Process of implementing and delivering the Prevention of Delirium system of care: a mixed method preliminary study

Abstract

BackgroundDelirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study.MethodsA comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload.ResultsPOD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. ‘Negotiated experimentation’ to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active ‘steer’, and senior ward ‘facilitator’ to extend ‘reach’ to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of ‘site readiness’ criteria without which implementation of this complex intervention was unlikely to occur.ConclusionsPOD implementation and delivery is feasible in NHS wards, but a necessary context for success is ‘site readiness.’

The Prevention of Delirium system of care for older patients admitted to hospital for emergency care: the POD research programme including feasibility RCT

“…We were thus ready to embark on project 2 of the research programme: pilot-testing the novel delirium prevention system of care (POD) for feasibility and acceptability. P arts of this section have been reproduced from Godfrey et al 46 © 2013 Godfrey et al; licensee BioMed Central Ltd. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.…”

Investigation of ward fidelity to a multicomponent delirium prevention intervention during a multicentre, pragmatic, cluster randomised, controlled feasibility trial

“…This comprehensive framework includes the contribution of possible barriers to the implementation and the assessment of moderating factors including intervention complexity, facilitation strategy and participant responsiveness. However, our randomised trial was the final part of a programme of interlinked studies and we had examined moderating factors and facilitation during an earlier stage [ 6 ]. Our intent in the current study was to investigate the extent to which the POD system of care was implemented and delivered as intended.…”

“…We developed a multicomponent system of care to prevent delirium for use in the English and Welsh NHS [ 5 , 6 ]. The Prevention of Delirium (POD) programme is a manualised, multicomponent intervention and systematic implementation process designed to secure ward practice changes consistent with a reduction in delirium.…”

“…Fidelity plays an important independent role in the effectiveness of multicomponent delirium prevention interventions with higher levels of fidelity resulting in lower rates of delirium incidence [ 9 ]. Previously, we investigated strategies to optimise intervention fidelity in a pilot study involving five wards in four sites [ 6 ]. This work suggested that the implementation of POD into routine ward practice would take about 6 months and was best achieved by prior verification of adequate ward staffing levels, through the formation of local implementation teams and by the provision of ring-fenced time (one day per week) for a senior healthcare professional (the ‘POD facilitator’) to lead the implementation.…”

A multicentre, pragmatic, cluster randomised, controlled feasibility trial of the POD system of care

“…A major issue faced by the National Health Service (NHS) in England and Wales, and acknowledged by the National Institute for Health and Care Excellence (NICE) [ 6 ], is the lack of a delirium prevention system of care suitable for widespread national implementation. To address this, we developed [ 9 ] and preliminary tested [ 10 ] the POD programme based on the Hospital Elder Life Program [ 11 ] and NICE guideline [ 6 ].…”