Delirium Care Reduces Length of Hospital Stay, Cost

Marcia Frellick

March 27, 2019

NATIONAL HARBOR, Maryland — Care designed to prevent and treat delirium was linked to reductions in length of hospital stay, cost, and 30-day readmission rates, according to results from a 1-year study.

Delirium affects more than 7 million hospitalized adults every year in the United States, said Catherine Lau, MD, from the University of California, San Francisco. And healthcare costs related to postoperative delirium exceed $150 billion a year, as previously reported by Medscape Medical News.

"We know from previous research that as many as one-third of hospital-acquired delirium cases are preventable," Lau reported here at the Society of Hospital Medicine 2019 Annual Meeting. "However, programs designed to prevent or treat delirium have had variable success."

"People are generally aware of what delirium is, that it can prolong length of stay, that it's bad for patients, and that it can lead to provider fatigue, but we don't have good systematic ways of screening for delirium or preventing it before it even starts," she explained.

Lau presented findings from a study of 5419 patients — 2594 treated at the UCSF Medical Center before the care protocol was implemented and 2825 treated after. All patients were at least 50 years of age and were hospitalized for at least 24 hours.

During the care period, patients admitted to three general medicine units — two acute-care and one step-down — were screened with the AWOL delirium risk-assessment tool, in which they were assigned points for the following criteria: age older than 80 years; the inability to spell "world" backward; disorientation to city, state, county, hospital name, or floor; and nurse-rated severity of illness.

Screening With AWOL

Patients with an AWOL score below 2 received standard care and those with a score of 2 or higher were assigned to delirium care.

The prevention measures included nonpharmacologic interventions aimed at maximizing mobility and improving sleep and daytime wakefulness. In addition, a pharmacist reviewed medications.

Patients were screened for delirium every 12-hour nursing shift using the Nursing Delirium Screening Scale (NuDESC). If the NuDESC score was less than 2, patients received standard care. However, if the score was 2 or higher, patients were assigned to delirium support, the primary care team was notified of the positive screen, and treatment of the underlying causes was initiated.

There was a reduction in length of stay — the primary outcome — of almost a full day per patient (from 6.5 to 5.7 days), which was significant even after adjustment for patient comorbidities, age, race, and complexity of disease (P < .0001).

The rate of "screening for delirium on nursing shifts was above 90%," Lau told Medscape Medical News. And doctors ordered delirium sets consistently about 75% of the time. Delirium care had broad institutional support from health system leaders, medicine units, and the internal medicine residency program, she pointed out.

Direct hospital costs decreased by an average $850 per patient (95% confidence interval [CI], –1505 to –197; < .0001) and the odds of readmission decreased by 30% (odds ratio, 0.7, 95% CI, 0.6 - 0.7; < .0001).

Over 1 year, "for our medicine units alone, we saved nearly $1 million in direct costs," Lau reported.

Study limitations include the fact that delirium rates were only determined after the protocol was implemented; delirium screening and measurement were not conducted before implementation, so rates could not be compared, Lau acknowledged.

There was also no control group, she pointed out, so "we cannot definitely exclude other factors contributing to our improved outcomes."

It's hard to understand how and if this intervention led to these improvements.

Reductions in length of stay coming from a large study are promising, said Vineet Arora, MD, from the University of Chicago.

However, "it's hard to understand how and if this intervention led to these improvements, since delirium rates were not collected in the baseline period and it is limited in its design to assess cause and effect," she told Medscape Medical News.

The rate of delirium did not change in a statistically significant way, Lau said, but the number of delirium days decreased from a peak of 178 down to 129 per 1000 patient-days.

"There was a clear downtrend," she said.

Lau and Arora have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2019 Annual Meeting: Abstract 596670. Presented March 26, 2019.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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