Modified HELP Intervention Staves Off Postoperative Delirium

Diana Phillips

May 25, 2017

A modified version of an evidence-based delirium-prevention intervention cut the risk for postoperative delirium in elderly surgical patients by more than half and significantly shortened median hospital stays, new data show.

The findings, reported by Cheryl Chia-Hui Chen, RN, DNSc, from National Taiwan University in Taipei, Taiwan, and colleagues in an article published online May 24 in JAMA Surgery, suggest the nonpharmacologic intervention may be "a highly effective starting point" for medical centers seeking to advance postoperative care for elderly patients.

For the study, the investigators compared the effect of a modified implementation of the widely disseminated Hospital Elder Life Program (HELP) with that of usual care in 377 patients aged 65 years or older who underwent major elective abdominal surgery between August 1, 2009, and October 31, 2012, in a Taipei medical center.

The HELP intervention is focused on keeping hospitalized older adults oriented to their surroundings; meeting their needs for nutrition, fluids, and sleep; and keeping them mobile to the degree that their physical conditions allow. The researchers modified the intervention by selecting three core protocols (orienting communications, oral and nutritional assistance, and early mobilization) and delivering them daily to patients in addition to usual perioperative care.

Of the 377 study participants, 197 received the mHELP intervention from trained nurses daily until discharge, and 180 received usual postoperative care only. There were no significant differences in baseline characteristics, including presurgical cognitive status, between the two groups, and the primary indication for surgery, malignant tumor, was similar for both.

Overall, there were 40 cases of delirium, including 13 (6.6%) in the mHELP group and 27 (15.1%) in the control group. The relative risk for delirium in the mHELP group compared with the control group was 0.44 (95% confidence interval, 0.23-0.83; P = .008), reflecting a 56% risk reduction.

"In absolute terms, the number of cases needed to treat to prevent 1 case of delirium was 11.8," the authors write.

Patients in the intervention group also had significantly shorter hospital stays, at a median of 12.0 days vs 14.0 days in the usual care group (P = .04).

"Stratified by surgical type, patients who underwent gastrectomy benefited more from mHELP, with a 6-day shorter [length of stay] than in the control group (12.0 vs 18.0 days; P < .001)," the authors write. "This subgroup also experienced a trend toward reduced delirium incidence."

The mechanism for this greater benefit in gastrectomy patients requires further research "to understand factors that may magnify or attenuate the mHELP effects and to define the effect of mHELP in various surgical procedures," according to the authors.

Adherence to the protocols and consistent daily application appear to be essential to their success. "In this study, we had a full-time–equivalent trained mHELP nurse to consistently deliver all 3 protocols to 196 patients, spending approximately 30 minutes with each patient daily," the authors write.

The return on investment associated with the 56% decrease in delirium and shortened length of stay is substantial, the authors observe. "By extrapolation, older patients in the United States had 7.96 million surgical hospital stays in 2012, with a mean cost of $11 600 per stay. Thus, mHELP could have prevented approximately 674 576 cases of delirium in the surgical service in 2012, resulting in a Medicare cost savings of approximately $10 000 per case or $6.7 billion for the year," they write. In addition, by cutting 2 days from median length of stay, "implementation of mHELP could have saved $1624 per hospital stay or $12.9 billion per year in Medicare costs for the hospital stay."

For patients in the intervention group whose exposure to the intervention was delayed because of a prolonged ICU stay of 3 or more days, the incidence of delirium was lower than those in the control group with similarly long ICU stays, but the difference did not reach statistical significance, nor was there a significant difference in overall length of stay.

The intervention is scalable and can easily be incorporated into existing postoperative care, the authors write. In addition, it is consistent with the American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults, as reported by Medscape Medical News; the guideline recommends multicomponent nonpharmacologic care for preventing postoperative delirium.

The findings of this study extend the body of knowledge regarding interventions for improving postoperative outcomes in older adults, write Pasithorn A. Suwanabol, MD, and Daniel B. Hinshaw, MD, from the Department of Surgery at the University of Michigan at Ann Arbor, in an accompanying invited commentary.

"A significant focus has been made on modifiable factors to improve postoperative outcomes in older adults, yet few studies, at least in the general surgery literature, examine postoperative interventions to reduce the incidence of delirium in this patient population," the editorialists note.

"This study highlights not only a feasible and effective intervention but also notably outcome measures that are most important to patients."

Because the effects of delirium, subsequent cognitive decline, and the potential for dementia are burdensome to older adults and their families, "[i]t is critical that we continue to examine these long-term outcomes of surgery on older adults and find measures to reduce [them]," according to the commentators.

In addition to improving patient quality of life and reducing healthcare costs, interventions such as mHELP "address patient priorities that may not be measured by typical surgical quality metrics, such as death and complications," they continue. "The surgical community should take notice of this important work because it may serve as a cost-effective model for achieving outcomes that are meaningful to surgeons and their patients."

The study and editorial authors have disclosed no relevant financial relationships.

JAMA Surg. Published online May 24, 2017. Article full text, Commentary full text

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