One in three hospital beds in Canada are occupied by older adults – people who are 65 years or older who are at risk of frailty. They are three times more likely to stay in hospital longer than 30 days, and twice as likely to be readmitted to hospital within 30 days. In BC, 20% of the senior population is frail which can lead to a reduction in function and quality of life, and which is compounded by a lack of community resources to keep pace with the aging population.
In short, frailty is the single largest contributor to disproportionate use of the health care system, where 16% of the population expends 50% of the health care budget. While frailty is a difficult problem for the health system, it can be prevented or slowed down with early intervention and better cross-sector collaboration. The key is upstream frailty prevention – and that’s where Fraser Health’s Frail Elderly-Older Adult Network stepped in.
Hospital-acquired delirium is the third highest hospital harm within Fraser Health (FH), often contributing to increased morbidity requiring alternative levels of care after discharge, as well as mortality, hospital cost, chance of readmission, long length of stay, and a predisposition to dementia. A patient safety priority, FH reported 1,544 hospital-acquired delirium cases in 2021/22 for an estimated cost of $18.6 million.
The Network believed a proactive, community-based change was required to meet the needs of the aging population. They partnered with care providers, patient partners, their families and the community at large to develop and roll out the Regional Delirium Strategy.
It included service mappings, gap analyses, and updated tools and resources for staff. Delirium Summits were held in December 2021 and November 2022 and a Delirium Change Package was launched in 2022 and revised in 2023, followed by weekly Geriatric Education Series for providers and patient partners across the care continuum for two straight years. A quality improvement project was piloted in January 2022 that embedded the Confusion Assessment Method (CAM) Tool, the gold standard for identifying delirium, in nursing flowsheets in three medicine units in Surrey Memorial Hospital (SMH) to increase delirium capture.
By June 2022, this pilot was rolled out across all 12 medicine units in SMH and has since evolved into what is now known as the Regional Delirium Strategy for Fraser Health. This is being replicated at Peace Arch, Delta, Burnaby, Langley and Eagle Ridge hospitals and sustained locally.
The primary driver for this strategic collaboration was to improve outcomes and experience for patients, clients and their families. However, the providers and organization also benefit from enhanced engagement and motivation, the removal of silos, improved morale and productivity of teams, streamlined processes and the creation of infrastructure to sustain the much-needed changes, as well as each other, as a unified purpose for teams to live by.
“Safe patient care can only be provided by staff who feel safe and cared for. Clinician well-being is our moral obligation to ourselves and each other,” says Victoria Casas-Alcuaz, a clinical nurse specialist with the Frail Elderly-Older Adult Network.
A Delirium Data Dashboard went live last year, developed and maintained by Systems Optimization with such metrics as delirium pre-printed orders utilization that help drive clinician decisions at point of care. Data has shown consistent upward trending towards more patients getting standardized delirium care. There has been greater insight about delirium, care planning and documentation by physicians and other members of the team, leading to seamless transitions. CAM utilization has shown a sustained increase from baseline of 25% in April 2021 to 100% by December 2022, with a corresponding jump in pre-printed order utilization from less than 10% in April 2021 to 80% by January 2023.
The Regional Delirium Strategy has been so successful that Vancouver Coastal Health has reached out to align their delirium strategy with FH, as have National Surgical Quality Improvement Program (NSQIP) leads in Ontario. It has also been presented at 20 local, provincial and international conferences, including the Institute for Healthcare Improvement (IHI) Scientific Symposium in Orlando, Florida, in December 2023, and has earned a spot in the BMJ Open Quality Publication.
“Having enhanced the care of people with delirium, we now look forward to embracing senior-friendly care for all,” says Belinda Robinson, regional medical director for Older Adults at Fraser Health. “Preventing frailty and cognitive impairment is the next major challenge we look forward to.”
