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Actionable Patient Safety Solutions (APSS)

8A Post-Operative Delirium in Older Adults

The Post-Operative Delirium in Older Adults APSS Blueprint outlines actionable steps healthcare organizations should take to successfully implement and sustain improvements in order to reduce cases of post-operative delirium in older adults. Actionable steps to improve delirium rates and summaries of available evidence-based practice protocols are included:

Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
Performance improvement plan to follow if improvements are necessary
Clinical workflow from pre-operative delirium risk screening to discharge and post-operative recovery
Knowledge base on risk factors and tests for delirium
How to educate patients and family members about delirium prevention, recognition, and treatment
Delirium resource guide
Guidance on how to measure outcomes

The Blueprint is revised annually and is available free of charge on our website.

Hospitals who make a formal commitment to improve delirium and share their successes on the PSMF website have access to an additional level of consulting services.

Executive Summary

The Problem Delirium in older patients following anesthesia and surgery (Postoperative Delirium (POD)) is a frequent occurrence that often goes undiagnosed. Delirium can lead to both short and long-term morbidity and mortality, including cognitive impairment. It is an immensely disturbing experience for patients and families which can lead to long-term neuropsychiatric

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Pat Denton

It all started in the fall of 2017. Pat, though she was not a fitness freak, had always been an avid aerobic exerciser. She practically wore out three stationary exercise bicycles in her 30’s and 40’s. Later, she became quite the walker. When the Fitbit craze was introduced, she needed no coaxing. She was all over it and soon became nearly obsessed with the famous 10,000 steps focus.

In early and mid-2017, Pat began to experience increasing difficulty in completing her neighborhood walks. At first, she described it as “running out of breath”, but later realized it wasn’t breath, but rather her energy that was depleting. She couldn’t walk further than 50 yards without stopping. She couldn’t endure any kind of incline. That’s what drove her to seek medical evaluation.

After voluminous testing, she was diagnosed with possible cardiac blockage of some sort. The cardiologist performed a scope, but no cardiac blockage was found. What was discovered was a femoral arterial blockage. Subsequent surgery removed that blockage, and as was predicted, she felt vastly improved, even before she recovered from the effects of the surgery itself. In short, the next six months or so were perhaps the most healthy-feeling six months of her adult life.

Unfortunately, all the testing uncovered another cardiac issue. She was diagnosed with Cardio Myopathy with mild Systolic Heart Failure. Her cardiac electrophysiologist said she needed a defibrillator implant. At first, she balked, stating that she didn’t feel ill. In fact, she hadn’t felt better in decades. However, after consulting with her cardiologist and primary care physician, who both agreed, she caved and reluctantly went through with the implant surgery on March 12, 2018.

The surgery, in and of itself, reportedly went well. The wound apparently healed well and the implant reportedly worked fine, though it never needed to intervene. There were no apparent visible signs of infection. However, the tenderness in the area of the surgical wound never abated. It should also be noted here that she was not given any special cleanser to use prior to her surgery, as is standard pre-op protocol.

Pat continuously complained about the ongoing tenderness and the lack of improvement thereof. She made phone calls and spoke directly to whomever would listen … the surgeon’s office nursing staff, the implant technician and the surgeon himself during all of her post-surgical office examinations. She and her husband even dropped in, unannounced, to the surgeon’s office and spoke in the lobby with his NP/PA. In every case, Pat was advised that there was nothing to worry about … all patients heal differently. We later found there to be no records, of any kind, for any of the phone calls or the visit with the NP/PA.

On the night of July 18, 2018, Pat developed an extraordinary and, at times, disabling pain in her spine. Having been treated for years for chronic osteoarthritis and two spinal surgeries, she assumed the pain was just another spinal bump in the road. She called her primary care physician who ordered an X-ray, which found nothing.

The pain worsened over the next few days and she developed chills. During a late-night visit to the ER on July 22, 2018, Pat explained to the ER nurse that she had a defibrillator implant. The ER nurse could not find this in her electronic health record. Pat was frustrated that the nurse could not find this in her record, when the surgery itself occurred just four months earlier in that very same hospital. She was admitted to the hospital overnight and released the next day, only to be called that evening to be advised that the cultures had come back with positive results of a staph infection. She was re-admitted the next morning, July 24, to begin what turned out to be several days and nights of testing along with oral and IV antibiotics and pain killers.

The conclusive results of the tests were the existence of massive, systemic, staph and other infections. In addition to them being systemic, the infections had found homes in her surgical implant cavity and on her spine.

That same week, on July 26, surgery was performed to remove the implant. The recovery team had trouble reviving Pat from the anesthetic. It took a lot longer than normal. Once she was returned to her room, she experienced some sort of delirium. The delirium eventually resided. Thereafter, the recovery from the surgery seemed to have gone well.

When the implant was removed, it was noted that not only was the implant loaded with infectious material, but the wire leads that went to her heart were loaded as well. When removed, infectious debris fell into her heart, and later found to have made their way to her lungs.

Over the next week, Pat experienced another delirium episode and she also begin retaining water and there was noticeable swelling in her ankles. On August 2, as she was walking around the IMCU floor, she suffered some sort of pulmonary event. She looked like a woman who was drowning. Dozens of medical personnel were quickly dispatched to her bedside, including a pulmonologist from the ICU. Her breathing was somewhat normalized. The ICU physician ordered that she be transferred to the ICU immediately.

And then it began … sepsis, more delirium and pulmonary trauma, cardiac issues, kidney failure, three admittances to the ICU with two involving intubation … all accompanied by a consistent, downward spiral of her strength, stamina, appetite and cognition. During a family meeting in her ICU room on August 22, where palliative care, cardiology and pulmonology teams were present, Pat was adamant that she was furious this had happened to her. She told the team in no uncertain terms, “I do not want to die”. She told the medical team to “do whatever it takes”. They agreed that as long as she was willing to fight, they’d keep fighting with her. It should be noted that this was the last time the family had spoken to the cardiology team.

Finally, after nearly seven weeks, Pat’s infections were all arrested. Her heart and lung capacities were diminished, but stable. The antibiotics were stopped and eventually, all other tubes were removed. Kidney dialysis was ongoing. Though clearly weak and utterly exhausted, she looked like a patient ready to be on the mend.

On Thursday of Pat’s sixth week in the hospital, the nephrologist paid her a visit. He approached the foot of her bed and told Pat and her family that she was in “miracle territory.” The next day he explained to Pat’s daughter that on paper, she should not still be alive. He went as far as to tell her “she is not so sick that she’s going to die in this hospital.” She was scheduled to start in-patient rehab the following week, with the goal of her being home by Halloween to accompany her grandchildren trick-or-treating for Halloween.

Some 48 hours later, just two days prior to going to rehab, Pat died peacefully in her sleep of heart failure.

We all agree, Pat’s inspirational fight to beat the infections and associated organ and system failures, exhausted her to the point she had nothing left. She won the battle, but lost the war.

What plagues us now, are the unanswered questions:

Why did the pre-op protocol not call for her to use a special cleanser prior to surgery?
Could a blood culture have been performed to ensure no infection existed in her body prior to surgery?
Could sepsis have been detected earlier?
Why had the cardiology team not spoken to the family for over 2 weeks prior to her death?
Why do the protocols seem to be aimed at those who will fit into the fat part of the bell-curve, leaving those on the edges vulnerable and likely to become just statistics?
How could the post-surgical, healthcare professionals not have seen the warning signs once Pat called it to their attentions … multiple times?
Why is there no record of those multiple contacts to her cardiac electrophysiologist?
When she called her PCP about the pain in her back, wouldn’t it have been useful for him to perform a blood culture then, in addition to an x-ray?
Had those professionals taken the extra step to run a post-op blood culture for infection before it was too late, might Pat still be alive today? Even a few days might have made the difference.

Pat was a fighter her entire life. She fought this illness with everything she had, and she never lost her will to live. Her family honors her memory every day to keep her legacy alive, especially for her young grandchildren.

Audrey Curtis

Patient Stories

Audrey Curtis

Audrey Curtis was a recently retired credit controller. After several years of cardiac symptoms, such as shortness of breath, investigations revealed she needed her aortic valve replaced.

Audrey was admitted to the hospital on 29^th March 2017 for her operation scheduled for 30^th March for replacement of aortic valve.

I spent 48 hours in intensive care postoperatively and then moved back to the ward.

‘The nightmare’:

It started with vision of a television screen and a group playing hard rock music which I hate. It continued to increase in volume and the screen appeared to have become 3-dimensional and was protruding towards me. I can remember wanting the music to stop and believe I was calling at it to stop. Then it switched to me starting to panic as I believed I had been kidnapped and tied up with rope. I became very frightened and wanting to escape and began frantically pulling at the rope that I had been bound with. Instead of rope, I had been pulling on the tubing attached to my body at the time of the operation and ripping them out, including the catheter – until I had removed all of the tubes. I remember having the sensation that I was in a very large ward with lots of beds lined up quite close together. I was in a state of panic by this time, when I realised what I had done and rang the bell for the nurse. I felt that I kept ringing but no one came. Eventually when the nurse came I felt terrible about what I had done and continued apologising to the nurse. The nurse tried to assure me not to worry as this sort of thing happens sometimes. I cannot remember if I was given something to calm me down, but feeling quite alone when the nurse returned to her duties. I cannot remember anyone discussing this incident with me, no nursing staff raised the issue other than the one who answered my initial ringing of the bell.

Prior to the nightmare, my Granddaughter Chelsea visited with other family members when I was on the ward. Chelsea remembers me commenting that a gorilla had come up in the lift with her and then asked why Chelsea had pink and yellow spots all over her body?

Impact:

I feel apprehensive about undergoing any further surgery, so unless it was something serious, I wouldn’t want to go through it again for risk of this happening again.

It was a terrifying experience and has taken me until recently (more than 18 months) to ‘get myself back’.

I would be happy to help in any way I can to stop this happening to someone else.

Katherine Kay

Patient Stories

Katherine Kay

As told by Kathy's daughter, Patti Parker

It was a day in March when my mom, Kathy, casually mentioned to me that she had been having bloody urine for the past few weeks. I asked her if she had notified her physician and she casually stated, “No, I will just watch it.” After much discussion, I convinced her to call her doctor and make an appointment to discuss the issue. The appointment was made for the following week and I went with her. We sat down in the exam room and as we waited I had an uneasy feeling in my gut. Maybe it was fear or intuition, but it was heavy. Her doctor, whom she had been going to for over 20 years, came into the room. After discussing symptoms, he said, “it sounds like you have Renal Cancer. I will write a referral and get you into a Urologist to do some tests.” Immediately, I went into my RN role and started asking questions and wanting answers. In that moment, all I heard were the words “cancer” and “wait”; either for insurance approval or for appointments available. Her doctor saw the frustration on my face, and knowing I worked for Kaiser, he turned to me and said, “Patti, this isn’t Kaiser. We don’t give the one-stop-shop, rapid appointment scheduling as Kaiser does.” He turned to my mom and said, “Kathy, here we have 1 urologist for 5 hospitals; At Kaiser, they have 5 urologists for 1 hospital. Your daughter knows Kaiser and as much as I don’t want you to leave my practice, I think you will get the care your daughter is looking for if you join Kaiser.” I was thrilled to hear this, however, my mom felt loyalty to staying with this group, especially since she was a RN and worked there for several years prior to retiring. After careful consideration, my mom became a Kaiser member on April 1^st.

The entire process moved rather quickly. Mom was seen by a Primary Care Physician, scheduled with Urology and completed several tests and procedures within 2 weeks. The diagnosis came back being positive for Left Kidney Ca. and on May 3^rd, she underwent a Left Ureteronephrectomy.

During recovery, mom developed some delirium from anesthesia. For the first time during this ordeal, I saw my mom as my mom, and not a patient. I was scared. She was confused and had what I thought to be a painful grimace on her face. As I sat with her in the recovery area, I sobbed. A PACU RN and a co-worker comforted me. Although I had seen this type of side effect with patients I have cared for, it felt so foreign to me. I was completely powerless! After a few hours, she was transferred to a Med/Surg floor to begin her post-op recovery. My brother and I alternated staying at her bedside for the next couple of days with support from our other siblings and friends. I noticed my mom having a stoic expression on her face whenever she repositioned. I asked her if she was in pain, and her answer was “a little bit, but I am fine. The nurses have sicker patients to care for.” This was a common response from my her. She often said, “if it’s not bleeding and still has a pulse, it can wait”. Maybe she came to this belief after witnessing morbidity and mortality as a RN or maybe it was generational. Either way, my mom would not complain until it was too late.

On post-op day #3, as I was headed back to the hospital, I received a call from my brother Pete. He said, “there’s a lot of people in mom’s room. The nurse here said mom triggered and alarm and a nurse who was monitoring her called him.” As my brother spoke, I realized my mom had triggered an Advanced Alert Monitor (AAM) response. Just a few months back, I transferred from Kaiser Sacramento and took a position as a Quality Nurse Consultant with AAM. My position allows me to use my critical care nursing skills to assess patients virtually. When I receive an alert, I call the Rapid Response Team (RRT) nurse and together we discuss the patient and look for early signs of deterioration. The RRT team, which consists of an ICU RN, a Physician, the House Supervisor, current care team and often a Social Worker arrive to the patient’s bedside and proactively intervene, thus preventing potential decline. As I entered my mom’s room, I saw the team at her bedside. They were communicating to her and my brother about the alert and the next steps. My mom’s vital signs had worsened. She had been hypotensive post-operatively, however now she was now tachycardic and became hypoxic. The team decided to send her for a STAT US, VQ scan and CXR to look for a PE and Pneumonia. A couple of hours later, the results were in: The US and VQ Scan were negative for a PE. Her CXR showed early infiltrates suggestive of pneumonia. She was started on IV antibiotics and transferred to the Telemetry Unit for observation.

Despite my mom’s initial reservations to join Kaiser, she now tells everyone and anyone of her “wonderful, impressive experience with Kaiser, and everyone should choose Kaiser.” She is a strong patient advocate! The entire process was reassuring to my family; it involved all of us, it allowed for open communication, but most importantly, it may have saved my mom’s life.

My mom and our family felt it was important to share this story. We believe, without a doubt, that Kaiser’s ability to bring Virtual Patient Monitoring to patients, saved her life. We are grateful to Kaiser for innovating medicine and providing quality care throughout every step of this course.

Irene Young

Patient Stories

Irene Young

As told by Irene's Daughter, Catherine Young

In 2010, my mother was in a residential care home. She had moderate vascular dementia and, I now realize, a delirium. She was disabled because she had no hip joint and had become doubly incontinent. I had done my best at home, but it became clear that she needed more professional support than I was able to give. She arrived on the 13th of July. 2 medication cycles were correct but not the third. On the 13th of September, I had become concerned over her deteriorating condition. It transpired that 2 patient records had been mixed at the doctors’ surgery. 12 changes had been made, 9 taken off and 3 added. Steroids were missing and 2 eye drops for glaucoma added. No-one had noticed, not the doctors, not the pharmacists and not the care home. I raised the alarm because of her withdrawal and skin reaction around the eyes. We were lucky that the medications involved were not more serious. We were lucky that I visited every day. There are many concerns here, but what health professionals have to realize is that residents need protecting from the care staff. In this home they did not employ nurses. I moved her and she lived for another 3 years.

Relevant Statistics

Up to 65% older post-operative patients suffer some form of delirium following a surgical procedure, especially if requiring ICU admission¹

Marcantonio, E. (2017). Delirium in Hospitalized Older Adults. New England Journal of Medicine, 377(15)

It is estimated that up to 40% of hospital-related episodes of delirium are preventable²

Inouye, S., Westendorp, R., & Saczynski, J. (2014). Delirium in elderly people. Lancet, 383(9920)

The cost of an episode of acute care is increased 2.5 times by the occurrence of delirium, increasing the cost of healthcare in the United States by over $125 billion dollars every year³

Inouye, S., Westendorp, R., & Saczynski, J. (2014). Delirium in elderly people. Lancet, 383(9920).; Brown, C. H., Laflam, A., Max, L., Lymar, D., Neufeld, K. J., Tian, J., … Hogue, C. W. (2016). The Impact of Delirium After Cardiac Surgical Procedures on Postoperative Resource Use. The Annals of Thoracic Surgery, 101(5), 1663–1669. doi: 10.1016/j.athoracsur.2015.12.074

10% to 30% of hospitalized patients age 65 and older have an episode of delirium during their stay⁴

Arnold, E. (2005). Sorting Out the 3 D’s: Delirium, Dementia, Depression. Learn How to Sift Through Overlapping Signs and Symptoms So You Can Help Improve an Older Patient’s Quality of Life. Holistic Nursing Practice,19(3)

Delirium is characterized by altered mental status and hallmarked by a fluctuating and fleeting attention span⁵

Brown, L. J., Fordyce, C., Zaghdani, H., Starr, J. M., & Maclullich, A. M. (2010). Detecting deficits of sustained visual attention in delirium. Journal of Neurology, Neurosurgery & Psychiatry,82(12), 1334-1340. doi:10.1136/jnnp.2010.208827

Delirium is defined as an acute change or fluctuation in the course of a patient’s mental status, plus inattention and either disorganized thinking or an altered level of consciousness⁶

Inouye SK, van Dyck CH, Alessi CA, et al: Clarifying confusion: The confusion assessment method. Ann Intern Med 1990; 113: 941–948

Many healthcare professionals acknowledge the severity of delirium in patients and many even admit to its misdiagnosis, confusion with other conditions, or mistreatment⁷

Ely, E. W., Stephens, R. K., Jackson, J. C., Thomason, J. W., Truman, B., Gordon, S., . . . Bernard, G. R. (2004). Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: A survey of 912 healthcare professionals*. Critical Care Medicine,32(1), 106-112. doi:10.1097/01.ccm.0000098033.94737.84

Early identification of delirium in patients can avoid inappropriate early discharge, thereby leading to successful outcomes through extended observation and care⁸

Breitbart W., Bruera E., Chochinov H.& Lynch M. (1995) Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer. Journal of Pain and Symptom Management 10, 131–141

“Delirium is associated with multiple serious outcomes including increased morbidity, length of hospital stay, healthcare costs, institutionalization, and mortality”⁹

Greer, N., Rossom, R., Anderson, P., MacDonald, R., Tacklind, J., Rutks, I., & Wilt, T. (2011). Delirium: Screening, Prevention, and Diagnosis – A Systematic Review of the Evidence. Europe PMC.

“Patients who are admitted to the hospital with delirium have mortality rates 10% to 26% higher than similar patients without delirium at the time of admission”¹⁰

10.

Goldstein, N. E., & Morrison, R. S. (2013). Evidence-based practice of palliative medicine. Philadelphia: Elsevier/Saunders.

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Actionable Patient Safety Solutions (APSS)

8A Post-Operative Delirium in Older Adults

Executive Summary

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Related Patient Stories

Pat Denton

Audrey Curtis

Katherine Kay

Irene Young

Relevant Statistics