Best Practices: Hospital reduces delirium in elderly patients

Throughout the 1990s, Dr. Fred Rubin tried a variety of strategies to prevent elderly patients from experiencing the sudden onset of stress and confusion known as delirium, which often occurs during a hospital stay.

Rubin, a geriatrician and chief of the medicine service at UPMC Shadyside Hospital in Pittsburgh, made sure clocks and calendars were visible from patients' beds. He instructed staff to keep the window shades up during the day. And he avoided medications known to cause confusion. “I tried everything I could think of to prevent it,” he said.

Delirium is caused by many risk factors, including old age, certain medications, dehydration and vision impairment. It's associated with increased complication rates, higher mortality and longer lengths of stay. Awareness of the issue has grown in recent years as new research showed the spiraling financial costs of delirium, estimated to be as much as $100 billion annually when additional post-discharge costs are taken into account.

Delirium affects 30% to 50% of older general medical-surgical patients and 80% to 90% of ICU patients over age 70, Rubin said. A delirium episode in an elderly patient can double or triple mortality risk over the following year. Patients who experience delirium are more likely to need nursing-home care after a hospital stay. And the effects of delirium can linger for weeks and months. One-quarter of patients over 70 with delirium do not return to their baseline cognition within three months, he added.

In 1999, Rubin read a New England Journal of Medicine article touting the benefits of the Hospital Elder Life Program, or HELP, a comprehensive delirium-prevention program, now available free of charge, created by noted geriatrics researcher Dr. Sharon Inouye. HELP uses staff and specially trained volunteers to keep older hospitalized patients mobile, hydrated, rested and oriented to their surroundings. He decided to try to implement it at UPMC Shadyside.

Rubin and his team received a small grant from the hospital's foundation to try HELP for one year. Before launching the program in 2001, Rubin met with hospital administrators to decide what it would take for them to extend the program. They set clear targets for length of stay, costs and patient-satisfaction scores. “I wasn't interested in doing a one-year experiment,” he said. “I knew I needed to convince administration that this was worth funding long term.”

The program achieved the administrators' targets and has continued operating for the past 14 years. During that time, the hospital's delirium rate has dropped from 41% to 19%. The rate of so-called incident delirium—delirium that begins after hospitalization—has stayed at 3% since 2004. In a 2011 article in the Journal of the American Geriatrics Society, Rubin and his colleagues found that the total yearly financial return from the program was $7.3 million, including revenue generated from additional available beds and variable cost savings.

Inouye, who directs the Aging Brain Center at Hebrew Senior Life in Boston, praised UPMC Shadyside's approach. “In a real way, they've been able to achieve the triple aim of improving quality and patient satisfaction while decreasing costs,” she said. “They are doing very important work.”

The hospital's delirium program has several paid staff members, including nurses who conduct the initial baseline assessments of patients' cognitive status and determine their risk of developing delirium. But most of the program's interventions are performed by roughly 100 trained volunteers who are in pre-health career paths. They chat with patients, ask them what day it is, replace hearing aid batteries, raise window blinds, engage patients in puzzles or word searches, help them at mealtimes and make sure the calendar date is visible on the patient's white board.

The program got a small grant to buy newspapers each day and distribute them to patients at risk of delirium. “Volunteers will sit with them and go over the news of the day, if they want,” Rubin said.

The hospital also received a small grant to buy iPads, which volunteers use to help patients play games, read the news or look at old photos. Those are simple interventions, said Phyllis Glass, a nurse who oversees UPMC Shadyside's HELP. But at many hospitals, they don't get done.

The program has faced an array of challenges over the past 14 years, including turnover among staff and volunteers and the constant need to show administrators that HELP is a worthwhile use of the hospital's limited funds. In addition, any initiative that relies on changes in human behavior is hard to sustain. Rubin advises careful measurement and regular feedback with everyone involved.

But he urged other hospitals to look at HELP and consider changes they could make to prevent delirium. “It's a lot of work, but it can really make a huge difference,” he said.

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