospitalized than those who did not have this diagnosis. Now medically ill patients with delirium stay the same number of days as those who are just medically ill, Flaherty noted.

Bruce Naughton, M.D., an internist, has instituted a comprehensive delirium education program at Buffalo General Hospital in Buffalo, N.Y. He is the director of geriatrics at the State University of New York at Buffalo School of Medicine.

Four times a year, the hospital’s 10 emergency department (ED) physicians attend lectures and participate in small-group discussions about delirium and its treatment.

To reinforce their learning, the ED physicians receive an 8-inch by 11-inch card featuring the Mini-Mental State Exam, the Confusion Assessment Method instrument, a four-question yes-or-no test for diagnosing delirium, and other information.

Also, a bright-green sticker with a checklist of four yes-or-no questions relating to delirium is placed on each ED patient’s chart. The ED physicians are required to complete this checklist.

Finally, posters hanging in the ED remind physicians to transfer patients to the ACE unit, which treats patients who are over age 75 and have cognitive impairment detected prior to arranging an admission.

Furthermore, on a regular basis, Naughton or a nurse practitioner observes ACE nurses conducting cognitive testing and then offers constructive feedback. Finally, ACE nurses complete a standardized flow sheet for each patient. The nurses determine, among other things, if the physician has prescribed medications such as benzodiazepines that can adversely affect delirious patients.

To ensure these initiatives are effective, Naughton audits the ED physicians’ green stickers every day and reports his findings to the ED physicians once a month. Also, twice a week on the ACE unit, Naughton or a nurse practitioner audits some of the nurses’ flow sheets. Their findings are discussed promptly with the nurses.

A study of these efforts that Naughton conducted found that before these initiatives were in place, 25 percent of delirious patients in the ED were diagnosed properly; now 65 percent are correctly diagnosed. Also, the use of benzodiazepines has significantly decreased. ▪

Anchor for JumpAnchor for Jump

José Maldonado, M.D., has developed a program at Stanford to teach nurses how to diagnose delirium accurately.

José Maldonado, M.D., has developed such a program at Stanford University Medical Center, where he is medical director of the consultation-liaison psychiatry service.

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