UTSW Perioperative Optimization of Senior Health: Initiatives to Reduce Delirium After Spine Surgery

INTRODUCTION: The UT Southwestern Perioperative Optimization of Senior Health (UTSW POSH) program is a multidisciplinary approach involving surgery, geriatrics, and anesthesia in an effort to reduce morbidity in high-risk elderly patients undergoing elective surgery. Modeled after the original POSH program developed at Duke University, one goal of the UTSW POSH program is to prevent delirium, an often-unrecognized source of adverse outcomes. In this two phase project, a validated chart review tool was used to determine delirium rates in UTSW POSH patients undergoing spine surgery. Concurrently, an initiative began to educate postoperative nurses about delirium risk assessment, recognition and management. As part of the initiative, nurses implemented a standardized screening tool (the 4 A's Test or 4AT) with the goal of increasing recognition of postoperative delirium in older adults undergoing spine surgery. METHODS: The records of 148 elderly patients who had undergone elective spine surgery were retrospectively reviewed. A chart review-based method was utilized to retrospectively identify delirium by applying CAM criteria. For intervention, nurses on the neurosurgical floor were asked to attend a 45-minute educational session conducted by a geriatric health care provider. Surveys regarding delirium knowledge were administered before and after each session. Three Registered Nurses became nurse champions to implement the 4AT and facilitate change in nursing workflow. Patient charts were audited using an EMR Reporting Tool to monitor rates of delirium screening. RESULTS: The incidence of delirium found in UTSW POSH patients through chart review was 11.6%. A greater proportion of nurses (76.07%) answered delirium knowledge questions correctly post-intervention as compared to pre-intervention (67.86%). The chi-square test showed the impact of nursing education was statistically significant (p = 0.0167, CI = 0.4763-0.9294). Daily delirium screening rates improved from 0% at baseline to 81.6% in a randomly selected 5-day period 7 weeks post-intervention. CONCLUSION: The incidence of delirium found in UTSW POSH patients was lower than most published rates, however there is still room for improvement. A delirium initiative utilizing nurse champions can be effective in educating nurses about delirium and initiating screening on a postoperative neurosurgical floor. Programs that provide multidisciplinary, specialized perioperative care for high-risk elderly patients may be effective in reducing the incidence of postoperative delirium.