Hunter New England Mental Health implemented a new screening tool and staff education to ensure patients with delirium are provided with the right care pathway.
Aim
To reduce the total number of bed days associated with a primary diagnosis of delirium by 30 per cent within six months (June 2017), compared to the same period in 2016.
Benefits
- Improves the identification and treatment of delirium.
- Provide delirium patients with appropriate clinical care in a timely manner.
- Improves the health and wellbeing of patients.
- Reduces the risk of recording a psychiatric diagnosis in patients who do not have a psychiatric condition.
- Reduces the risk of clinical bias in future mental health assessments and stigma associated with mental health conditions in the community.
- Improves staff satisfaction as they care for patients whose needs meet their skills.
- Ensures valuable health resources are better targeted and distributed.
Background
Delirium is a state of confusion that can be caused by a number of physical health problems. It requires medical care to treat the cause and psychiatric care to help with the management of challenging behaviours or symptoms that result from the delirium, such as psychosis, severe mood disturbances or suicidal ideation. As delirium presents in a similar way to psychiatric illness, it is essential to consider it as a cause or contributing factor when treating classical psychiatric symptoms.
While delirium is known to be under-diagnosed in medical and surgical patients, some people who present with delirium are admitted to psychiatric units rather than provided with general medical care. This is not ideal, as it can increase their length of stay in hospital and lead to inappropriate care pathways and treatments, such as antipsychotic therapy. This is particularly important for individuals with a history of psychiatric problems, as it can lead to patients believing they have a significant mental health problem when they do not.
With ongoing demand for bed availability, NSW Mental Health Services must focus its resources and expertise on patients who are most likely to benefit from its care. Senior medical expertise can be difficult to access in some mental health inpatient units, particularly when the cause of the patient’s condition is complex or unidentified. As such, it was determined that educating and training staff in the correct diagnosis of delirium would reduce inappropriate admissions to psychiatric units and provide a care pathway that treats the underlying cause of the condition.
Implementation
- A working group was established to review existing processes, conduct a literature search and brainstorm solutions using a driver diagram.
- Baseline data was obtained, which showed that 12 patients were diagnosed with delirium in the period January to June 2016.
- The Short CAM1 screening tool was used to assess all patients on admission to the Mater Mental Health Centre. It was selected as it is a validated tool that does not take long to implement and was accepted by staff as the best option.
- Medical and nursing staff tasked with doing assessments in the Psychiatric Emergency Centre were trained in the use of the screening tool and relevant clinical protocols to treat delirium, including the Hunter New England Local Health District (HNELHD) Sepsis Pathway.
Project status
Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.
Key dates
- August 2016: Project start
- October 2016: Baseline data and screening tool sourced
- December 2016: Screening tool training
- January 2017: Screening starts
- February 2017: Sepsis Pathway education
- June 2017: Project evaluation
Implementation sites
The Mater Mental Health Centre, Hunter New England Mental Health
Partnership
Clinical Excellence Commission
Results
Screening was conducted for a six-month period, with results compared to the same period the previous year. Results showed the number of patients with a diagnosis of delirium reduced from 12 in June 2016 to two in June 2017, with 80 per cent of all patients screened. It appears that raising awareness, systematic delirium screening and education on delirium treatments was successful in reducing the number of people with delirium who were admitted to Hunter New England Mental Health.
The number of bed days associated with a primary diagnosis of delirium was reduced by 88.3 per cent, from 300 in June 2016 to 35 in June 2017. While this exceeded the aim of 30 per cent, there are limitations to interpreting the data. These include the small number of patients involved and the delays associated with a formal diagnosis from the local clinical coding department, which can take up to six weeks. This means there may have been patients who should have been diagnosed with delirium and were not.
However, if results are accurate, it represents an opportunity to increase the quality of care for patients with delirium and maximise specialist resources within the mental health sector. The Mater Mental Health Centre is now looking to roll out the project across other mental health inpatient units in HNELHD and beyond.
Lessons learnt
While the project seemed small, it was quite complex. There is a desire to improve admission decisions at Hunter New England Mental Health and as such, this project was supported widely. However, it was difficult to overcome the perception that the screening process was ‘just another form’. By adding the screening form to the admission pack this problem was alleviated. In retrospect, administrative staff should have been included in the working group as they had insights into the admission pack and process. The project also provided significant benefits to mental health clinicians, who often feel ill-equipped to manage significant medical issues.
References
- Inouye SK. The Short Confusion Assessment Method (Short CAM): Training Manual and Coding Guide. Boston: Hospital Elder Life Program; 2014.
Further Reading
- Care of Confused Hospitalised Elderly Persons (CHOPS) Program
- Inouye SK, van Dyck CH, Alessi CA et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine 1990;113(12):941-8.
Contact
Dr Brendan Flynn
Director of Medical Services
Hunter New England Mental Health, HNELHD
02 4033 5156
Brendan.Flynn@hnehealth.nsw.gov.au
