A Quality Improvement Initiative to Reduce Postoperative Delirium among Cardiac Surgery Patients
Abstract
:1. Introduction
2. Methods
2.1. Context for the QI Project
2.2. Use of an Established QI Model
2.3. Applying the QI Model to Reduce Postoperative Delirium among the Cardiac Surgery Patients
3. Results
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
POD | Postoperative Delirium |
rPOD | Reduction of Postoperative Delirium |
CPAC | Cardiac Pre-Admission Clinic |
CSIU | Cardiac Surgery Inpatient Unit |
ICCS | Intensive Care Cardiac Surgery |
References
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Step 1: Summarizing Evidence to Identify Potentially Beneficial Interventions | Step 2: Identifying Local Barriers to Implementation | Step 3: Selecting and Developing Performance Measures | Step 4: Ensuring All Patients Receive the Interventions |
---|---|---|---|
|
|
| E-Engage E-Educate E-Execute E-Evaluate |
Preoperative Intervention (CPAC, CSIU, 5A)—Preoperative Assessment Package | Operative Intervention | Postoperative Intervention—ICCS |
---|---|---|
|
|
|
Nurse education package and Yearly self-learning module |
A Positive CAM Indicates Delirium, a Medical Emergency and Should Be Translated to Following Action | |
---|---|
Investigations | Interventions |
|
|
Barriers | Strategy to Overcome Barriers | |
---|---|---|
1 | Lack of leadership |
|
2 | Lack of delirium-related knowledge and training among nursing staff |
|
3 | Lack of preoperative baseline risk assessment |
|
4 | Over sedation |
|
5 | Delirium screening |
|
6 | Perceived pain and discomfort screening |
|
7 | Early mobilization |
|
8 | Interventions aimed at preventing delirium |
|
9 | Lack of patient and caregiver engagement |
|
10 | Lack of communication with the community physician (family physician) |
|
Measure (S) | Mode of Assessment |
---|---|
Process Measures (Intervention adherence) | |
Intervention adherence | Rate of completion of baseline risk assessment |
Rate of completion of delirium assessment | |
Outcome Measures | |
Primary outcome | Rates of delirium screening |
Quality indicators | Number of positive CAM screens in clinical database for patients screened with CAM |
Number of patients restrained in ICU, Wards | |
Hospital LOS, ICU LOS | |
All-cause in hospital mortality | |
Major adverse cardiac events | |
Rate of sternal wound infection |
Patient Characteristic | Pre-rPOD Intervention (2009–2011) | During-rPOD Intervention (2012–2015) | Post-rPOD Intervention (2016–2018) | p-Value |
---|---|---|---|---|
Age | 66 (58–74) | 67 (58–74) | 68 (59–75) | <0.001 |
Sex (Female) | 28.2% | 27.9% | 27.8% | 0.942 |
Type of Cardiac Surgery | ||||
CABG | 60.9% | 46.9% | 45.6% | <0.001 |
Valve | 14.8% | 20.2% | 23.0% | <0.001 |
CABG + Valve | 11.2% | 11.3% | 11.1% | 0.969 |
Other | 13.1% | 21.6% | 20.3% | <0.001 |
MoCA Score | - | 26 (23–28) | 26 (23–28) | 0.479 |
CFS (Nursing Assessment) | - | 3 (2–4) | 4 (3–4) | <0.001 |
Patient Health Questionnaire (Version 9) | - | 1 (0–3) | 2 (0–6) | <0.001 |
7.1. Process Measures | During-rPOD Implementation (2012–2016) | Post-rPOD Implementation (2016–2018) | p-Value |
---|---|---|---|
7.1.1 Baseline risk assessment | |||
MoCA completion rate | 30.0% | 46.6% | <0.001 |
CFS completion rate | 30.7% | 49.2% | <0.001 |
7.1.2 Delirium assessment | |||
Any CAM Assessment Recorded | 97.3% | 98.5% | 0.002 |
Any RASS Assessment Recorded | 98.4% | 99.2% | 0.006 |
7.2. Quality Improvement Measures | Pre-rPOD Intervention (2009–2011) | During-rPOD Intervention (201–2016) | Post-rPOD Intervention (2016–2018) | p-Value |
---|---|---|---|---|
7.2.1 Primary outcome | ||||
Postoperative delirium screening rates | 9.0% | 23.3% | 19.1% | <0.001 |
7.2.2 Quality indicators | ||||
Number of Positive CAM screens in clinical database for patients screened with CAM | 2 (1–4) | 2 (1–5) | 3 (1–6) | <0.001 |
Number of patients restrained—ICU | - | 3.0% | 1.2% | <0.001 |
Number of patients restrained—Ward | - | 0.4% | 0.4% | 0.955 |
Length of ICU stay for patients screened with delirium (Hours) | 79 (43–161) | 90 (42–165) | 74 (41–147) | 0.329 |
Length of Hospital Stay (Surgery to Discharge) for patients screened with delirium (Days) | 12 (7–22) | 13 (8–23) | 12 (8–23) | 0.282 |
Major Adverse Cardiac Events (MI, Stroke, Dialysis, In-Hospital Mortality) | 5.4% | 8.1% | 6.3% | <0.001 |
Sternal Infection (Superficial or Deep) | 0.2% | 1.3% | 1.3% | <0.001 |
In-Hospital Mortality | 2.5% | 3.2% | 2.1% | 0.012 |
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Sanjanwala, R.M.; Hiebert, B.; Kent, D.; Warren, S.; Grocott, H.; Arora, R.C. A Quality Improvement Initiative to Reduce Postoperative Delirium among Cardiac Surgery Patients. Geriatrics 2021, 6, 111. https://doi.org/10.3390/geriatrics6040111
Sanjanwala RM, Hiebert B, Kent D, Warren S, Grocott H, Arora RC. A Quality Improvement Initiative to Reduce Postoperative Delirium among Cardiac Surgery Patients. Geriatrics. 2021; 6(4):111. https://doi.org/10.3390/geriatrics6040111
Chicago/Turabian StyleSanjanwala, Rohan M., Brett Hiebert, David Kent, Sandy Warren, Hilary Grocott, and Rakesh C. Arora. 2021. "A Quality Improvement Initiative to Reduce Postoperative Delirium among Cardiac Surgery Patients" Geriatrics 6, no. 4: 111. https://doi.org/10.3390/geriatrics6040111
APA StyleSanjanwala, R. M., Hiebert, B., Kent, D., Warren, S., Grocott, H., & Arora, R. C. (2021). A Quality Improvement Initiative to Reduce Postoperative Delirium among Cardiac Surgery Patients. Geriatrics, 6(4), 111. https://doi.org/10.3390/geriatrics6040111