Discharge When Medically Ready.

QUALITY PROBLEM: The timing and pace of patient discharges are not level-loaded throughout the day at many institutions including ours, an academic medical center and adult Level I trauma center located in Milwaukee, Wisconsin. INITIAL ASSESSMENT: Only 4% of patients were being discharged with rooms marked dirty by 11 AM at our institution. CHOISE OF SOLUTION: We put together a multidisciplinary team of approximately 30 stakeholders to develop a revised process that focused on coordination of discharge activities, plan of care awareness among team members, and communication with patients and families. IMPLEMENTATION: The discharge process was piloted and iteratively adjusted on a single medicine floor. EVALUATION: Our interventions made a noticeable impact on median room "ready to be cleaned" (RTBC) time without having an adverse impact on length of stay. RTBC improved by a median of 39 minutes (P = 0.019), and the proportion of rooms ready to be cleaned by 11 AM increased from 4.19% to 8.13%. LESSONS LEARNED: Having a multidisciplinary team participate in the evaluation and development of a new process was critical. Additionally, implementing solutions on a single unit allowed for rapid iteration of changes.

Improving the Validity of Nurse-Based Delirium Screening: A Head-to-Head Comparison of Nursing Delirium-Screening Scale and Short Confusion Assessment Method.

BACKGROUND: As part of a multicomponent delirium prevention protocol the Confusion Assessment Method (Short-CAM) was introduced to nursing as the standard delirium screening instrument on the general medical units. Despite significant educational efforts, quality monitoring revealed poor sensitivity with the use of Short-CAM. OBJECTIVES: To compare the validity of the Nursing Delirium Screening Scale (Nu-DESC) and Short-CAM on general medical units and to explore the impact of delirium education on the successful implementation of delirium screening tools. METHODS: In this quality improvement project, both Nu-DESC and Short-CAM were scored by nurses on 2 general medical units, per standard practice. Two blinded physician-raters determined delirium diagnosis in 192 patients on these units on 8 separate days, utilizing the Diagnostic and Statistical Manual of Mental Disorders-5 criteria as the reference standard. Sensitivity and specificity of both scales were calculated. RESULTS: Thirty-five of 192 patients (18.2%) were suffering from delirium on the day of assessment. The Short-CAM scored positive for 3 (1.6%) patients and the Nu-DESC for 50 (26.0%) patients on the same day as the physician-raters assessment. Sensitivity and specificity were respectively calculated at 8.6% and 100% for the Short-CAM and 77.1% and 85.4% for the Nu-DESC. There was no statistical difference in sensitivity and specificity of the Nu-DESC on the units regardless of the level of preimplementation delirium education. CONCLUSIONS: The Nu-DESC was shown to be an easy-to-deploy delirium-screening tool on general medical units with improved sensitivity when compared to the Short-CAM.