READI-SET-GO: Researching Efficient Approaches to Delirium Identification - Sustaining Effective Translation to create Gero-friendly Organizations
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ABSTRACT for READI-SET-GO Delirium has a devastating impact on older adults and their care partners. It is associated with in hospital adverse events (e.g., falls), declines in physical and cognitive function, nursing home placement and increased mortality. Despite its poor outcomes and high costs, < 50% of all delirium cases are detected in routine care. To address this challenge, in READI (Researching Efficient Approaches to Delirium Identification) we developed, validated, and field tested the Ultra-brief CAM (UB-CAM), a two-step delirium identification protocol that combines an ultra-brief 2-item screen (UB-2) with a validated diagnostic tool (3D-CAM). We enrolled 527 patients, avg. age 80 years, 35% with ADRD, at 2 study hospitals, performed reference standard delirium evaluations on 924 hospital days (153 with delirium), followed by blinded UB-CAM App-directed assessments by physicians, registered nurses, and certified nursing assistants. The UB-CAM was feasible (97% completion rate), brief (average 1 min 15 seconds), had overall accuracy of 89%, and performed well by all disciplines. We found similar positive results in the enriched subset of READI participants with Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD). We simultaneously conducted qualitative research to understand barriers and facilitators to implementation of delirium screening. While READI substantially advanced the field, it did not test full scale implementation of screening among all hospitalized older adults. We now propose to take this critical next step in READI-SET-GO (READI—Sustaining Effective Translation to create Gero-Friendly Organizations) by integrating daily delirium screening using the UB-CAM into routine care for every older adult admitted to 6 acute medical/surgical units at 3 hospitals in 2 states. We will conduct a stepped-wedge implementation design, where UB-CAM screening will be launched at a new unit every 6 months over a 42-month study. We will utilize evidence-based implementation strategies and test fidelity, accuracy, sustainability, and impact. Using a pragmatic cohort of 20,000 older adults, plus a nested patient- oriented sample of 1050 older adults enriched for AD/ADRD, we propose the following Specific Aims, 1. To test the fidelity, accuracy, and sustainability of integrating daily nurse screening for delirium using the UB-CAM into routine care for all hospitalized older adults. 2. To evaluate the impact of UB-CAM delirium screening on patient and care partner centered outcomes and perceptions of care assessed at one month follow-up interviews. 3. To evaluate the impact of UB-CAM screening on rates of delirium complications (falls, pressure injury, aspiration) and adverse delirium management (psychoactive medication, restraint use). Findings from the proposed study will be readily adopted into clinical care and will directly inform best practices for delirium screening, particularly for vulnerable older individuals with AD/ADRD. Our results have the potential to make the hospital a safer place for older adults, improving outcomes and reducing distress.
