Massachusetts mandated that all healthcare organizations need to present an operational plan as to how patients with dementia and/or delirium are assessed and treated. The operational plan must address six issues, namely the environment in the hospital, PMH and screening/assessment tools, management of treatment in the hospital, transitions of care, and advanced care planning. These standards highlighted an area of opportunity for the system as there was no harmonization between providers, nursing, and ancillary departments in the treatment of these patient populations. There was also a lack of communication between the inpatient and ambulatory care settings. The current care provided was not standardized and did not differentiate between treatment for dementia and delirium.
A core group comprised of system quality, clinical informatics, and geriatric-focused nurse practitioners was formed. A gap analysis was completed and a multidisciplinary steering committee convened. Changes made would improve and coordinate care across the academic medical center, community hospitals, and ambulatory care practices.
Solutions: For patients with a history of dementia or dementia on the problem list, two care plans automatically trigger for nursing – “fall injury risk” and “adult chronic confusion.” A banner stating “patient has a history of cognitive dysfunction” will appear in all clinical and non-clinical patient facing areas. Even though the language in the banner is standardized, each department/area determined where the banner would appear in Epic. For any patient over the age of 65, regardless of diagnosis, a CAM (confusion assessment method) triggers for nursing as part of the nursing admission assessment. A positive CAM causes a BPA to fire to the provider with a reminder to add “acute delirium” to the hospital problem list. Once acute delirium is added to the problem list, a banner stating “patient has acute delirium during this hospitalization” appears in the same areas as described for dementia. A positive CAM also auto triggers the “fall injury risk” and “IP delirium adult” care plans for nursing with associated care plan education. There are areas in which the CAM will not fire including peri-op, emergency department, behavioral health, and within 24 hours of anesthesia administration. The CAM will not re-fire if there was a positive CAM during the hospitalization. The banner stating that the patient has acute delirium during this hospitalization is deleted after discharge.