Quality Improvement and Patient Safety Initiatives

CONTINUING EDUCATION

Developing a Strategy to Identify and Treat Older Patients With Postoperative Delirium PAULA BROOKS, DNP, RN, FNP-BC; JEFFREY J. SPILLANE, MD, FACS; KAREN DICK, PhD, RN, GNP-BC, FAANP; EILEEN STUART-SHOR, PhD, RN, ANP-BC, FAHA, FAAN 3.5

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Purpose/Goal To provide the learner with knowledge specific to assessing

elderly patients for preoperative cognitive status, risk of

postoperative delirium, and the presence of postoperative

delirium after surgery and for instituting treatment measures if

delirium is identified.

Objectives

1. Define postoperative delirium.

2. Describe the manifestations of postoperative delirium.

3. Describe the risk factors for postoperative delirium.

4. Identify assessment tools that help nurses screen patients

for postoperative delirium.

5. Discuss options for treating postoperative delirium.

Accreditation AORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center’s

Commission on Accreditation.

Approvals This program meets criteria for CNOR and CRNFA recertifi-

cation, as well as other CE requirements.

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Registered Nursing, Provider Number CEP 13019. Check with

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Conflict of Interest Disclosures Paula Brooks, DNP, RN, FNP-BC; Jeffrey J. Spillane, MD,

FACS; Karen Dick, PhD, RN, GNP-BC, FAANP; and Eileen

Stuart-Shor, PhD, RN, ANP-BC, FAHA, FAAN, have no

declared affiliations that could be perceived as posing potential

conflicts of interest in the publication of this article.

The behavioral objectives for this program were created

by Helen Starbuck Pashley, MA, BSN, CNOR, clinical

editor, with consultation from Susan Bakewell, MS, RN-BC,

director, Perioperative Education. Ms Starbuck Pashley and

Ms Bakewell have no declared affiliations that could be

perceived as posing potential conflicts of interest in the pub-

lication of this article.

Sponsorship or Commercial Support No sponsorship or commercial support was received for this

article.

Disclaimer AORN recognizes these activities as CE for RNs. This rec-

ognition does not imply that AORN or the American Nurses

Credentialing Center approves or endorses products mentioned

in the activity.

http://dx.doi.org/10.1016/j.aorn.2013.12.009

256 j AORN Journal � February 2014 Vol 99 No 2 � AORN, Inc, 2014

Developing a Strategy to Identify and Treat Older Patients With Postoperative Delirium PAULA BROOKS, DNP, RN, FNP-BC; JEFFREY J. SPILLANE, MD, FACS; KAREN DICK, PhD, RN, GNP-BC, FAANP; EILEEN STUART-SHOR, PhD, RN, ANP-BC, FAHA, FAAN 3.5

www.aorn.org/CE

ABSTRACT

Postoperative delirium is one of the most common adverse outcomes in elderly patients

undergoing surgery and is associated with increased morbidity, length of stay, and

patient care costs. The purpose of this quality improvement project was to evaluate the

effectiveness of amulticomponent strategy to identify and treat general surgical patients

65 years of age or older at risk for and who develop postoperative delirium at Cape Cod

Hospital, a community hospital in southern New England. We evaluated 96 patients

using the Mini-Cog assessment tool preoperatively and the Confusion Assessment

Method (CAM) delirium screening tool or CAM-Intensive Care Unit (CAM-ICU)

assessment tool postoperatively. Patients who tested positive during preoperative

assessment underwent a postoperative deliriummanagement protocol. We summarized

data using descriptive statistics. The results showed an association between compliance

and outcomes. High compliance with implementation of CAM and CAM-ICU

assessment tools resulted in increased identification of postoperative delirium in the

older surgical population. The use of screening tools helped facilitate early identifica-

tion of postoperative delirium in elderly surgical patients. AORN J 99 (February 2014)

257-273. � AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.12.009

Key words: delirium, postoperative delirium, postoperative assessment, assessment

tools, delirium screening tools, Mini-Cog assessment, cognitive assessment method,

CAM, CAM-Intensive Care Unit, CAM-ICU, Richmond Agitation and Sedation

Scale, RASS.

P ersons 65 years of age or older comprise the

most rapidly growing segment of the US

population.1 As the average life expectancy

extends, the incidence of chronic disease and

comorbidities in the elderly population also in-

crease.1 This older population requires more hos-

pitalized care than patients younger than 65 years

of age, and a significant part of this care is provided

by surgical services.2 In 2009, for example, patients

65 years of age or older accounted for more than

37% of all interventional and surgical procedures in

the United States, more than 57% of all coronary

artery bypass graft surgeries, and 50% of all

large bowel resections.3 For those older patients

http://dx.doi.org/10.1016/j.aorn.2013.12.009

� AORN, Inc, 2014 February 2014 Vol 99 No 2 � AORN Journal j 257

undergoing surgery, the development of post-

operative delirium (ie, an acutely altered and fluc-

tuating mental status with features of inattention

and an altered level of consciousness4) is one of

the most common undesirable consequences of

hospital-based treatment and has been shown to be

associated with increased morbidity, length of stay,

and patient care costs.5-8

DESCRIPTION OF THE PROBLEM

Because of the growing population of elderly pa-

tients, postoperative delirium is an emerging area

of interest. The development of delirium in the

elderly surgical patient is unique because elderly

patients often present with a different pattern of

disease and have a different response to treatment

than younger patients.9 In addition, elderly patients

have a very high incidence of postoperative de-

lirium that leads to an increase in hospital stay and

morbidity.5,7,10 Furthermore, the economic burden

of delirium to the US health care system is more

than $100 billion annually.11 The total estimated

cost of caring for hospitalized patients with de-

lirium ranges from $16,303 to $64,421 per pa-

tient.11 After adjusting for patient demographics

and clinical characteristics, the average cost per day

among hospitalized patients with delirium was

more than 2.5 times greater than that for patients

without delirium.11 Additional costs are attributable

to the greater need for institutionalization, reha-

bilitation, and home care after discharge.5,12

Research has demonstrated that resolution of

symptoms of delirium in older patients as a result

of early diagnosis and treatment correlates with the

most favorable outcomes.6,8 Although evidence-

based treatment strategies among elderly surgical

patients remain unclear, researchers agree that

identifying at-risk patients and managing the un-

derlying cause or combination of causes of delirium

are first steps in treatment.13 A careful preoperative

assessment and continuous monitoring of factors

that affect cognitive function are essential in all

elderly patients undergoing surgery and are critical

components in the detection and treatment of at-

risk patients.

BACKGROUND

In the past century, the growth rate of the elderly

population (ie, persons 65 years of age or older) has

significantly exceeded the growth rate of the pop-

ulation of the country as a whole.14 According to

the US Census Bureau, the world’s older popula-

tion will triple from 516 million in 2009 (ie, 13%

of the population) to 1.53 billion (ie, 16% of the

population) in 2050.14

According to USA Today, approximately 25% of

residents are more than 65 years of age in the Cape

Cod, Massachusetts, area, compared with about

13% nationwide.15 Very few regions in the United

States, with the exception of a small number of

areas in Florida, have as great a proportion of

elderly residents as does Cape Cod.16 Cape Cod

Hospital is a 259-bed community hospital that is a

major referral center in southern Massachusetts.

We perform more than 12,500 surgical procedures

each year, and because approximately 25% of the

area residents are older than 65 years of age,15 a

significant proportion of the surgical patients are

elderly. A review of 6,837 surgical procedures

performed by the hospital’s general surgeons in

2006 and 2007 demonstrated that 3,590 patients

(53%) were older than 70 years of age. Despite the

high number of older patients who underwent sur-

gical procedures, our hospital lacked a standard of

care for identifying and managing patients at risk

for developing postoperative delirium. Personnel at

the hospital also lacked a systematic postoperative

assessment tool to assist with identifying elderly

patients who develop delirium. Personnel needed

both a preoperative cognitive assessment to identify

elderly patients at risk for postoperative delirium

and a postoperative assessment tool for early

identification and management of patients who

developed postoperative delirium.

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LITERATURE REVIEW

Postoperative delirium is classified as either emer-

gence delirium (ie, developing within 24 hours af-

ter surgery)17,18 or interval delirium (ie, occurring

after a lucid interval of one or more days).18 Classic

manifestations of both types of delirium include

impaired cognition with confusion and decreased

ability to maintain attention.19 Common clinical

features include an impaired ability to maintain or

shift attention, combined with a change in cogni-

tion.18,20 Patients also may develop perceptual

disturbances, such as hallucinations, illusions, or

misinterpretations.18,20,21 Symptoms often vary from

patient to patient, arise in a short period of time, and

tend to fluctuate during the course of the day.18,20 In

the elderly surgical patient, delirium generally oc-

curs 24 to 72 hours postoperatively and can result in

weeks to months of lasting cognitive dysfunction.21

The prevalence of postoperative delirium after

general surgery can range from 5% to 10% and up

to as high as 70% to 87% among elderly patients

in surgical intensive care units (ICUs).7,22 Despite

this recognized significance of occurrence, post-

operative delirium in elderly patients often goes

unrecognized, or perioperative personnel misdiag-

nose it because of its unpredictable course.23,24

According to Marcantonio,25 clinicians fail to

recognize and address postoperative delirium in as

many as 80% of cases. Predicting those patients

who will develop delirium during the postoperative

period is especially difficult because the risk factors

for the development of postoperative delirium are

variable and multifactorial in etiology.8,26-32

Many studies have demonstrated that post-

operative delirium can result from a combination of

both predisposing and precipitating factors and can

be a consequence of the surgery or hospitalization

itself.5,8,27,28,30,31 Predisposing clinical factors are

independent variables that increase a patient’s

susceptibility of developing postoperative delirium.

These include

n older age,5,8

n medical comorbidities,5,33

n preoperative impairment in cognition,5,31,33-35

n depression,5,33

n poor nutritional and functional states

preoperatively,10,33

n hypoxia,8,36 and

n abnormal glycemic control.5,10

Inouye and Charpentier37 define precipitating fac-

tors as “noxious insults or hospitalization-related

factors that contribute to delirium.” These include

n medications,29,38

n physical restraints,5,36

n sedation,30

n analgesia,29,38

n postoperative pain,39

n prolonged bed rest,5,36 and

n sleep deprivation.5,36

Precipitating risk factors often are modifiable and

therefore represent an area in which intervention

would be most effective (Table 1).

Early diagnosis and resolution of delirium in

the elderly patient correlate with the most positive

outcomes.8,10,22,26,32,34,38,40-42 A careful preopera-

tive assessment, including screening for cognition

and delirium risk, is essential to the treatment of all

older patients. To make an accurate diagnosis of

delirium, knowledge of the patient’s baseline mental

status is essential. A simple cognitive test, such as

the Mini-Cog assessment tool, can be used as a pre-

operative predictor of patients who are at high risk

for the development of postoperative delirium.43-45

Postoperatively, an assessment tool that is highly

sensitive in identifying the subtle signs and symp-

toms of delirium in elderly patients is necessary.

Many screening tools have been developed for

identification of postoperative delirium, but those

most commonly used can be found in the literature

and are the Confusion Assessment Method (CAM)

and the CAM-ICU.46,47 Both instruments have

demonstrated sensitivity of 94% to 100%, speci-

ficity of 89% to 95%, and high inter-rater reli-

ability, with several studies validating their clinical

usefulness.47

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PROJECT GOALS

The purpose of this quality improvement project

was to pilot test a postoperative delirium identifi-

cation program in which personnel used screening

tools to identify patients 65 years of age or older

admitted for elective surgery to the general surgical

service who might be at risk for and/or develop

postoperative delirium. Secondary goals for the

pilot program included

n early identification of older patients who

would be undergoing general surgery and

could be at risk for developing postoperative

delirium,

n early identification of patients who developed

postoperative delirium, and

n treatment of reversible causes of postoperative

delirium.

PROJECT METHODS

Members of the project team conducted this quality

improvement project at Cape Cod Hospital in

Hyannis, Massachusetts. For the sample popula-

tion, we selected all patients 65 years of age or

older who were scheduled for an elective surgical

procedure with one of the hospital’s 10 general

surgeons. We excluded patients who were admitted

to the hospital before the day of surgery because

there is an already high occurrence rate of delirium

among hospitalized patients.48 All patients in the

sample were English speaking.

TABLE 1. Clinical Features and Factors Contributing to Postoperative Delirium in Elderly Surgical Patients1-6

Clinical features of delirium Predisposing factors Precipitating factors

n Acute onset n A fluctuating course n Inattention n Disorganized thinking n Alteration in consciousness n Cognitive deficit (eg, memory,

orientation, executive function) n Hallucinations (occur in 30%

of patients) n Psychomotor disturbances n Lethargy (ie, hypoactive delirium) n Agitation (ie, hyperactive delirium) n Emotional disturbances

n Advanced age n Male gender n Pain n Hypercarbia or hypoxia n Hypotension n Metabolic disorders (eg, hyponatremia,

hypercalcemia, hypoglycemia) n Medical illness and/or sepsis n Drug withdrawal n Alcohol abuse n Preexisting disease (eg, depression,

dementia, stroke) n Compromised functional status n Sensory impairment n Use of psychoactive drugs n Anticholinergic medication

n Surgery n Central nervous system medications

(eg, anesthetics, sedatives, benzodiazepines, anticholinergics)

n Sleep deprivation n Medications n Physical restraint n Sleep deprivation n Alteration of sleep/wake cycle

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.

2. Bekker A, Lee C, de Santi S, et al. Does mild cognitive impairment increase the risk of developing postoperative cognitive dysfunction? Am J Surg. 2010;199(6):782-788.

3. Koebrugge B, Koek HL, van Wensen RJ, Dautzenberg PL, Bosscha K. Delirium after abdominal surgery at a surgical ward with a high standard of delirium care: incidence, risk factors and outcomes. Dig Surg. 2009;26(1):63-68.

4. Kolanowski AM, Fick DM, Clare L, Steis M, Boustani M, Litaker M. Pilot Study of a nonpharmacological intervention for delirium superimposed on dementia. Res Gerontol Nurs. 2011;(4)3:161-167.

5. Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009;249(1):173-178.

6. Smith PJ, Attix DK, Weldon BC, Greene NH, Monk TG. Executive function and depression as independent risk factors for postoperative delirium. Anesthesiology. 2009;110(4):781-787.

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IMPLEMENTATION AND EVALUATION DESIGN

Implementing change in a small community hos-

pital requires the commitment of all personnel, and

long-term strategies are needed to promote and

facilitate an environment that supports change. The

Improvement Model, developed by W. Edward

Deming, has been shown to be an effective process

in helping to implement these types of changes.49

Members of the project team used the Plan-Do-

Study-Act (PDSA) cycle in developing our hy-

pothesis for the improvement. This cycle has

four phases:

n Plan: identify a need for improvement and plan

the intervention.

n Do: implement a protocol that includes data

collection and observing, analyzing, and inter-

preting the results.

n Study: evaluate, analyze, and interpret outcomes

and results.

n Act: review and determine any modifications

that should be made for the next PDSA cycle.50

Both The Joint Commission51 and the Institute

of Medicine52 recommend the PDSA cycle as an

effective approach to quality improvement projects

that are complex and involve multiple systems.53

Plan: Identify a Need for Improvement and Plan the Intervention

Initial planning by members of the project team

involved the surgical nurse practitioner pre-

senting evidence-based research, which we

identified through the literature review, to stake-

holders at the hospital. The presentations included

information about the incidence of postoperative

delirium and the use of assessment tools for iden-

tifying postoperative delirium. We shared findings

from the literature search that indicated a knowl-

edge gap existed in delirium etiology and supported

the need for early identification of patients at risk

for postoperative delirium.54 After obtaining insti-

tutional review board approval, the surgical nurse

practitioner prepared PowerPoint� presentations

and presented them to multiple committees

throughout the hospital, including the hospital’s

Board of Trustees; the pharmacy personnel; mem-

bers of the Therapeutics Committee, the Medical

Records Committee, the Medical Executive Com-

mittee, the Nursing Management Committee, and the

Nursing Education Committee; and surgical grand

rounds. This approach helped to secure stakeholder

buy-in, which was critical to obtaining hospital-

wide support.

To aid in the collection of data for the PDSA

cycle, during the “plan” phase, the surgical nurse

practitioner performed chart audits to determine the

total number of patients with documented post-

operative delirium before beginning our pilot pro-

gram. Because there is some evidence in the

literature55 of an association between seasonal

variation and delirium prevalence with higher rates

in the winter than in the summer months, we ob-

tained seasonal variation information on 106 his-

torical controls by matching the sample time of

three months (ie, June through August) and

reviewing charts that we obtained from the previ-

ous calendar year (Table 2).

Do: Implement a Study and Collect Data

A careful preoperative assessment and continuous

monitoring of factors that affect cognitive function

are essential in all older patients undergoing surgery.

During the pilot program, members of the project

team used the Mini-Cog test,43-45 the CAM, and the

CAM-ICU56 combinedwith theRichmondAgitation

and Sedation Scale (RASS).57 As discussed in the

preceding text, we identified these tools during the

literature review and specifically selected them

because, when used correctly, they have been found

to be effective, reliable, and valid instruments when

screening for cognitive impairment.44,56,58 We then

developed a screening and treatment algorithm for a

delirium management protocol that incorporates

these tools to guide perioperative personnel with

implementation(Figure 1).

Researchers consider the Mini-Cog assessment

tool to be a simple, reliable, valid, and effective

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POSTOPERATIVE DELIRIUM www.aornjournal.org

instrument that personnel can easily administer.44,58

This preoperative test enables evaluation of the

patient’s executive functions through examination

of his or her ability to plan, manage time, organize

activities, and manage working memory.59 Such

functions often are impaired in patients with mild

cognitive impairment or dementia. The test com-

prises a three-item recall for memory and a simply

scored clock drawing. The clock-drawing portion

of the test serves as an “informative distractor,”

meaning that asking a person to draw a clock in

between asking him or her to remember something

indicates whether the person can recall items after

interruption. This helps to clarify scores when the

memory recall score is indeterminant.45 To perform

the test, the perioperative evaluator names three

unrelated objects and asks the patient to repeat

them back. Then the evaluator asks the patient to

draw a clock. A positive Mini-Cog occurs if a pa-

tient recalls none of the three words or if he or she

recalls one or two of the three words and draws an

abnormal (eg, misshapen or incorrectly numbered)

clock. Similarly, a negative Mini-Cog occurs if the

patient recalls all three words or if he or she recalls

one or two of the three words but draws a normal

clock. As an evidence-based test, the Mini-Cog is

easy to administer and, according to the literature,

not too challenging for either the patient or pro-

vider.44,45,60,61 Members of the project team chose

this test to assess for baseline cognitive function

during preoperative assessment because the test

uncovers cognitive impairment in its earliest

stages.59

Postoperatively, we assessed delirium by using

the CAM test, which was administered by the RN

caring for the patient on the medical/surgical units.

The CAM test assesses fluctuations in mental sta-

tus, inattention, disorganized thinking, and level of

consciousness to determine the presence or absence

of delirium. It is the most widely used assessment

method by nonpsychiatric clinicians with proven

validity and reliability (ie, sensitivity of 94% [95%

confidence interval {CI}, 91%-97%]) and speci-

ficity of 89% [95% CI, 85%-94%]).56,62-64

For those patients requiring a stay in the ICU, we

used the CAM-ICU tool combined with the RASS

assessment, which determines whether the patient

is too sedated to cooperate during the CAM-ICU

assessment. The CAM-ICU, adapted from the

CAM developed by Inouyo et al,56 is designed for

use in intubated patients. This combined assess-

ment tool has high sensitivity of 93% to 100%, high

specificity of 89% to 100%, and high interrater

reliability (k ¼ 0.81-1.0).56,63 Several studies have been performed to validate the clinical effective-

ness of using both CAM-ICU and RASS in con-

junction, and both the CAM and the CAM-ICU

instruments have demonstrated sensitivity of 94%

to 100%, specificity of 89% to 95%, and high

interrater reliability (k ¼ 0.96).47,56 Initially, the surgical nurse practitioner identified

patients 24 hours before admission by using the

Picis OR manager�. We placed the Mini-Cog assessment tool in the admission packet of patients

identified as 65 years of age or older by the primary

investigator and used this assessment to obtain

TABLE 2. Preoperative and Postoperative Characteristics of the Sample

Preimplementation (June to August 2010)

Postimplementation (June to August 2011)

Number of patients 106 (67%) 96 (68%) Age in years (mean) 77 (SD 7.08, range 65-90) 77.5 (SD 7.17, range 66-98) Number of female patients 59 (56%) 63 (66%) Ethnicity (white, non-Hispanic) 102 (96%) 94 (98%) Postoperative delirium 9 (8%) 12 (13%)

SD ¼ standard deviation.

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February 2014 Vol 99 No 2 BROOKS ET AL

baseline cognitive function data about the pa-

tients. After the patient arrived to the preoperative

area, the RN assigned to the patient performed the

Mini-Cog test to obtain baseline cognitive func-

tion. The RN placed the completed Mini-Cog

assessment in the patient’s chart as a permanent

part of the medical record. The surgical nurse

practitioner scored the Mini-Cog assessments ac-

cording to standard guidelines.

When members of the project team identified

postoperative delirium as being present, we initi-

ated a daily postoperative delirium assessment

and physician order sheet (Figure 2). The surgical

nurse practitioner developed the order sheet for this

Figure 1. Postoperative delirium screening and treatment algorithm.

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Figure 2. Cape Cod Healthcare daily postoperative delirium assessment and physician order sheet. Adapted and printed with permission from Cape Cod Healthcare, Inc, Hyannis, MA.

264 j AORN Journal

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project in an attempt to standardize diagnostic tests,

procedures, and interventions used in the treatment

of the elderly patient experiencing postoperative

delirium. This order sheet also put into place orders

for nonpharmacological interventions, such as im-

plementing a fall risk assessment, avoiding phys-

ical restraints, including family members in the

patient’s care, encouraging frequent interaction,

avoiding sleep disturbance and excess stimulation,

and frequently reorienting the patient. We encour-

aged appropriate antipsychotic medication use only

when the patient placed himself or herself or others

at risk, and we encouraged appropriate dosing of

antipsychotics that required reordering on a daily

basis. The daily postoperative delirium assessment

and physician order sheet also offer clinicians the

option to initiate referrals to case managers, phys-

ical or occupational therapists, a nutritionist, and

psychiatric consults if necessary.

Antipsychotics have been studied extensively

in the elderly patient population and should be

administered at the lowest adequate dosages.65

Haloperidol, the most widely studied antipsychotic,

is the most frequently used antipsychotic medica-

tion for delirium because of its few anticholinergic

side effects, few active metabolites, and small

likelihood of causing sedation.65-68 Most studies

have used doses of 0.25 to 0.50 mg haloperidol

given every four hours for elderly or seriously

medically compromised patients and doses of 2 to

3 mg per day in healthier patients.65,67-69 For very

agitated patients, bolus doses of 5 to 10 mg per

hour intravenously have been used in hospital set-

tings.65,67-69 In the ICU for patients with hyperac-

tive delirium, it has been suggested that health care

providers administer 2 mg of haloperidol intrave-

nously followed by repeated doses (ie, doubling

the previous dose) every 15 to 20 minutes while

agitation persists.70 Although haloperidol is the

gold standard in pharmacological management of

delirium in elderly patients, adverse reactions such

as prolonged QTc intervals on electrocardiograms

and extrapyramidal side effects (eg, akathisia,

dystonia, pseudoparkinsonism, dyskinesia) can

occur.19,67 Electrocardiograms should be monitored

closely, and adding lorazepam may reduce the

extrapyramidal side effects.69

Newer atypical antipsychotics (eg, risperidone,

olanzapine, quetiapine) are being used to relieve

psychotic symptoms while minimizing adverse ef-

fects.66,67 A Cochrane review of three studies on

the use of antipsychotics for delirium showed no

difference in efficacy or adverse effects between

risperidone, olanzapine, and quetiapine and halo-

peridol.71 However, Lonergan et al71 found that

high-dose haloperidol is associated with a greater

incidence of side effects than the atypical

antipsychotic.

In a small 2008 study by Khouzam,72 quetiapine

was found to be effective in reversing postoperative

delirium without adverse events. More recently, in

a prospective, randomized, double-blind, placebo-

controlled study evaluating 36 patients in the ICU

with delirium, researchers found quetiapine to be

associated with a shorter time to first resolution of

delirium and a reduced duration of delirium and

required fewer doses than haloperidol.73 Thus,

quetiapine added to as-needed haloperidol resulted

in faster delirium resolution, less agitation, and

shorter hospital stays.73 Most recently, in a 2011

double-blind, randomized, controlled trial, Tahir

et al74 also found that quetiapine has the potential

to quickly reduce the severity of noncognitive as-

pects of delirium, and the patients receiving que-

tiapine improved more rapidly than the patients

receiving placebo.

Other medications also are being considered for

the treatment of delirium in the hospitalized pa-

tient. Most recently, a small prospective case report

showed promising results with fluvoxamine as

rapidly effective for treating postoperative delirium

in older patients.75 However, the authors studied

only three patients and a large, randomized,

double-blind, placebo-controlled study of fluvox-

amine will be needed to confirm its efficacy.75

Despite the fact that antipsychotics are useful for

the treatment of delirium, these medications also

have been associated with an increased risk of

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mortality in elderly patients, especially those pa-

tients with dementia, a common comorbid condi-

tion. One recent study documents the risk of a

serious adverse event (ie, an event leading to acute

care hospital admission or death) to be 2.4 times

greater for patients on typical antipsychotics than

placebo and 1.9 times greater for patients on

atypical antipsychotics than placebo.76

Short-acting sedatives have been used but are

reserved for delirium resulting from seizures or

withdrawal from alcohol or sedative hypnotics.66

However, medications such as benzodiazepines are

not recommended for the management of delirium

because these medications can be etiologic risk

factors for delirium in elderly patients.70

Finally, other investigators have studied anti-

psychotics as a preventive measure. In a 2005

randomized, placebo-controlled trial of 430 pa-

tients undergoing elective hip replacement surgery,

Kalisvaart et al77 found that haloperidol reduced

the severity and duration of delirium with a reduced

overall length of hospital stay. However, there was

no decrease in incidence. Similar findings were

reported by Markowitz and Narasimhan65 in 2008

in a randomized controlled trial comparing halo-

peridol with olanzapine. In this study, patients

showed a significant improvement of delirium in

the haloperidol and olanzapine groups compared

with patients in the control group. Researchers

found little difference between the medication

groups but demonstrated that haloperidol and

olanzapine were superior to placebo. In a 2007

randomized controlled trial by Prakanrattana and

Prapaitrakool,78 cardiac surgery patients who re-

ceived a single dose of risperidone postoperatively

had a reduced incidence of delirium.

The surgical nurse practitioner initiated nursing

education and training one month before imple-

menting the project. During that training time, the

surgical nurse practitioner presented information as

a PowerPoint presentation at surgical grand rounds

and then conducted educational sessions with

perioperative RNs in the preoperative area,

the surgical suite, the postanesthesia care unit

(PACU), the postoperative surgical floor, and the

surgical ICU. These sessions also involved group

presentations and individual one-on-one educa-

tional instruction, which included a general over-

view of each of the cognitive assessment tools and

how to administer them. In addition to the

training sessions, we provided resource material

on each unit for later reference and made pocket

reference cards that we distributed to all

involved nurses.

Study: Evaluate Outcomes

We evaluated outcomes for patients who were id-

entified as being at risk for postoperative delirium

by using the Mini-Cog assessment method; moni-

tored for postoperative delirium using the CAM,

CAM-ICU, or RASS assessment tools; and recor-

ded results on the daily postoperative delirium

assessment and physician order sheet as part of the

delirium management protocol. We summarized

data using descriptive statistics to describe mea-

sures of central tendency, such as mean, median,

and mode, as well as measures of variability that

included standard deviation (or variance).

Act: Review and Determine Modifications

The most significant contribution of this quality

improvement project was the identification of a

greater incidence of postoperative delirium in our

elderly surgical patients, and this appears to be

related to the new screening process that we put in

place. During a three-month period, we identified a

12% prevalence of postoperative delirium in the

elderly general surgical population undergoing

elective surgery. This percentage demonstrated an

increase in the detection of postoperative delirium

from the previous year, when assessment and

screening tools were not used. Although this ap-

peared to be a small increase, this project included

only patients who were undergoing elective general

surgery. We could have expected a higher per-

centage of postoperative delirium if the project had

included patients who were admitted urgently or

from other surgical services at the hospital, because

266 j AORN Journal

February 2014 Vol 99 No 2 BROOKS ET AL

delirium is more common in patients undergoing

nonelective orthopedic surgery (eg, hip frac-

ture).79,80 One could also expect there to be a sig-

nificant difference in incidence at a larger facility in

which a greater number of surgical procedures are

performed daily.

Members of the project team agreed that the

major aim of the projectdearly identification of

patients who develop postoperative deliriumd

had been met. The results showed an association

between compliance and outcomes. The RN

compliance rate for use of the CAM/CAM-ICU

assessment combined with the RASS assessment in

the postoperative period was 91%, which resulted

in an increase in the number of patients identified

with postoperative delirium. The use of assessment

tools in the identification of postoperative delirium

supports the finding that the CAM assessment and

the ICU-CAM facilitated identification of delirium

in the postoperative period and allows for early

initiation of treatment and management with a

standardized evidence-based treatment strategy.

Using a tool that detects patients who developed

postoperative delirium at an earlier stage during the

postoperative period increased the services pro-

vided for these patients. These services included

interventions such as implementing a fall risk as-

sessment, avoiding physical restraints, including

family members in the patient’s care, encouraging

frequent interaction, avoiding sleep disturbance and

excess stimulation, and performing frequent reor-

ientation. Finally, using a tool that helps nurses

identify postoperative delirium will make it easier

for clinical staff members to understand their pa-

tients’ reactions and symptoms and to help initiate

needed services.

We did not meet the secondary aim of our

project, which was early identification of patients

65 years of age or older who would be undergoing

general surgery and could be at risk for developing

postoperative delirium by using the Mini-Cog. A

surprising finding was the low incidence (ie, only

one patient out of 12) of patients with postoperative

delirium who had positive Mini-Cog assessments.

This finding contradicts some of the previous

reports using the Mini-Cog to determine baseline

cognitive impairment.44,58 A possible explanation

for this unanticipated finding may be that some

elderly patients with cognitive impairment are able

to compensate for or even mask their symptoms of

cognitive dysfunction. In addition, nurses did not

complete 21% of the Mini-Cog assessments. Many

nurses admitted that the Mini-Cog assessment was

not considered a priority in their care when trying

to prepare their patient for the OR. Another pos-

sible reason that nurses failed to complete these

assessments was their comfort level with adminis-

tering cognitive assessments. Studies have shown

that health care providers are often reluctant to

perform cognitive screening tests because these

tests are perceived as being uncomfortable for the

patient or his or her family members.81 Nurses also

may be hesitant to place a patient in an uncom-

fortable testing situation, especially when the pa-

tient is about to undergo a surgical intervention.81

The literature also supports early identification

and special consideration for patients who are at

risk for postoperative delirium because it is asso-

ciated with a greater mortality rate and longer

length of stay and affected patients are more likely

to require transfer to a rehabilitation facility on

discharge.82,83 Although we did not use inferential

statistics in this quality improvement project, it

appears that this project did exhibit similar findings

noted in the literature demonstrating longer lengths

of stay and greater transfers to rehabilitation

facilities in addition to showing a higher 30-day

readmission rate for patients who developed post-

operative delirium than for those who did not. Early

identification of those patients 65 years of age or

older and at risk for delirium allows these pa-

tients to benefit from delirium prevention mea-

sures that are targeted by personnel during the

postoperative period. The benefits of early iden-

tification and treatment of postoperative delirium

may decrease costs and the risk of complications

related to postoperative delirium. These results

further highlight the need for increased efforts in

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identifying patients at risk. Prevention of post-

operative delirium should be the goal.

PROJECT RESULTS

Out of a possible 635 patients, a total of 332 pa-

tients (52%) were 65 years of age or older and

scheduled for elective general surgery. Of those

332 cases, 96 were directly admitted to the preop-

erative area and were included in this project.

Those excluded were patients younger than 65

years of age, patients admitted to the hospital

before the day of surgery, or emergent surgical

patients. A broad range of procedures were per-

formed, including hernia repair, cholecystectomy,

mastectomy, peripheral vascular surgery, thoracic

surgery, and colorectal surgery. Of the 96 patients

included in the project, the compliance rates for RN

use of the Mini-Cog and CAM assessment tools

were high (79% and 91%, respectively) (Table 3).

Of the 87 patients who RNs assessed using the

CAM assessment tool, 15 of those patients were

admitted to the ICU, where RNs used the CAM-

ICU combined with the RASS assessment tool to

perform an evaluation. Although members of the

project team expected to see a relationship between

preoperative cognitive impairment by using the

Mini-Cog assessment and postoperative delirium

by using the CAM/CAM-ICU, members of the

project team were surprised to find that only one

of the 12 patients (8%) who tested positive for the

Mini-Cog assessment had a positive CAM assess-

ment. It was expected, resulting from the review

of the literature, that a greater number of patients

who had positive Mini-Cog assessments preopera-

tively were at greater risk for both a positive

CAM assessment and postoperative delirium

postoperatively.

The ability to detect postoperative delirium by

using standardized assessment tools increased from

9 of 106 surgical patients to 12 of 96 surgical pa-

tients compared with the preimplementation period

(Table 4). Over a three-month period, we identified

a 13% prevalence of postoperative delirium in our

elderly general surgical population undergoing

elective surgery compared with 8% from the pre-

vious year. We placed all patients who developed

postoperative delirium on the daily delirium as-

sessment and physician order protocol. In our

sample, a higher percentage of increased mortality

rates occurred for those patients who developed

postoperative delirium compared with the percent-

age of patients who did not develop delirium (25%

and 6%, respectively), which is consistent with the

TABLE 3. Number of Patients Assessed and Assessment Tools Used

Assessment tool n ¼ 96 Percentage (%) Mini-Cog assessment 76 79 Confusion Assessment Method (CAM)

87a 91

CAM-Intensive Care Unit (ICU)/Richmond Agitation-Sedation Scale (RASS)

15 100

a Total includes the 15 patients assessed using the CAM-ICU/RASS.

TABLE 4. Characteristics of Patients With Postoperative Delirium Compared With Patients Without Delirium

Positive CAM (n ¼ 12)

Negative CAM

(n ¼ 84) Age in years (mean) 83 77 Female 6 (50%) 57 (68%) History of dementia 3 (25%) 5 (6%) History of alcohol abuse 3 (25%) 10 (12%) Alcohol withdrawal 4 (33%) 1 (1.2%) Positive Mini-Cog score 1 (8%) 14 (17%) Length of stay (mean days)

11.8 3.58

30-day readmission 4 (33%) 8 (10%) Number of days to readmission (mean)

9 14.5

Discharge to rehabilitation facility

7 (58%) 15 (18%)

Mortality 3 (25%) 5 (6%)

CAM ¼ Confusion Assessment Method.

268 j AORN Journal

February 2014 Vol 99 No 2 BROOKS ET AL

literature. Patients who developed postoperative

delirium had a greater incidence of preoperative

dementia (25% versus 6%) and alcohol abuse (25%

versus 12%) identified in their dictated history and

physical examinations. Surprisingly, we did not

identify these patients using the Mini-Cog assess-

ment tool. These patients also required a longer

length of hospital stay (11.8 days and 3.58 days,

respectively), had a greater readmission rate (33%

versus 10%), and were transferred more often to

a rehabilitation facility at discharge (58% versus

18%) than those patients who did not develop

postoperative delirium.

Limitations

Despite the contribution of this project to patient

care, it had limitations. Based on the informal

feedback from nurses during the implementation

phase of this project, members of the project team

learned that it could have been useful to administer

a survey instrument after the project was completed

to assess nursing satisfaction in using the new tools.

A post-project survey of nurses’ opinions would be

valuable in providing feedback regarding potential

barriers and enhancements to implementation of

the assessment tools going forward. A survey of

the nurses’ opinion of the assessment tools is an

essential element of continuous quality improve-

ment, because respondent suggestions could be

incorporated into better screening options and the

development of a more comprehensive preopera-

tive evaluation tool.

To achieve nursing compliance with performing

the Mini-Cog assessments, it was necessary for the

surgical nurse practitioner to be physically present

in the preoperative area, have face-to-face com-

munication with the nurses, and place the assess-

ment tools in the admission packet. In addition, one

member of the project team (PB) did all the scoring

of the assessment tools. This technique, however,

was not sustainable. Implementation of the assess-

ment tools had to be accepted, supported, and

recognized by all nurses as a new, standardized

nursing practice. To accomplish this, nurses must

be educated to recognize, integrate, and deliver

high-quality patient care using evidence-based

practice tools. Nurses need to be educated not only

about how to score assessments but also how to

interpret results, and policies must be developed so

that evidence-based assessment tools can be in-

corporated into daily practice. Nurses need to be

responsible for the initiation of the assessment and

completion of the scoring of patients under their

direct care.

Another limitation we noted was that the popu-

lation consisted only of older patients admitted for

elective general surgery. This was a pilot study, and

therefore we evaluated only a limited number of

patients and excluded other surgical specialties and

patients undergoing emergent procedures. The

limited sample could have resulted in an under-

estimation of the number of elderly patients who

develop postoperative delirium.

Finally, because this was a quality improvement

project, we did not addresss possible confounding

risk factors affecting postoperative delirium. One

purpose of this project was to use screening tools to

identify patients 65 years of age or older admitted

for elective surgery to the general surgical service

who may be at risk for or develop postoperative

delirium. However, members of the project team

addressed only one risk factor for postoperative

delirium: baseline cognitive function. Postoperative

delirium results from a combination of both pre-

disposing and precipitating factors and can be a

consequence of a surgery or hospitalization itself.

To improve this project, the assessment of risk

factorsdsuch as hypoxia, poor glycemic control,

hypothermia, metabolic imbalances, alcohol abuse,

and polypharmacy, which have been shown to in-

crease the risk of postoperative deliriumdmay

need to be systematically incorporated into preop-

erative assessments.

DISCUSSION

Consistent with the literature, the use of the

CAM and the CAM-ICU assessment tools hel-

ped to determine that older patients who develop

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POSTOPERATIVE DELIRIUM www.aornjournal.org

postoperative delirium were more likely to have

adverse clinical outcomes after undergoing surgical

procedures. Patients with positive CAM/CAM-ICU

scores had longer lengths of stay, higher mortality

rates, and ultimately higher patient care costs than

patients who tested negative on the CAM/CAM-

ICU assessments.

As witnessed in this quality improvement proj-

ect, integrating evidence-based interventions into

practice is a complex and challenging processes.

Knowledge gained from quality improvement pro-

jects helps to improve patient care and increases

our understanding of how to implement effective

change.84 Recognizing that evidence exists and

agreeing that it needs to be transformed into prac-

tice is not enough; to be effective in changing

practice in health care, a system-wide commitment

from leaders, health care providers, and nurses is

necessary. Health care providers need to optimize

the care of comorbidities and address issues that

affect elderly patients.

It has been established in the literature that the

use of evidence-based protocols in the assessment

and treatment of postoperative delirium helps to

standardize care, promotes patient safety, reduces

hospital costs, and improves patient outcomes.

The use of the assessment tools described in this

quality improvement project helped to demon-

strate that nurses are uniquely positioned to im-

plement and coordinate new services for their

patients. Personnel who provide postoperative

care need to concentrate not only on the patient’s

cognition but also his or her ability to perform

activities of daily living. This project helped to

support nurses’ abilities, with the use of formal-

ized assessment tools, to identify elderly patients

at risk for developing postoperative delirium and

who develop postoperative delirium early in the

perioperative process. This project also prepared

personnel for protocol revisions and implementa-

tion of a multidisciplinary approach to addressing

the needs of the hospital’s elderly surgical patient

population.

CONCLUSION

Although a large body of knowledge exists about

the effectiveness of evidence-based nursing in-

terventions, there is clearly a gap between what is

known and what is practiced. Implementation of

new protocols requires long-term strategies to

promote and facilitate an environment that supports

change. Nursing research and evidence-based

practices must be integrated into nursing care de-

livery to provide excellence in patient care. As

witnessed by the use of standardized assessment

tools in this project, transforming evidence-based

research into practice can be challenging. There are

many barriers in any quality improvement project

that must be overcome to ensure acceptance and

compliance. Members of the project team found

the CAM and CAM-ICU assessment tools to be

effective and have since incorporated them into the

nursing assessments of all general surgical patients.

The next step is to revisit the Improvement Model/

PDSA cycle to develop a new plan that involves a

pilot project for all surgical patients 65 years of age

or older. What needs to be identified is a more

comprehensive preoperative evaluation tool that

screens for additional risk factors associated with

the development of postoperative delirium in the

elderly patient population, in addition to baseline

cognitive functiondand this evaluation tool will

need to be pilot tested. By building evidence that

supports the use of assessment tools, the hope is

that a comprehensive postoperative assessment for

delirium will become a part of the surgical stan-

dard of care for hospitals that care for elderly

patients.

Editor’s notes: PowerPoint is a registered trade- mark of Microsoft Corp, Redmond, WA. Picis OR

manager is a registered trademark of Picis, Inc,

Wakefield, MA.

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Paula Brooks, DNP, RN, FNP-BC, is a surgical

nurse practitioner at Cape Cod Healthcare,

Hyannis, MA. Dr Brooks has no declared affil-

iation that could be perceived as posing a po-

tential conflict of interest in the publication of

this article.

Jeffrey J. Spillane, MD, FACS, is a general and

thoracic surgeon at Southeastern Surgical Asso-

ciates, Hyannis, MA. Dr Spillane has no de-

clared affiliation that could be perceived as

posing a potential conflict of interest in the

publication of this article.

Karen Dick, PhD, RN, GNP-BC, FAANP, is a

clinical associate professor of nursing, director

of the master’s program, and co-director of the

doctor of nursing practice program, Department

of Nursing, at the University of Massachusetts,

Boston, MA. Dr Dick has no declared affiliation

that could be perceived as posing a potential

conflict of interest in the publication of this

article.

Eileen Stuart-Shor, PhD, RN, ANP-BC, FAHA,

FAAN, is an assistant professor at the University

of Massachusetts, Boston, MA. Dr Stuart-Shor

has no declared affiliation that could be per-

ceived as posing a potential conflict of interest in

the publication of this article.

AORN Journal j 273

POSTOPERATIVE DELIRIUM www.aornjournal.org

EXAMINATION CONTINUING EDUCATION

3.5 www.aorn.org/CEDeveloping a Strategy to Identify

and Treat Older Patients With Postoperative Delirium

PURPOSE/GOAL

To provide the learner with knowledge specific to assessing elderly patients for

preoperative cognitive status, risk of postoperative delirium, and the presence of

postoperative delirium after surgery and for instituting treatment measures if

delirium is identified.

OBJECTIVES

1. Define postoperative delirium.

2. Describe the manifestations of postoperative delirium.

3. Describe the risk factors for postoperative delirium.

4. Identify assessment tools that help nurses screen patients for postoperative delirium.

5. Discuss options for treating postoperative delirium.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE.

QUESTIONS

1. Postoperative delirium is defined as an acutely

altered and fluctuating mental status with fea-

tures of inattention and an altered level of

consciousness.

a. true b. false

2. Postoperative delirium

1. has a very low incidence in elderly patients.

2. costs the US health care system more than

$100 billion annually.

3. results in total estimated hospital costs of

$16,303 to $64,421 per patient.

4. costs an average of 2.5 times more among

hospitalized patients with delirium than for

patients without delirium.

5. incurs additional costs after discharge that

are attributable to a greater need for institu-

tionalization, rehabilitation, and home care.

a. 1 and 3 b. 2, 4, and 5

c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

3. Postoperative delirium that occurs after a lucid

interval of one or more days is called __________

delirium.

a. delayed. b. emergence

c. immediate d. interval

274 j AORN Journal � February 2014 Vol 99 No 2 � AORN, Inc, 2014

4. Manifestations of postoperative delirium include

1. impaired ability to maintain or shift attention.

2. confusion combined with impaired cognition.

3. perceptual disturbances.

4. hallucinations.

5. misinterpretations.

a. 4 and 5 b. 1, 2, and 3

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

5. Symptoms often vary from patient to patient, can

arise in a short period of time, and tend to remain

the same during the course of the day.

a. true b. false

6. Predisposing clinical factors that increase a per-

son’s susceptibility for developing postoperative

delirium include

1. older age.

2. medical comorbidities.

3. preoperative impairment in cognition.

4. depression.

5. poor preoperative functional or nutritional

states.

6. abnormal glycemic control.

a. 1, 3, and 5 b. 2, 4, and 6

c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

7. Precipitating factors (ie, noxious insults,

hospitalization-related factors) that contribute to

delirium include

1. medications, analgesia, or sedation.

2. physical restraints.

3. preoperative euphoria.

4. prolonged bed rest or sleep deprivation.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

8. A preoperative assessment tool that helps predict

which patients are at higher risk for experiencing

postoperative delirium is the

a. Mini-Cog assessment tool.

b. Confusion Assessment Method (CAM).

c. DiSC assessment.

d. CAM-Intensive Care Unit.

9. Some nonpharmacological interventions that can

be implemented if an assessment identifies a pa-

tient as having postoperative delirium include

1. implementing a fall risk assessment.

2. using physical restraints.

3. avoiding sleep disturbance and excess

stimulation.

4. reorienting the patient frequently.

5. including family members in the patient’s

care.

6. encouraging frequent interaction.

a. 1, 3, and 5 b. 2, 4, and 6

c. 1, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6

10. It is appropriate to use antipsychotic medications

for patients experiencing postoperative delirium

a. when a patient is a danger to himself or herself

or others.

b. as soon as a patient has been diagnosed with

postoperative delirium.

c. to help a patient sleep.

d. if the patient is 65 years of age or older.

AORN Journal j 275

CE EXAMINATION www.aornjournal.org

LEARNER EVALUATION CONTINUING EDUCATION PROGRAM

3.5 www.aorn.org/CEDeveloping a Strategy to Identify

and Treat Older Patients With Postoperative Delirium

T his evaluation is used to determine the extent to

which this continuing education program met

your learning needs. The evaluation is printed

here for your convenience. To receive continuing

education credit, you must complete the online

Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Define postoperative delirium.

Low 1. 2. 3. 4. 5. High

2. Describe the manifestations of postoperative

delirium. Low 1. 2. 3. 4. 5. High

3. Describe the risk factors for postoperative delirium.

Low 1. 2. 3. 4. 5. High

4. Identify assessment tools that help nurses screen

patients for postoperative delirium.

Low 1. 2. 3. 4. 5. High

5. Discuss options for treating postoperative delirium.

Low 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

9. Will you change your practice as a result of reading

this article? (If yes, answer question #9A. If no,

answer question #9B.)

9A. How will you change your practice? (Select all that

apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/im-

plement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the ef-

fect of the change at regular intervals until the

change is incorporated as best practice.

5. Other: ________________________________

9B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others about

the purpose of the needed change.

3. I do not have management support to make a

change.

4. Other: ________________________________

10. Our accrediting body requires that we verify

the time you needed to complete the 3.5 con-

tinuing education contact hour (210-minute)

program: _________________________________

276 j AORN Journal � February 2014 Vol 99 No 2 � AORN, Inc, 2014

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