Case study: A remarkable turnaround on 5T
Delirium among hospitalized patients is a serious condition, associated with higher morbidity and mortality. Over the past two years, Asante hospitals have developed a program to take a proactive approach to preventing or treating delirium, starting with a pilot program at ATRMC’s Medical E Unit and ARRMC’s 5T Neuro/Ortho department.
The following illustrates the effectiveness of the program’s multipronged approach to delirium.
A 63-year-old man was admitted to ARRMC and diagnosed with a left-sided thalamic intracranial hemorrhagic stroke. He required an intraventricular drain due to elevated intercranial pressure. After spending 13 days in the CCU, he was transferred to Neuro/Ortho, where he stayed for 65 days. On transfer, his Nursing Delirium Screening Scale score was a 2, but over time it rose to 6.
Because of his intermittent outbursts of agitated behavior, poor memory, lack of self-awareness, his high fall risk and increased delirium, he required an around-the-clock patient safety attendant.
The patient struggled to make progress with physical and occupational therapy. His case was too complex for discharge and the care he needed was too difficult for his family to provide. Nonetheless, he did not qualify for inpatient rehab at ARRMC or any other facility.
Discharge planners brought this complex case to the attention of then-manager Rob Koning, who worked with nurse leaders to pull together a care meeting to work on the patient’s behalf.
The care team consisted of department nurse leaders, discharge planners, a bedside RN and rehab services managers. We decided to fully implement the interventions established in the Asante Delirium Prevention Program.
5 Tower leadership built a daily schedule for the patient with the collaboration of his care team. We were all very hopeful this would help the patient progress and become eligible for inpatient rehab.
0700: PSA to order breakfast for patient.
0800-0830: Breakfast – assist patient as needed, he prefers to be as independent as possible.
0830: Brush teeth and wash face.
0845: Clean/tidy the room.
0830-1000: Physical therapy session — PT will work with the PSA to show how to ambulate patient safely.
1030-1130: Hands-on activities — delirium cart activities, puzzles, cards, reading, music, etc.
1130-1230: Lunch — assist patient as needed; he prefers to be as independent as possible.
1230-1300: Ambulate patient in hallway.
1300-1400: Occupational therapy (three or more days a week).
- During OT sessions, patient needs to be set up for shower. PSA will help the patient with showering.
- OT and PT times are interchangeable. OT will see patient on Monday, Wednesday and Friday mornings.
1430-1530: Let patient read, have him sit by windows in a wheelchair. If patient is agitated, let him rest and watch TV.
1600-1700: Ambulate patient in hall.
1730-1830: Dinner — assist patient as needed; he prefers to be as independent as possible.
1830: Brush teeth and wash face.
1830-1845: Clean/tidy the room.
1845-2000: Hands-on activities — delirium cart activities, puzzles, cards, reading, music, etc.
2000-2100: Settle for bed — low lights, low stimulation.
Typically the patient safety attendant would observe and ensure the safety of the patient, but in the new daily schedule the PSA played an integral part.
Within 10 days of implementing this daily schedule that used his care team’s skills and resources, along with the delirium interventions, the patient made great progress and was transferred to inpatient rehab. The transfer to IRC was bittersweet for him. He was happy but said he would really miss the 5 Tower team. With tearful eyes he asked for pictures with several team members; it was very sweet. We were all so proud of him and honored to be part of his success!
Four ways we helped reduce the patient’s delirium
- Adhere to a routine
- Blinds open in the day
- Lights off at night
- Correct date on whiteboard
- Frequent reorientation
- Frequent reassurance
- Reduced environmental stimuli
- Up to chair for meals
- Frequent ambulation
- Scheduled ambulation (PT/OT)
- Family sitting with patient
- Activity cart
- Reminiscence card and magazines
- Busy bags
- Finger maze
- Scheduled TV time/down time