An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults

Abstract

BACKGROUND: Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution. METHODS: This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of “high-risk” screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night. RESULTS: During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as “high risk” during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95–0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91–1.05, P = .52) per month during the QI period in comparison to baseline. CONCLUSIONS: A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.

Postoperative delirium prediction using machine learning models and preoperative electronic health record data

“…A schematic depicting how this screening tool would be used in our healthcare system is pictured in Fig. 4 , which also highlights the extensive resources automatically triggered by a high-risk delirium screen in our institution’s existing delirium prevention pathway [ 14 , 45 ]. The care interventions were modeled after available guidelines for the prevention of postoperative delirium [ 1 , 16 , 46 – 48 ].…”

“…Many cases of POD can be prevented with multicomponent non-pharmacologic interventions [ 10 ], the Hospital Elder Life Program [ 11 ], or perioperative geriatric consultations [ 12 , 13 ]. Effective perioperative interventions combining delirium risk stratification with focused delirium prevention care practices have been described [ 14 ], though further improvement in the discrimination of the delirium risk stratification tool used in this intervention [ 15 ] could allow for better targeting of finite resources to the patients who need them most. Since preventative interventions require significant time and energy from busy clinicians [ 16 ], improving and automating risk stratification procedures is critically important.…”

Cognitive impairment and frailty screening in older surgical patients: a rural tertiary care centre experience

“…Previous work by Donovan et al used a similar hybrid design to implement a perioperative delirium prevention pathway. 24 This programme was set in an urban healthcare setting with a wider array of resources available, including a hospital-wide Delirium Reduction Campaign. However, using comparable techniques including stakeholder involvement, continual feedback and EHR enhancements, the authors were able to significantly reduce administration of Beers Potentially Inappropriate Medications in the perioperative setting.…”

“…However, using comparable techniques including stakeholder involvement, continual feedback and EHR enhancements, the authors were able to significantly reduce administration of Beers Potentially Inappropriate Medications in the perioperative setting. 24 Of note, the American Geriatric Society Beers Criteria is an explicit list of medications that should typically be avoided in older adults. 25 Our programme design encountered similar success as evidenced by the increase in AD8 cognitive impairment screening adherence in our PCC from 46% to 86% with programme implementation.…”

“…This healthcare redesign process placed an equal emphasis on clinical implementation and effectiveness, which allowed us to tailor our programme to the needs of our end-users before waiting for effectiveness data. Previous work by Donovan et al used a similar hybrid design to implement a perioperative delirium prevention pathway 24. This programme was set in an urban healthcare setting with a wider array of resources available, including a hospital-wide Delirium Reduction Campaign.…”