Journal of Gerontological Nursing

Feature Article Supplemental Data

Implementing Nurse-Facilitated Person-Centered Care Approaches for Patients With Delirium Superimposed on Dementia in the Acute Care Setting

Andrea Yevchak, PhD, GCNS-BC, RN; Donna M. Fick, PhD, GCNS-BC, RN, FGSA, FAAN; Ann M. Kolanowski, PhD, RN, FGSA, FAAN; Jane McDowell, MSN, APRN, GNP-BC†; Todd Monroe, PhD, RN-BC, FNAP, FGSA, FAAN; Anna LeViere, MPH; Lorraine Mion, PhD, RN, FAAN

Abstract

Little is understood about the use of person-centered care (PCC) for individuals with delirium superimposed on dementia (DSD), especially in the acute care setting. As part of a larger clinical trial, the purpose of the current exploratory study was to describe examples and qualitatively derived themes of nurse-facilitated PCC for hospitalized older adults with dementia and delirium. A total of 750 delirium rounds were analyzed across three diverse acute care sites. Qualitative derived themes of PCC included: (a) Knowing the Patient's Baseline; (b) Knowing the Patient's Interests and Values; (c) Enhancing Sensory Abilities to Communicate; (d) Individualizing Cognitive Stimulation; and (e) Enhancing Behavioral Approaches to Comfort and Sleep. Barriers included failure to see the patient as an individual and lack of time. Principles of PCC were effectively used, demonstrating the potential for PCC to ease the burden of DSD for all members of the health care team. [Journal of Gerontological Nursing, 43(12), 21–28.]

Abstract

Little is understood about the use of person-centered care (PCC) for individuals with delirium superimposed on dementia (DSD), especially in the acute care setting. As part of a larger clinical trial, the purpose of the current exploratory study was to describe examples and qualitatively derived themes of nurse-facilitated PCC for hospitalized older adults with dementia and delirium. A total of 750 delirium rounds were analyzed across three diverse acute care sites. Qualitative derived themes of PCC included: (a) Knowing the Patient's Baseline; (b) Knowing the Patient's Interests and Values; (c) Enhancing Sensory Abilities to Communicate; (d) Individualizing Cognitive Stimulation; and (e) Enhancing Behavioral Approaches to Comfort and Sleep. Barriers included failure to see the patient as an individual and lack of time. Principles of PCC were effectively used, demonstrating the potential for PCC to ease the burden of DSD for all members of the health care team. [Journal of Gerontological Nursing, 43(12), 21–28.]

Person-centered care (PCC) is considered the standard of care for older adults with dementia because it improves quality of care and quality of life (Clissett, Porock, Harwood, & Gladman, 2013; Van Haitsma et al., 2013). PCC can be defined as knowing the individual, his/her needs and preferences, and using that information to shape the delivery of health care (American Geriatrics Society [AGS] Expert Panel on Person-Centered Care, 2016; White, Newton-Curtis, & Lyons, 2008). PCC relies on reciprocal communication among the individual and all stakeholders. The majority of research focusing on implementation and outcomes of PCC in the context of individuals with dementia has focused primarily in long-term care settings (Shier, Khodyakov, Cohen, Zimmerman, & Saliba, 2014). Little is known regarding the models or delivery of PCC in the context of individuals with delirium superimposed on dementia (DSD) in the acute care setting. Thus, there is a critical need to continue improving the understanding of PCC in hospitalized individuals with dementia.

Individuals with dementia and delirium are likely to benefit from instituting PCC in the context of an acute care setting, yet this has not been fully explored. Up to 50% of older adults with dementia experience delirium while in the hospital (Fick, Agostini, & Inouye, 2002). The outcomes of hospitalization for these highly vulnerable individuals includes increased risk of mortality and morbidity, greater rates of cognitive and physical declines (Krogseth et al., 2016; Morandi et al., 2015b), increased risk of institutionalization, and overall higher health care costs (Fick, Steis, Waller, & Inouye, 2013).

Although studies have shown that nurse-led and multicomponent delirium interventions result in reducing the incidence and severity of delirium in hospitalized older adults (AGS Expert Panel on Person-Centered Care, 2016; Bannon, McGaughey, Clarke, McAuley, & Blackwood, 2016; Marcantonio, Flacker, Wright, & Resnick, 2001; Siddiqi et al., 2016), whether acute care nurses and staff implement PCC in individuals with dementia and delirium is unknown. The current study was part of a larger study aimed at improving nurses' practices in the assessment and management of DSD. The purpose is to describe exploratory examples and themes of nurse-facilitated PCC for this vulnerable group.

Method

The current study is an exploratory, descriptive study converging quantitative and qualitative data to address PCC in hospitalized older adults with dementia and/or delirium. It is a sub-analysis of data collected from a 5-year, cluster-randomized trial of Early Nurse Detection of Delirium Superimposed on Dementia (END-DSD). END-DSD used an intervention consisting of four elements to improve nurses' recognition and management of delirium in hospitalized older adults with pre-existing dementia: (a) nursing education; (b) computerized decision support embedded within the electronic health record (EHR); (c) a designated unit delirium champion; and (d) weekly rounding sessions led by an advanced practice nurse (APN). Data presented herein were captured during the weekly rounding sessions with the designated unit delirium champion. PCC drove development of the delirium intervention by emphasizing that knowing the patient and individualizing care were important for this population. PCC is particularly important for delirium in the presence of dementia where behavioral and psychological symptoms of distress may be more common and lead to over medication and the development of delirium (Inouye, Westendrop, & Saczynski, 2014). As the nurse identified appropriate risk factors, targeted nonpharmacological interventions would then emerge as embedded within the EHR that could guide the nurse's decision and implementation of strategies specific to the patient's individual characteristics and preferences. For example, nursing staff were encouraged to talk with patients and family members to learn more about hobbies, interests, and occupation so that cognitive interventions and behavioral approaches could be tailored to their preferences and, in the case of individuals with dementia, possibly avoid over medicating. Institutional Review Board (IRB) approval was obtained from each facility and also Pennsylvania State University IRB.

Education was provided to nursing staff regarding delirium, risk factors, and appropriate identification and management of delirium per the individual as illustrated above. Computerized decision support included use of the Confusion Assessment Method (Inouye et al., 1990) to identify delirium, determine individual risk factors for delirium, and choose targeted strategies to manage delirium specific to each older adult.

Measures

A rounding form (Table A, available in the online version of this article) was used during each rounding session and included closed and open-ended questions, serving as a standardized checklist for rounds. The nurse facilitator completed the rounding form. General descriptions of the rounds, such as who was in attendance, length of rounds, and categories of items discussed during rounds, were also included. The rounding forms asked if different aspects of care specific to this population were discussed during each rounding session, such as delirium assessment; strategies put into place to prevent and/or manage delirium, including mobility protocols, sleep strategies, and cognitive stimulation; provision of pharmacological and nonpharmacological interventions; and communication about discharge. Risk factors and management strategies were evidence-based approaches to care for this population and setting.

Weekly Unit Champion Delirium RoundsWeekly Unit Champion Delirium Rounds

Table A:

Weekly Unit Champion Delirium Rounds

Procedures

Weekly rounding sessions are the focus of the analyses presented regarding the application of PCC. Rounds were initiated and conducted weekly on every shift by the nurse facilitator, who was a research team member (A.Y., D.M.F., J.M., T.M., L.M.). All nurse facilitators were board certified APNs by the American Nurses Credentialing Center and were either a geriatric clinical nurse specialist or nurse practitioner. Designated delirium unit champions (i.e., staff nurses employed by the facility) attended and co-facilitated rounds if they were available. Rounds were specifically scheduled to align with the unit champions' work schedule, but due to unforeseen circumstances or unit needs they were not always present at rounds. Each unit had at least one nurse designated as a delirium champion per shift who was considered an expert resource. The patient and informal, family caregiver, if present, nursing staff, physicians, pharmacists, social workers, physical therapists, nursing assistants, and students also attended rounds as available. Relative to day shift rounds, rounds conducted on evening or night shifts in general had fewer of these individuals in attendance. Geriatric care issues were discussed on rounds, with an emphasis on assessment and management of cognition and function. Rounding sessions that were analyzed occurred between September 2010 and November 2013 across all shifts at the following settings: regional medical center in central Pennsylvania, a regional trauma center in western central Pennsylvania, and an academic medical center in Tennessee.

Data Analysis

Descriptive statistics were determined on all nursing rounds using quantitative data. All statistical analyses were performed using SAS 9.4. Qualitative analyses were conducted using data provided in the open-ended questions. A research assistant (A.L.) independently reviewed the rounding form for open-ended comments showing recognition of individual preferences; knowing or learning about the patient as an individual; and understanding the patient's needs as related to delirium assessment, medications, pain, mobility, sleep, cognitive stimulation, communication, discharge teaching, and other items that were discussed and/or acted on by the nursing staff or research staff. Individual codes were discussed and agreed on as a group and condensed and expanded in a series of meetings with members of the research team (D.M.F., A.L., L.M.) to incorporate the breadth and depth of PCC included on the rounding forms. From these codes, high-level themes were developed and thematic analysis was performed by the research team to identify specific examples of PCC for individuals with delirium and dementia.

Results

Rounding sessions (N = 750) were performed between September 2010 and November 2013 and typically occurred weekly across all shifts. The three clinical sites included a regional medical center (n = 270), regional trauma center (n = 297), and academic medical center (n = 183). A total of 803 patients were seen during the rounding sessions, with 185 of these patients being active participants enrolled in the parent study. Total number of patients seen at the three sites included: 335 at the regional medical center, 159 at the regional trauma center, and 309 at the academic medical center. The study was initiated in a staggered fashion at each of the sites, which led to a different number of total rounds performed at each site. The majority of rounds (51.4%) included research staff and the unit champion. More than three quarters (76.3%) of rounds included additional members. Delirium rounds focused primarily on discussion of delirium assessment (73%), whereas additional information including pharmacological causes for delirium (59%), the need for increased physical activity (59%), and establishing a sleep routine to prevent delirium (52%) were also discussed (Table 1).

Most Frequently Discussed Items During Nursing Rounds (N = 750)

Table 1:

Most Frequently Discussed Items During Nursing Rounds (N = 750)

Person-Centered Care in the Context of Dementia and Delirium

Five qualitative themes that demonstrate PCC in the context of a larger research study are discussed, followed by barriers to implementing PCC in an acute care setting for individuals with dementia and delirium. Qualitative analysis revealed five themes related to PCC including: (a) Knowing the Patient's Baseline; (b) Knowing the Patient's Interests and Values; (c) Enhancing Sensory Abilities to Communicate; (d) Individualizing Cognitive Stimulation; and (e) Enhancing Behavioral Approaches to Comfort and Sleep. In addition to themes of PCC, barriers to providing PCC in this population and setting were also identified and included: (a) Failure to Recognize the Patient First and (b) Not Enough Time.

Knowing the Patient's Baseline. The ability to provide individualized care is a key aspect of PCC and allows for a foundational understanding of the individual and his/her family so that goals for care can be established (AGS Expert Panel on Person-Centered Care, 2016). To provide this type of care, formal health care providers need to be aware of an individual's baseline cognitive and physical function, as well as his/her preferences for care (Curyto, Van Haitsma, & Towsley, 2016; Van Haitsma et al., 2013). This baseline knowledge is particularly important to individuals with dementia who may develop delirium. The ability to assess for delirium rests on understanding prior cognitive and physical function.

Because establishing baseline in an acute care setting is often difficult, the current study emphasized the need to talk with family members and/or facility staff to determine the patient's normal function and cognition. The importance of taking the time to determine a patient's baseline is illustrated by the following report during a round:

“The nurse called the skilled nursing facility the patient has been living in and spoke to the nurse there. She obtained the patient's baseline functional status and was able to determine a change from her baseline.”

On another round, it was reported that a noted change in mental status contributed to a change in medication:

“MD stopped Seroquel® today after notice of changes in mental status by nursing staff.”

Knowing the Patient's Interests and Values. Knowing what is important to patients, what they value, their interests, and their hobbies was considered to be a crucial aspect of PCC. This knowledge helps patients maintain their sense of self and also provides a means of establishing a connection and bond of trust between nursing staff and patients and allows for individualized care. Research study staff provided the following quote while completing rounds with nursing staff:

“88-year-old, did MMSE [Mini-Mental State Examination] (Folstein, Folstein, & McHugh, 1975) [had RN score]. Asked him what he did formerly [claims adjustor] and [he stated that he] enjoyed classical music. MMSE score 8/30…. The unit supervisor to follow up with RN with cognitive activity/sensory board, cards, sleep kit, and music.”

On another round, the nurse reported that she was taking the time to find out what interested the patient and was going to record it on a whiteboard in the patient's room for other staff:

“Nurse stated she is getting a whiteboard and will write down patient's interests—music, writing letters. Discussed what she liked—grandchildren, country music.”

Enhancing Sensory Abilities to Communicate. For many patients with dementia, communicating is often difficult, especially in a hospital setting. Patients' hearing aids and glasses are often not brought with them to the hospital and the environment is starkly different than what they are used to. The current study promoted the use of an amplified hearing device in conversations between nursing staff and patients and implemented the All About Me Board (Fick, DiMeglio, McDowell, & Mathis-Halpin, 2013). These tools improved the ability of patients to communicate and allowed them more understanding and input into their medical care. A nurse reported the following during one of the nursing rounds:

“We went into the patient's room and gave her an amplified hearing device. It made the patient very happy and the CNA [certified nursing assistant] noted how much better they could communicate. The RN will do the MMSE later in the shift using the hearing device.”

Individualizing Cognitive Stimulation. Nursing rounds focused on tailoring activities and cognitive stimulation for each patient by determining what interests and activities the patient engaged in before being admitted to the hospital. From one of the rounding forms:

“Rounded on 87-year-old male with Parkinson's disease who stated, 'I love word searches and country music.' Discussed with his daughter, whom he lives with, keeping his mind and body active while in hospital.”

To encourage individualized cognitive stimulation, “activity kits” were stocked with a wide range of activities on each treatment unit of the hospital. Nurses were encouraged to use the kits to engage patients in the particular type of activity they enjoyed. For example:

“Found out patient liked puzzles.”

By tailoring the activities to patients' specific interests, patients were more likely to remain engaged and show cognitive improvement:

“Family noted as saying to nurse last week that leisure activities and cards created moments of normalcy.”

This theme has some overlap with the previous theme identified in the data of Knowing the Patient's Interests and Values, but it was specific to the type of intervention model used in the parent research study.

Enhancing Behavioral Approaches to Comfort and Sleep. The current study addressed issues of unmet needs during rounds and encouraged nursing staff to view agitation as a presenting symptom for an often-unrecognized, underlying condition or unmet need, such as infection, pain, or hunger. Behavioral interventions to respond to agitation in patients were promoted versus using medications to calm them. Thus, reducing the number of psychoactive medications a patient was receiving and increasing behavioral approaches in response to acts of agitation were critical aspects of PCC in the hospital setting. This response is exemplified by the following quote during one of the nursing rounds:

“Nurse will try non-pharm sleep protocol.”

Nurse facilitators advocated review of the medications lists of each patient enrolled in the study and made as-needed suggestions for changes to the unit champions and nursing staff. They educated the nurses about potentially inappropriate medications, using tools such as the AGS Beer's criteria (AGS 2015 Beers Criteria Update Expert Panel, 2015), and encouraged limiting medications that may have harmful effects in patients with dementia. Non-drug approaches also extended to sleep enhancement:

“We have one patient who has been very agitated at night. We have tried everything we can think of and haven't wanted to use medications. Last night we gave her a baby doll [used based on an assessment of preferences] to hold and she immediately became a new person! She was very calm and then slept the whole night!”

An intervention component for the current research study was conceptualized as an individual approach to avoiding medications. Although not typically an essential element of PCC, in the acute care setting, agitation, restlessness, and other behavioral symptoms of dementia are often managed pharmacologically. However, these behavioral symptoms are often the result of unmet needs, such as thirst, hunger, or pain (Algase et al., 1996; Kolanowski, Van Haitsma, Resnick, & Boltz, 2014; Whall & Kolanowski, 2004). The intervention encouraged assessing for and meeting unmet needs with non-drug approaches prior to administering drugs.

Barriers to Person-Centered Care

In the process of identifying instances where PCC was implemented by hospital and nursing staff, the data also revealed several examples where PCC could have been improved. Two primary categories were found: (a) Failure to Recognize the Patient First and (b) Not Enough Time.

Failure to Recognize the Patient First. The data revealed instances where PCC would have been promoted if the patient had been fully included in the discussion. By not including the patient, nurses overlooked his/her opinions and ability to make decisions. An example of this situation is when a patient's family members were consulted to ascertain the patient's preferences and interests as they related to cognitive stimulation and activities. Nursing staff approached the family to determine what the patient liked, when preferences could have been asked of the patient first; however, it is not known from the rounding forms whether nursing staff tried to ask the patient but, due to impaired cognitive or altered communication, he/she was unable to answer.

Not Enough Time. A majority of the observed areas where PCC could have been improved related to time as a deterrent, as demonstrated by the following quote during rounds:

“Unit champion present but busy, expressing concern, does not have time (sometimes) to help peers, patients with dementia take time to implement non-drug alternatives.”

Occasionally, the resources for individualizing cognitive stimulation were also not used due to time constraints, as illustrated below:

“Nurse said she had never used the cognitive stimulation kit due to time demand.”

Nurses also reported not having time to perform formal cognitive testing, such as the MMSE (Folstein et al., 1975), or baseline cognitive evaluation on the patient. A baseline and routine evaluation of cognition is critical in helping prevent and treat delirium in patients with dementia, which is also critical to knowing the individual in PCC:

“Nurse states that she doesn't have the time to establish a baseline understanding of her patients.”

In addition, there was also repeated documentation of nurses and unit champions being too busy or lacking the time to fully participate in the rounds or use the study screens, as noted:

“Saw patient [non-study] but nurse was very busy. Patient was delirious with history of dementia according to MD. Nurse said she would try to activate computer screens but ‘too busy now.’”

Discussion

The purpose of the current study was to describe instances of PCC in an acute care setting for individuals with dementia and delirium within an existing delirium clinical trial. Although PCC was not used as a framework for this intervention, aspects of PCC were emphasized, such as knowing the patient and individualizing care. The AGS recently convened an Expert Panel on Person-Centered Care where a consensus on a definition of PCC was put forth after a comprehensive review of the literature (AGS Expert Panel on Person-Centered Care, 2016). The current study's themes of Knowing the Patient's Interests and Values and Individualizing Cognitive Stimulation relate to elements of forming a foundation for health care based on preferences (AGS Expert Panel on Person-Centered Care, 2016) and can be implemented in the clinical arena by focusing on assessment and also by tailoring interventions as identified by the themes found within the current research.

Focused assessment is exemplified by the themes of Knowing the Patient's Baseline and Knowing the Patient's Interests and Values. Knowing the patient's baseline mental status is a critical component of assessment for delirium in individuals with pre-existing dementia considering overlap of symptoms, as well as the lack of full understanding of management of delirium once it occurs and prevention and management of delirium in individuals with dementia (Morandi et al., 2017). Assessment is made even more difficult because of the lack of consensus on how to define and also detect delirium in individuals with dementia (Morandi et al., 2017; Richardson et al., 2016). Family and other informal caregivers need to be included in care, especially to assist in detection of delirium. Health care providers, patients, and family members should come together to provide PCC as outlined by the AGS Expert Panel on Person-Centered Care (2016). Caring for individuals with dementia and delirium is challenging and potentially distressing for health care providers (Morandi et al., 2015a). Research suggests that when caring for these individuals, health care staff are concerned about understanding their needs and being able to provide appropriate care (Morandi et al., 2015a). Knowing the patient's baseline, interests, and values uses elements of PCC for individuals with dementia and delirium in the acute care setting through focused assessment and when implemented may help alleviate the associated issues of caring for individuals within this context.

Failure to Recognize the Patient First is an example of the identified AGS barrier Traditional Approaches to Clinical Practice, which posits that the health care provider is often seen as the leader and patient as the follower. By implementing focused assessment of the patient's baseline, interests, and values, older adults with dementia and delirium are able to communicate and participate to the fullest extent possible as a member of the health care team. This PCC change addresses the barrier of Failure to Recognize the Patient First as it relates to assessment. Although it is still beneficial that the nursing staff in the current study took the time to determine patients' interests from family members, preserving patients' autonomy is a critical aspect of PCC; therefore, patients should always be consulted whenever possible. Using the framework of PCC for focused assessments allows for integration of PCC elements.

Tailoring interventions incorporates the themes of Enhancing Sensory Abilities to Communicate, Individualizing Cognitive Stimulation, and Enhancing Behavioral Approaches to Comfort and Sleep. Using PCC approaches may help ease this burden when staff are trained in these methods and the environment is modified for the inclusion of PCC principles. Small changes in delivering interventions, such as the provision of low-cost hearing amplification devices or white board communication templates (e.g., All About Me Board [Fick, DiMeglio, et al., 2013]), can be readily used for older adults to facilitate participation in health care decisions and activities. Assessment of interests and values allows for cognitive stimulation to be tailored to the patient. Barriers to the implementation of tailored interventions were seen in the theme Not Enough of Time. Small, PCC measures presented herein can be incorporated into routine clinical care and can begin the movement of an institution's culture toward PCC. Table 2 lists some resources nursing and other health care professionals can use to learn more about PCC for delirium care.

Resources for Person-Centered Care for Delirium

Table 2:

Resources for Person-Centered Care for Delirium

Limitations and Strengths

The purpose of END-DSD was to test an intervention comprising four elements on nurses' recognition and management of delirium in hospitalized older adults with preexisting dementia. As such, whether a relationship exists between provision of PCC and delirium occurrence cannot be determined. Another significant limitation is that the rounding form used to collect the data analyzed was not meant to describe facilitators and barriers to PCC in this context, or patient and family engagement with research or nursing staff; therefore, data surrounding PCC may not have been adequately described. No additional long-term follow up was performed to determine whether the changes continued after the end of the research study, and nursing staff turnover may influence any long-term findings. A final limitation is the possibility that the nursing staff's behaviors were influenced by the presence of the research team, which led to more instances of PCC than would have occurred in the absence of the research team member. Despite these limitations, the study has significant novelty and strengths. It is one of the first to describe PCC for this population in the acute care setting. Being nested within a larger, cluster-randomized controlled study allowed for a large sample over three different sites.

Future Research

Areas for future research include systematically and objectively measuring the impact of widespread PCC in the acute care setting to determine the effect on occurrence of delirium. The measurement of PCC and its effect on delirium in individuals with pre-existing dementia is made even more difficult because detecting delirium in the presence of dementia is challenging and no specific criteria have been established (Morandi et al., 2017). In addition, there is a need to establish a validation system for coding qualitative measures of PCC, cross-referencing this system with the widely recognized AGS definition of PCC. Lastly, interventions for dementia and delirium may be more effective if designed with key elements of PCC in mind. If the patient is targeted first and the disease second, the efficacy of intervention strategies may improve.

Conclusion

The current study demonstrates successful facilitation and implementation of real world examples of PCC in hospitalized older adults with DSD. PCC can be implemented through delirium rounds at a variety of hospital settings. Although further investigation is needed to determine whether the adopted changes will remain after the current study is complete and if there is any impact on the course of delirium, this exploratory approach of implementation of PCC-driven interventions appears to be a success in the context of acute care.

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  • White, D.L., Newton-Curtis, L. & Lyons, K.S. (2008). Development and initial testing of a measure of person-directed care. The Gerontologist, 48(Special No. 1), 114–123. doi:10.1093/geront/48.Supplement_1.114 [CrossRef]

Most Frequently Discussed Items During Nursing Rounds (N = 750)

TopicTimes Discussed (n, %)
Delirium assessment549 (73.2)
Medications445 (59.3)
Mobility441 (58.8)
Sleep392 (52.2)
Cognitive stimulation289 (38.5)
Discharge teaching288 (38.4)
Pain254 (33.9)
Communication168 (22.4)
Other164 (21.9)

Resources for Person-Centered Care for Delirium

ResourceURL
American Geriatrics Society Person-Centered Care: A Definition and Essential Elementshttp://geriatricscareonline.org/ProductAbstract/person-centered-care-a-definition-and-essential-elements/CL020
Nursing Home Toolkithttp://www.nursinghometoolkit.com/index.html
Preference-Based Living and Preferences for Everyday Living Inventory©http://www.polisherresearchinstitute.org/assessment-instruments
Dementia Collaborative Research Centres 14 Essentials for Good Dementia Care in General Practicehttp://www.dementiaresearch.com.au/newsletters/48-2013/sum/180-ed2013.html
iDeliriumhttp://www.idelirium.org/home.html
American Delirium Societyhttps://www.americandeliriumsociety.org
United Kingdom Alzheimer's Societyhttps://www.alzheimers.org.uk

Weekly Unit Champion Delirium Rounds

Date/time _________________
Staff and role participating in rounds (RN, CNA, PT, OT, social work, pharmacy, etc.): ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________ 1) Number of patients seen on rounds _________ 2) Number of patients discussed (unavailable to be seen) _________ 3) Resources used (pocket cards, articles, etc.): __________________________ 4) Check items discussed in rounds and record any details and comments relevant to those items.

Item ReviewedDetails/CommentsItem ReviewedDetails/Comments

Delirium AssessmentNutrition

MedicationsHygiene

InfectionsCognitive Stimulation

Hydration/ElectrolytesDischarge Teaching

PainEquipment

Mobility/Activity LevelPhysician Roles

SleepCommunication

SkinFamily Issues

Lab ValuesDepression

5) Additional Items Reviewed or Comments: 6) Please note here any barriers to delirium management THIS WEEK (note if these came from your observance or brought up by nurse- things like leadership support, time, physician or other provider buy in, family issues, other demands, etc.). Check items below or write in barriers.
___ Busy on unit-unable to fully engage in rounds___ Unit champion not present
___ Difficulties with the screens___ other (describe)
7) Please note here any facilitatorsto delirium management THIS WEEK (note if these came from your observance or brought up by nurse- things like leadership support, time, physician or other provider buy in, family issues, other demands, etc.)
___ Interested/supportive staff members to round__ Nurse/unit champ took time
___ Unit champs facilitating well, enthusiastic__ other (describe)
Authors

Dr. Yevchak is Clinical Assistant Professor, Dr. Fick is Elouise Ross Eberly Professor of Nursing and Professor of Psychiatry, Dr. Kolanowski is Professor of Nursing and Professor of Psychiatry, College of Nursing, The Pennsylvania State University, University Park, Pennsylvania; Dr. Monroe is Assistant Professor of Nursing and Medicine (Psychiatry), School of Nursing, Vanderbilt University, Nashville, Tennessee; Ms. LeViere is Clinical Research Manager, Science Facilitation Department, FHI 360, Durham, North Carolina; and Dr. Mion is Research Professor, Interim Director, Center of Excellence in Critical and Complex Care, College of Nursing, The Ohio State University, Columbus, Ohio.

†:

Deceased.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Drs. Fick, Kolanowski, and Mion acknowledge partial support from the National Institutes of Health/National Institute of Nursing Research (NIH/NINR; grant R01 NR011042: END-DSD). Dr. Fick also acknowledges partial support from the NIH/National Institute on Aging (NIA) (grant R01 AG030618-05A1: Researching Efficient Approaches to Delirium Identification [READI]). The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIH/NINR/NIA.

Dr. Fick was not involved in the peer review or decision-making process for this manuscript.

The authors gratefully acknowledge the contributions of the patients, family members, nurses, physicians, research assistants, and hospital staff who participated in the END-DSD study. This work is dedicated to the memory of Jane McDowell, MSN, APRN, GNP-BC.

Address correspondence to Andrea Yevchak, PhD, GCNS-BC, RN, Clinical Assistant Professor, College of Nursing, The Pennsylvania State University, 201 Nursing Sciences Building, University Park, PA 16802; e-mail: amy139@psu.edu.

Received: February 13, 2017
Accepted: May 23, 2017
Posted Online: June 30, 2017

10.3928/00989134-20170623-01

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