From the 2024 HVPA National Conference
Robin Ji BA (University of Chicago Pritzker School of Medicine), Patricia Lee MD, Lauren Gleason MD, MPH, Caleb Murphy MD
Background:
Delirium is an acute confusional state that commonly develops in older adults during hospitalization. This condition contributes to patient morbidity and mortality and substantial financial burden to the healthcare system through prolonged hospitalization and increased resource utilization. Clinical decision support within the electronic medical record (EMR) has shown potential to improve adherence to evidence-based practices.
Objective:
To develop and pilot test EMR-embedded clinical decision support using a point-of-care alert to identify patients at high risk of delirium and an order set to encourage evidence-based delirium management.
Methods:
Our team created a Best Practice Advisory (BPA) within the Epic EMR to alert hospitalists to patients with high risk for delirium. The BPA is activated after a positive delirium screening score on the 4A’s Test (4AT). Our institution had previously implemented universal nursing-led delirium screening using 4AT, with results entered in the EMR. The BPA provides one-click options to access the order set or deactivate the BPA either permanently or for 24 hours.
Order set content was determined through literature review and feedback solicited from our institution’s multidisciplinary Delirium Taskforce, with final decisions on order set design made by team consensus. Notable order set features include a pre-selected high-value management bundle (e.g., frequent re-orientation) and de-emphasis of antipsychotic utilization through embedded education and “collapsing” the antipsychotic section upon opening the order set.
This initiative was pilot tested in a 160-bed medical-surgical unit within a large Midwestern academic medical center. The BPA and order set were introduced to hospitalists at a section-wide meeting and then implemented on January 24, 2024, with data collected for six weeks before and four weeks after implementation. Patient inclusion criteria were age 65 or older and a 4AT score of at least 4. Process measures of interest included antipsychotic and benzodiazepine utilization, restraint utilization, presence of standing bowel regimen, and head CT imaging.
Results:
Number of hospitalizations analyzed was 150 patients in the pre-intervention period and 46 patients in the intervention period. Patient characteristics were similar between groups, including average age (78.3 versus 80.1 years), sex (59.3% versus 52.2% female), and peak 4AT score (6.7 versus 6.1 points). There was a significant decrease in utilization of any antipsychotic or benzodiazepine between the pre-intervention and intervention periods (24.7% versus 10.9%, p=0.046).
There was no statistically significant difference in restraint utilization (32.7% versus 26.1%, p=0.40), standing bowel regimen orders (46.0% versus 41.3%, p=0.58), or head CT imaging (6.67% versus 0.00%, p=0.073). Of 46 BPA activations, 37% (n=17) resulted in providers placing new orders through the order set, 48% (n=22) led to opening the order set without placing new orders, and 15% (n=7) of BPA activations were disregarded.
Conclusions:
A novel BPA and order set for delirium awareness and management was associated with a 15% decline in antipsychotic utilization among patients at high risk for delirium during a four-week pilot testing period. Notable features of our approach include targeted BPA activation for patients with a positive delirium screen and de-emphasis of antipsychotic utilization within the order set in favor of high-value orders such as frequent patient re-orientation. Next steps include iterative clinical decision support refinement and ongoing monitoring of process measures.
Clinical Implications:
Pilot testing results of the clinical decision support tool indicate its potential to advance evidence-based delirium management, particularly by mitigating antipsychotic utilization.