Medical Floor CAM Implementation and Assessment of Risk Factors

Background: Fifty percent of older hospitalized patients experience delirium. This translates into an estimated cost of $164 billion per year worldwide. Early identification of patients at risk for developing delirium allows for implementation of specific interventions to mitigate the adverse effects of delirium. Purpose: The purpose of the quality improvement project was to initiate the use of the Confusion Assessment Method (CAM) screening tool and analyze potential risk factors for the development of delirium. Methods: First, 24 Medical floor nurses at a 302- bed community hospital participated in a 90-minute multifaceted educational intervention. Didactic delirium information was interspersed with video demonstrations, case scenarios, and administration of CAMs using standardized patients. Administration of a delirium knowledge pretest and posttest occurred at the beginning and end of the educational intervention. This information provided knowledge acquisition scores. Second, within one week of the educational intervention the nurses began administration of CAMs on the medical unit. Nursing staff administered 1057 CAMs to 208 consecutively admitted patients during the 3-month study period. Additionally all 208 patients were screened for five potential risk factors of delirium from the multifactorial model of delirium. Outcomes: Based on the educational intervention, overall mean scores improved significantly from pretest to posttest: 6.83(±1.7) vs 10.33(±1.09); t(23) = -8.06, p = 0.000. Nurses identified delirium and subsyndromal delirium in 25% of the 208 consecutively admitted patients to the medical unit. A year previously, only 1% of all patients admitted hospital-wide were identified as having delirium and no patients were identified with subsyndromal delirium. Consistent with the literature, patients who had a urinary catheter (R = -0.175; p < 0.05) and/or experienced an iatrogenic event (R = -0.218; p < 0.002) were more likely to develop delirium. Additionally, Benzodiazepine administration had a statistically significant correlation with the development of delirium (x² = 8.55, p < 0.003). Conclusions: The results of this quality improvement project suggest that delirium education combined with the use of the CAM is effective in identifying delirium accurately in medical floor patients. Future studies will analyze the integration of the CAM into the electronic medical record and quantify the impact of delirium on patients, hospital staff, and hospital expenditures.