Delirium is a prevalent and serious condition among hospitalized patients, particularly those aged 65 and older. It is associated with increased morbidity, prolonged hospital stays, and higher rates of discharge to post-acute care facilities. Accurate and timely delirium assessment is a critical component of the recently enacted Center for Medicare and Medicaid Services Age-Friendly Health Systems initiative and the Society of Critical Care Medicine ICU liberation bundle. In addition, the geriatric ED level-one gold accreditation identified a need for improved delirium screening workflows and documentation. Historically, inconsistent workflows and fragmented documentation processes have hindered effective delirium screening and management across care settings.
This project describes the enterprise-wide redesign of information technology (IT)-supported nursing workflows to enhance the accuracy, consistency, and visibility of delirium assessments across emergency department (ED), inpatient (non-ICU, ICR, and ICU), and pediatric intensive care unit (PICU) settings within a multi-hospital health system in Suffolk County, New York. This initiative replaced outdated, underutilized and inconsistent assessment tools with age friendly and specialty-based validated instruments. These tools include the 4AT Assessment test for delirium & cognitive impairment for ED patients, nursing delirium screening scale (NuDESC) for adult non-critical care units, intensive care delirium screening checklist (ICDSC) for ICUs, and Cornell assessment of pediatric delirium (CAPD) for pediatric populations.
Key informatics interventions included the development of dynamic, rules-based clinical decision support (CDS) logic to automate the generation of delirium assessment orders and corresponding nursing tasks. These were tailored to patient age, unit type, and acuity level, ensuring appropriate timing and frequency of assessments. This logic prevents manual entry of duplicate orders and tasks and also cancels old orders and generates new orders when patients transition between levels of care to ensure seamless automated updates during intrahospital transfers. Additionally, the IT team collaborated closely with nursing subject matter experts to streamline and enhance documentation by optimizing placement of assessments within the electronic medical record to improve visibility.
Pre-/post-implementation workflow diagrams illustrate the transformation from a fragmented, partially manual process to a fully integrated, IT-driven system. To enable longitudinal tracking and intervention planning, a new order, positive delirium screen quality measures, is automatically triggered by a positive delirium score. Icons display on patient tracking boards for patients who score positive. Nursing transfer notes were updated to provide real-time visibility into delirium status enterprise-wide to support continuity of care and interdisciplinary communication. Iterative validations proved the need to revise and share delirium interventions fields to standardize documentation across the organization.
This project demonstrates the power of nursing informatics in driving clinical transformation. By aligning IT capabilities with front-line nursing workflows, the initiative provides the framework to improve compliance with regulatory standards, streamline and optimize workflows, enhance the quality and safety of patient care, and relieve the burdens of manual order entry for providers and overtasking for nursing. The scalable design supports future expansion to additional facilities within the enterprise.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and the potential of implementing the improvements into practice.