A Standardized, Bundled Approach to Providing Geriatric‐Focused Acute Care

Abstract

Background Computerized provider order entry (CPOE) systems in the electronic medical record and checklists may present opportunities to improve care in older hospitalized adults. Objectives To determine if a bundled intervention can increase detection of delirium and facilitate safer use of high risk medications. Design Pre-post interventional trial Setting Large academic medical center Participants Patients ≥ 70 years (n=19,949) admitted 5/1/2008 to 9/30/2011. Patients ≥ 80 years admitted after 4/26/2010 received the intervention; those admitted prior were primary controls. Patients aged 70–79 were concurrent controls. Intervention The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the CPOE system to provide elder focused care. Measurements Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol > 0.5 mg or IV morphine > 2 mg, and discharge disposition. Results Patients receiving the intervention were 86.1 ± 4.6 years old and 58.2% female. The number of orders to activate the rapid response team for altered mental status increased in both patients receiving the bundle and in controls [odds ratio (OR) for the difference of differences = 1.23 (95% CI 0.68–2.24, p=0.49)]. Patients receiving the bundle were less likely to receive haloperidol > 0.5 mg IV/IM/PO [OR=0.60 (0.39–0.91) p = 0.02] and morphine > 2 mg IV [OR=0.52 (0.42–0.63), p < 0.0001]. More patients who received the bundle were discharged home than to extended care facilities [OR 1.18 (CI 1.04–1.35) p = 0.01]. Conclusion An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high risk medications, and possibly results in less need for extended care.

Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors

“…Despite this, relatively low rates of potentially excessive dosing overall were found, with even lower rates of excessive dosing in older adults. This may reflect a successful computerized decision support prompt at the medical center reminding clinicians of recommended (lower) psychotropic medication doses in older adults, and dosages may therefore be higher in hospitals without such decision support . These findings should be validated at other institutions.…”

Antipsychotic medication utilization in nonpsychiatric hospitalizations

“…27 Our results suggest that physicians are similarly not following recommendations to use lower doses of haloperidol when treating older patients, given the almost identical incidence of potentially excessive dosing among admissions of patients aged 65 years and older in our cohort. 25 Clinical decision support prompts have been effective at increasing appropriate use of antipsychotic medications in several single-center analyses, [28][29][30] and widespread implementation of such support with a focus on haloperidol dosing should be considered on the basis of our results. The patient characteristics associated with antipsychotic use in this large, nationally representative analysis are consistent with those identified in prior singlecenter analyses.…”

Multicomponent, nonpharmacological delirium interventions for older inpatients

“…3 (“overview of included studies”), the selected studies were performed in 12 countries with 13 studies (52%) from Europe [55–67], eight (32%) from North America [68–75] and four (16%) from Australia [76–79]. Of the studies 11 (44%) were conducted using a pre-test and post-test design [55, 59, 60, 65, 68, 71–73, 75, 78, 79], six (24%) studies were performed as a prospective observational study [57, 62, 63, 67, 69, 70] and four (16%) studies were RCTs [56, 64, 66, 77]. Furthermore, one nonrandomized study (combined with pre-test and post-test design) [61], one propensity-matched cohort study [74], and two qualitative studies were conducted [58, 76].…”