Advanced medical treatment and surgical procedures are increasingly being performed in older patients. This is a patient group with complex clinical features, which makes them vulnerable to complications and requires an interdisciplinary approach.

older man

Delirium is a serious complication that can manifest in four motor sub-types; hyperactive form, hypoactive form, mixed form and no-subtype form. The syndrome puts additional burdens on the patients, increases number of hospitalizations, and decreases cognitive and physical functions - complications that may entail further institutionalization. Healthcare professionals often experience patients with delirium as both challenging and resource demanding. Increased knowledge and competence might secure a more satisfactory patient care.

The purpose of the project

Studies have shown that early identification of delirium, together with implementation of preventable measures, might reduce burdensome symptoms and treatments for the patients. The purpose of DelirPrevent is to increase knowledge, competency and awareness of delirium in healthcare professionals at Haukeland University Hospital.

Mapping the prevalence of delirium and the identification of delirium sub-types

On the World Delirium Awareness Day 2018, the PROCARD Research group conducted a point prevalence survey to determine the prevalence of delirium in patients ≥65 years of age. Fourteen departments (8 surgical and 6 medical) participated in the study, and delirium was identified with the use of the validated screening instrument 4AT.

Subgroups of delirium were identified with the use of the Delirium Motor Subtype Scale (DMSS). Approval by the Data Protection Official at Haukeland University Hospital was granted. All included wards were contacted and approval to perform the screening was obtained from the department directors and section leaders. To secure implementation of the survey, stakeholders were chosen from each department. In order to secure the quality of the screening process, standardized questionnaires were used. All included departments were closely followed up in the days before the survey. Furthermore, the routines of the screening-procedure was thoroughly reviewed.

Six experienced nurses from the PROCARD Research group participated in the screening process. All were experienced with older patients, delirium and the screening tools. Inclusion and exclusion criteria for the survey was predetermined and verbal consent was obtained from all participants.

Photo of the screening team. From the left: Hege A. Amofah, Irene Instenes, Nina Fålun, Tone M. Norekvål and Trond Pettersen.Pho

Photo of the screening team. From the left: Hege A. Amofah, Irene Instenes, Nina Fålun, Tone M. Norekvål and Trond Pettersen.

In total, 123 patients were included in the survey performed during 00.00 to 24.00 hours. In general, the patients experienced the screening process as positive. Only a few patients declined participation. During study, the screening team could concentrate exclusively on the patients and the screening process. They could adapt to the ward routines, adjust for procedures and the daily rhythm of the patients. This was a valuable experience to bring into the implementation process of a validated screening tool at selected departments in the autumn of 2019.

The implementation of Confusion Assessment Method (CAM) on selected medical and surgical posts

Screening for delirium was initiated at the Department of Heart Disease and the Department of Respiratory Diseases at Haukeland University Hospital in 2019. In this project, the Confusion Assessment Method (CAM) was piloted as an electronic version in DIPS. Before the introduction of the electronic version, the project leader and the project coordinator worked in close collaboration with the Section for e-health. The purpose was to link screening for delirium and CAM to the “Safe Care” platform, since delirium is linked to increased risk of falling, pressure ulcers, and malnutrition.
The work with the electronic version of CAM also involved development of various user manuals and precise user descriptions for the electronic competency handbook (EK). Material targeting the introduction process was also developed.

Implementation at the departments included several teaching sessions on delirium, and a thorough introduction to CAM. The teaching modules were carefully planned in order to fit into the busy clinical work schedule at the departments and were limited to a maximum of 30 minutes per session.

In addition to the planned modules related to implementation of the screening tool, several teaching sessions on delirium were conducted at the Department of Heart Disease. The departments were followed closely during the implementation process. First daily, then weekly and monthly. All departments are offered teaching and guidance if needed.

Feedback from the departments indicate that CAM is a practical screening tool in a busy hospital workday. Several of the departments have developed good routines, and are now performing CAM screenings routinely.

During the autumn of 2020, an electronic survey among healthcare personnel who participated in the screening process was conducted. This questionnaire included questions about CAM, the experience of using the screening tool and its utility value. Results from this study will guide future work.

Developing of an e-learning course on delirium

In 2018, the the development of an e-learning course on delirium was approved at Haukeland University Hospital. After a comprehensive planning phase, development of the course started in the autumn of 2019. Main developers of the course are Irene Instenes, Tone M. Norekvål and Leslie Eide in collaboration with an interdisciplinary working group at the university hospital. An external interdisciplinary reference group from several health trusts in the region was also established. The course aims to give an introduction to identification and diagnosis of delirium, possible consequences, prevention and treatment, and ethical aspects.

Illustration: Nancy Andrews

Illustration: Nancy Andrews

Read more about the e-learning course here:

Innsiden Haukeland University Hospital (intranet for the Hospital)

Link to the Læringsportalen at Haukeland University Hospital.

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