NICHE

Pinpointing Risk Factors to Prevent Postoperative Delirium

by Lauren Woods


With rising surgery demands among the growing population of older adults, the UConn Center on Aging and UConn John Dempsey Hospital are teaming up to identify older patients at the greatest risk of developing postoperative delirium in order to prevent it.

Patients with delirium have an altered level of alertness and are sometimes excessively drowsy, hyper-alert, or agitated. Although postoperative delirium is usually short-term, lasting hours or days, the brain may not recover for weeks or months in older adults. If the condition is not identified and addressed, delirium can lead to a decline in an older patient’s surgical recovery and cognitive and physical health, a need for caregiver or nursing home care, or potentially an increased risk of death.

“Our goal is to do everything in our power to screen older patients before surgery for delirium’s risk factors and to prevent it after surgery — or at least minimize its duration and effect,” says UConn Center on Aging’s Dr. Patrick Coll, who has been working closely with surgeons and anesthesiologists to modify preoperative delirium screening protocols at UConn Health. “All doctors really should be adding delirium-risk-factor screening to their preoperative evaluations for patients age 75 and above.”

Risk factors for postoperative delirium in older patients include prior delirium after a surgery, underlying or existing cognitive impairment such as dementia or Alzheimer’s disease, heavy alcohol consumption that increases withdrawal risk, depression, frailty, malnutrition, immobility, infection, or taking certain medications.

Historically, surgery risk-prevention primarily focused on such areas as cardiac or pulmonary health. Last year, the American College of Surgeons and the American Geriatric Society issued new guidelines for optimal geriatric surgery patient management, which for the first time included screening for delirium risk before and after surgery.

“If a patient is deemed high-risk, the patient should have a geriatric assessment prior to surgery to help mitigate their risk and, after surgery, the hospital care team should plan to very closely monitor the patient,” said Coll.

The hospital care team can take simple, proactive steps to quickly reorient an older patient after surgery, Coll says. Even having a patient’s reading glasses and hearing aids readily available can make a big difference, as well as avoiding or limiting medications that can contribute to delirium, such as opioids.

With the help of aging expert Dr. Lavern Wright, UConn Health’s NICHE (Nurses Improving Care for Healthsystem Elders) program is expanding its scope to the surgical floors of the hospital to reduce older patients’ risk of delirium and other health complications. Further, all nurses now have access to the Confusion Assessment Method (CAM) tool and an electronic medical record order set to guide them in decreasing delirium’s impact.

In addition, Dr. Richard Fortinsky and his team are studying the effect of visiting clinical care teams at the homes of older adults with a history of delirium and other cognitive vulnerabilities to improve patient outcomes. This study, funded by the Patient-Centered Outcomes Research Institute, involves an in-home care program featuring a nurse practitioner who assesses older adults for delirium using a brief version of the CAM. The nurse practitioner also assesses for depression and dementia and teaches the patient and family members how to manage these conditions at home.

Magnifying Nursing Excellence

nurses do rounds inside UConn Health


UConn Health has launched its journey to Magnet nursing excellence recognition by the American Nurses Credentialing Center of the American Association of Nursing (AAN).

“Magnet designation is the ultimate honor for a hospital’s high-quality nursing,” says Sue Ellen Goodrich, RN, nursing director of Professional Practice for UConn Health. “Research shows us that stellar nursing practice truly makes a difference in patient care and outcomes.”

To pave the road to Magnet status for its more than 1,200 nurses, UConn John Dempsey Hospital is raising patient safety, satisfaction, and evidence-based outcomes benchmarks to above the national average while increasing nurse satisfaction, retention, collaboration, research, and professional development opportunities.

Of the 5,564 hospitals in the U.S., only 6.6 percent are Magnet-designated, with 460 total Magnet hospitals worldwide.

The Magnet Recognition program, created in 1990, is based on 14 “Forces of Magnetism” characteristics grouped into five pillars: Transformational
Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovation, and Improvements; and Empirical Outcomes.

To jump-start the Magnet journey, UConn Health has adopted a nursing professional practice model of compassion, integrity, collaboration, and innovation, with improvement initiatives aimed at preventing patient falls, central line–associated blood stream infections, catheter-associated urinary tract infections, and hospital-acquired pressure ulcers. UConn Health has also joined the national program NICHE (Nurses Improving Care for Healthsystem Elders).

“We look forward to building an even stronger foundation of nursing excellence while providing greater benefits to our patients and nurses,” says UConn Health Chief Nursing Officer Ann Marie Capo, RN, whose leadership and vision was pivotal to starting the Magnet process.