iDREAM: Phase I
Conducted at
Owensboro Health Regional Hospital
2020-2021
Phase I: Background and Oversight
About iDREAM
The iDREAM program was started as a unified effort by the Owensboro Health Regional Hospital system to implement a new systems engineering approach to the screening, prevention, treatment, and management of delirium within the inpatient setting
As a part of Owensboro Health and the University of Louisville Family Medicine Residency commitment to the IHI Age-Friendly program, iDREAM used the 4M model of care framework to design a phased intervention strategy for inpatient delirium care according to the systems engineering “V” model of development.
IRB Approval
The iDREAM program was approved by the University of Louisville IRB as a quality improvement project for data collection, analysis, and implementation. Additionally, the project was approved by the Owensboro Health Regional Hospital Research Review Committee.
Phase I: Goals and Analysis
iDREAM Phase I: Goals
The iDREAM program targeted the following areas of improvement:
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Targeted delirium rounding on high risk and delirium positive patients
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Nursing education regarding screening, non-pharmacologic interventions, and high risk medications
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Improved delirium screening by the transition form the bCAM to NuDESC tools
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Identification of population-specific pharmacologic risk factors through a baseline delirium analysis for the hospital system from 2016 to 2021
Statistical Analysis
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Odds ratios for medications effects on delirium were calculated and utilized Pearson Chi-Square for significance. A p<0.05 based on a two-tailed analysis was considered significant.
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Run charts were used to determine special cause variation after the implementation of the new screening process during the transition from bCAM to NuDESC
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All statistical calculations were performed using IBM SPSS v28. Run charts were created and analyzed in excel using QI Macros v2022.
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All data was retrospectively pulled from the EPIC EMR system at Owensboro Health Regional Hospital
Baseline Delirium Analysis
Inclusion/Exclusion Criteria
Inclusion criteria: All patients admitted to the Owensboro Health Regional Hospital between 2016 and 2021 over the age of 65 were included in the analysis. Delirium positive was identified as a positive screen using either the bCAM or NuDESC screening tool in EPIC.
Exclusion criteria: All patients < 65 were excluded from the study.
Pharmacologic Criteria
Diphenhydramine, metoclopramide, scopolamine, zolpidem, benzodiazepine, and digoxin were studied
Medications were analyzed if ordered in EPIC. Medications were not verified as administered.
Average Age
A total of 31,372 admissions with a total of 5883 cases of documented delirium occurred between 2016 and 2021. The average age for patients with delirium was 77.7 and without delirium was 76.0 which was statistically significant (p<0.001)
Length of Stay
The median length of stay for delirium positive patients was 6 days over those patients without delirium was 4 days. Having delirium increased the expected median length of stay by 2 days (p <0.001)
Medications
Use of Benzodiazepine and Digoxin was found to be statistically significant in increasing the risk for delirium. Scopolamine was found to be statistically significant but was based on a very small sample size (< 220 patients). A more directed research study is required to understand the relationship from our sample data.
X/R - Chart NuDESC
X/R Chart Split NuDESC
Transition from bCAM to NuDES
2020/2021 Run Chart
Run chart analysis shows a special cause variation in July/August 2021 at the start of the NuDESC screening program within the hospital. Delirium rate increases were expected given the focused training, use, and monitoring associated with the transition from bCAM to NuDESC
2021 Split at July Transition
The average monthly delirium rate using the bCAM screening tool was 15.5% in the 6 months prior to transition to the NuDESC. After the transition, the rate increased to 22.1% on average for the following 6 months using the NuDESC with an initial increase to 29.7% during the first month of implementation
Phase I: Next Steps
iDREAM Phase II
Based on these initial results, a new AWOL risk screening will be implemented with a nurse-driven, best-practice order set for delirium precautions for high-risk patients. Delirium rounds will be expanding with a strong emphasis on prevention and proactive interventions building on Phase I progress.
Acknowledgements
We would like to acknowledge the hard work of the staff and faculty of the University of Louisville – Owensboro Family Medicine program and the Owensboro Health Regional Hospital for their dedicated commitment to caring for the aging patient through innovative programs
Authors and Contributors to iDREAM: Phase I
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Jerry Bradley, MD - Systems Engineering / Development / Analysis
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Ariel Ross, MSN, RN (Owensboro Health) - Clinical Nurse Specialist / Nursing Education / Implementation / Development
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Bill Bryant, MD, FAAP, CMD, CPPS, CPHQ (Owensboro Health) - Vice President of Quality / Oversight / Project Champion
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Jon Sivoravong, DO, FAAFP - (University of Louisville) - Program Director
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Darby Cole, MD - (University of Louisville) - Associate Program Director