Can you do anything to PREVENT delirium from developing in the ED?
Do what you can to minimize delirium in your ED:
- provide food and drink
- promote mobility
- minimize restraints
- maximize familiar faces and orientation
Many of our older patients stay in the ED for >8 hours. They are at significant risk for developing a confusional state especially if they:
- Already have some dementia
- Are sleep deprived (the patient in the hallway over night)
- Are immobilized (an O2 sat monitor and a Foley may not seem like restraints to you but for sure that patient is not going to get out of bed – do they really need those interventions?
- Are visually impaired (the glasses were left at home)
- Are hearing impaired (EMS didn’t bring the hearing aid for fear it would get lost)
- Are Dehydrated (the only patient who needs to be NPO is one who is going to have surgery within the next 6 hours or who is actively vomiting – but how often is NPO the default position in your department?)
Discussion: Preventing Delirium
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We can make more pleasure situations for these older patient ,showing if imaging
Or nature imaging ,
difficult when boarding is high and so many in hall and sleep deprived.
Difficult when you need to keep the patient under monitoring
difficult when boarding is high and so many in hall and sleep deprived.
one on the cause of low BGL is not giving food to patients and ignoring their basic needs
this assessment will be helpful for better treatments
agree with this reminder
preventing delirium or keeping it from getting worst is going to be key in gaining control of the patient and therefore getting proper treatment. delirium is a challenge on any given day but escalation has to be avoided if possible.
Completely forgot about nutrition and and hydration being KEY in preventing delirium, thanks!
some of them are inevitable,but could be contributing to the patient’s pre existing delirium
Great info. Will surely implement in my patient care
kepp someone around who knows the patient
offer an environment where the patient is oriented, know when it is day and when it is night, avoid changing the personnel assigned to the patient too many times, and keep them oriented in time and space.
Ethical dilemma between restraint free vs patient safety.
very true statement you made
This part is very important. How many times is a patient in an ED and they have been kept NPO too long. No food or drink. Why? A much better plan MUST be put in place for older adults . There is no excuse for this.
Good points posted
Ensure well lighted rooms as well
Simple, great ideaa
agreed, be vigilant
Frequent orientation questions needed.
Case management can help
Incorporating social services into ED services can help with some of these issues.
We have them just for our ED only and yes, they are Godsent!
Agreed. PT in emergency would be so beneficial to have these patient’s up and moving. Also it is a worry that devices such as hearing aids and glasses or even walkers become missing, so I understand why EMS doesn’t bring them, or family take them home; however, they are essential to the patient.
Be proactive …
Not all patient need to be NPO. Good point about food and drink.
very good point about diet status and how the default is usually NPO.
Recognizing delirium is the first step
good points on prevention
good to know ways to prevent delirium in the ED
these slides are very helpful
Agree with everything- great points
All good points especially hydration it is easy to forget to offer food and drink to patients in ED because of the patient flow fluctuation.
without proper hydration, infections can result, which can also cause confusion. great tips
must be aware of each clients individual needs
Hallway medicine is a huge problem in my province!!! So sad
basic preventative measures good idea for these patients, often in ER long hours and sometimes left alone or in isolation.
we have lots of elders in our hallways ALL the time…need a much more pro active approach to delirium prevention
Definitely feed patients, especially if have been in ER several hours before reaching floor or unit. Unless having surgery (uptodate says can eat up to 2 hrs prior to surgery) feed patient, let them have something to drink, will make life much simpler.
great points, especially the glasses, hearing aides and food
we dont board in my ED for 8 hours typically
Food & drink is the big issue. everyone is default NPO on arrival and frequently no one checks to see if they need to stay that way.
simple but useful preventative measures.
Being comfortable, as possible in a busy department, and having a small meal or snack is normalizing for a patient who already feels unwell. Having food,fluid and feeling warm creates a physical environment for the body’s cells to function better. I have also found that having a family member or other person recognizable to the patient promotes patient well being and makes their hospital stay less frightening
Providing an environment that feel safe. This helps to minimize any other stresses the patient may have, as well, to continuously monitor fluid intake and output and ensuring nutrition is maintained.
This is so true
Great tips but difficult to implement in practice
helpful points. thanks
We are so afraid of patients falling that we do everything in our power to take away mobility. How much harm are we doing with this approach?
Patient who come to ER are often labelled ALOC and not delirium
most elderly patients from NH is dehydrated..they do not get the fluids they need to ward off delirium
In an ideal world all patients would be assessed rapidly, would be provided with appropriate hydration and nutrition and placed in a restful environment, unfortunately its more like a battle zone in our department most of the time.
My role as a paramedic in the field is quickly ruling in and ruling out to give the ER a heads up. We gather all the information, including BGL and mental status.
Don’t forget to check a glucose
make sure they eat and drink well. take their meds on a regular basis.
Refreshing to hear preventative measure that should shift the practices such as nothing PO but unfortunately unrealistic unless our ED’s coach family and they are present and willing to provide these measures as manpower is stretched to the limit currently.
– Ask family or friends to stay with patient or try early/safe discharge to facility or home
– Encourage usage of eyeglasses and hearing aids
– Encourage oral intake if not nil by mouth and adequate hydration
– Encourage mobility by minimising restraints such as monitoring devices and IDC
– Adequate light in room, avoid noisy equipment such as beeping monitoring machines
MOST ELDERLY PATIENTS IN ED ARE AFRAID OF BEING INCONTINENT IN THE BED. ANTICIPATE THIS NEED AND TAKE THE PATIENT TO THE BATHROOM OR GET SOMEONE TO DO SO.
DIM OR MINIMIZE BRIGHT LIGHT
That accounts for all our elderly cohort of patients who attend ED.
promote mobility, and maximize familiar family faces to make them feel safe and comfortable.
I think it is a very good idea to make a policy in ER of minimal restraint in elderly and early mobilization except when the elderly is at high risk of fall. The elderly can be offered a glass of water if he is not on NPO order.
inability to get patients in and assessed quickly is a regular difficulty in our department and is a major challenge with respect to the above concerns
wow, we need more nursing support to attend to these patients properly, so that their ER visit doesn’t make them worse
I’ve found that avoiding excessive wait times in the ER and ensuring a family member is with them at all times is helpful. I agree that ensuring they receive regular meals and hydration during their time in the ER is essential.
Have seen many admissions from Emerg who are bordering on dehydration unless they have an IV
Involving family in care is helpful for all involved and significantly better for the patient overall.
I find utilizing the family in these situations extremely helpful
Try and see these older patients as quickly as we can. Have family members or care givers stay with the patient if at all possible. Orders all necessary tests through order sets to avoid delays. Educate other health care members to avoid sending their patients to the emergency room when at all possible-home visits or office visits or clinic settings.
Have a high index of suspicion of acute event in these patients and think of mobility issues as well as self care issues. Many live in circumstances that they can not sustain due to financial and other issues. Collateral history important as well
The ED is a horrible environment for patient with dementia/delirium and extended stays not only increase morbidity but also increase LOS in the hospital. Hospital administrators must be educated that this is not an ED issue but rather a hospital issue and should develop policies with appropriate sticks and carrots to reduce ED LOS. The hospital would not tolerate the increased mortality associated with significant delays in getting STEMI pts to the cath lab; nor should it tolerate prolonged ED LOS for elderly (all) patients.
Great answers. Keeping the noise level down in the ER can be effective.
Simple solutions – small investment for strong ROI
Promote comfort and allow visitors to help with familiarity.
There are efforts that can be made to make the patient more comfortable in the ER. Food/fluids, warm blankets (its always cold for patients
Especially an uncomfortable stretcher
WILL KEEP ALL OF THIS IN MIND IN THE FUTURE
Offload delay is the real killer!
All valid issues, particularly wait times
food water exercise communication tlc calm approach and reassurance
Avoiding confusion in older people in the ED is an art – the art of caring. Keep them well informed. Feed them and water them. Let there families stay with them. Keep them mobile and comfortable (make sure they can get to or use a toilet when necessary!). Most of all, when waiting times are long, keep talking to and listening to patients and relatives.
I FIND YOUR COMMENT OF “FEED THEM AND WATER THEM” DISRESPECTFUL OF THE ELDERLY. WE WILL GET THERE SOON ENOUGH AND I WOULD NOT WANT TO HEAR A HEALTH CARE PROFESSIONAL IMPLY THAT I AM A FLOWER.
great list of things to advocate getting for our patients in the ER.
do not underestimate severity
do not assume older patients have baseline cognitive impairment and look for change
Calm approach with clear communication by health care workers, especially in busy environment is very important
better places to take the sun
pacienes keep in quiet places and comfortable with caretaker relative or acquaintance and try to prevent complications of underlying diseases
Frontline have risk factors for identification
Easy to minimize delirium in the ED
Comfort, private time, food which you like, and drink which gives small pieces freedom
food, drink, washroom, familiar face, toilet, chance for sleep- it’s what we all need to keep sane.
Glasses, hearing aids, familial faces around, proper feeding, pain control can prevent delirium
This is helpful.
definitely notice sleep deprived patients become delirious, especially when in hallways. try to move to quiet, dark room if possible for sleep overnight
Diet, oral care, sedation, least restraints, safe mobility can all help with orientation and comfort.
I agree with all of these. I also find in emerg that patients that have to stay in hallway stretchers are at high risk because of the constant stimulation
Agree with the food part,patient spent long hours in ER and missing a meal is very common especially with seniors.
I agree regarding the basic necessities: Food, Drink, warm blanket and access to the bathroom.
the ER is not the place for an elderly demented patient. the staff do not know them and do not have time to provide what they need.
It may not be the “ideal” place for elderly demented patients — however if that patient has a perforated bowel, an MI, or a tri-malleolar fracture, then it really is the “only” place for them. Given that reality, these are some strategies that can minimize the harm done during a prolonged or even short ED stay. Get rid of the restraints; feed; fluid; mobilize as much as possible; maximize sensory stimulation; minimize pain.
Yes Don you are so right ! My thoughts explained…many residents are sent to ER for non emergent care, or care that could be provided in a much safer place; their home, whether LTC or residential. A home visit reduces many risks including those mentioned and not to forget the psychological stress and anxiety of an unfamiliar environment. Offering care in house, I believe is; quality care, it reduces stress and chance of infection or fracture, dehydration and skin ulcers not to mention cost effectiveness for both the health care system and the family paying for transportation to get the resident and their wheel chair home!
I couldn’t agree more!
all he wanted was a POP and settled down nicely totally agree food and drink the basics
“Feed the patient” is anI had an excellent policy. Here is a funny anecdote about some unintended consequences… I had an elderly schizophrenic patient who would call 911 when she got hungry hoping to be transferred to MSH ER for soup and a sandwich. Starting MOW with daily hot meals and sandwiches delivered to her at home greatly reduced her trips to ER!
Any body frustrated with hospital not providing food in the ER to pt.
Not all the time but woa be tided the poor patient who arrives at 6 pm (after supper) and requires a 4 hour work up for their delirium – there is no way the kitchen is going to give away any free food!
Great comment! In our department we have worked to develop a “feed the patients” policy — where the default position is “yes you can eat” unless an MD has specifically put an NPO order on the chart. We also have a supply of sandwiches, re-heatable soup, and juice in the fridge. And have done a lot of eduction with the nurses that feeding older patients solves more problems than it causes. Google IPPOD (InterProfessional Prevention of Delirium) or visit http://stopdelirium.com/
I am in complete accord with your comment
agree with food and drink that is appropriate to patients ability to chew and swallow, glasses hearing aids on board not at home, quiet area where they can sleep, push fluids po or iv if indicated
This is probably the area where Emerg physicians can be the most proactive and effective in promoting better care for older patients. Often something as simple as writing “DAT = diet as tolerated” or even “Food please” makes all the difference between a hungry dehydrated patient and a functional one.