Accountable care demands that healthcare providers meet quality metrics while managing the total cost of care. As we move away from fee-for-service reimbursement models to accountable care, it is more important than ever to use best practices and evidence-based medicine to reduce variations in care and achieve optimum outcomes.

At Saint Francis Medical Center, we assessed our clinical care strategies for efficiency and effectiveness. To stay competitive, we decided to focus on our specialized Critical Care Units (CCU) where the costs and risks remained high. We zeroed in on delirium to reduce patient complications and length of stay, and to improve our clinical and financial performance.

The Clinical Condition: Delirium

A confused, disoriented state, delirium causes complicated clinical and financial challenges for critical care patients and providers. Often undetected, the condition affects up to 80% of patients in intensive care, and costs between $4 and $16 billion annually in the U.S.1 The longer that patients are delirious, the greater the chance for increased morbidity, mortality, prolonged hospital stays and cognitive dysfunction.2

These statistics prompted the Center for Medicare & Medicaid Services (CMS) to propose delirium as one of the hospital-acquired conditions (HAC) for which they will not pay. Although it has not been added as an HAC yet, we believed that by proactively monitoring for delirium, we could achieve better outcomes and protect reimbursement for episodes of care.

Implementation Plan

Historically, the general approach to stabilizing critically ill patients has been long periods of immobility and bed rest, often with mechanical ventilation – which increases the risk for delirium. To achieve our goal of proactively addressing patients at risk for delirium, we conducted an evidence-based review of clinical practices for delirium management.

The protocol we’ve implemented is specific to critical care and is based on the Agency for Health Research and Quality’s (AHRQ) Clinical Practice Guideline for delirium. This interdisciplinary project incorporates the ABCDE bundle, which includes awakening and breathing trial coordination (respiratory therapy), careful sedation choice (pharmacy), delirium monitoring and documentation (critical care nurses), and early exercise and mobility (physical therapy) to reduce the incidence of modifiable delirium in the future.3

To implement our new delirium policy and protocol, we conducted bedside and classroom education across interdisciplinary departments to improve clinician collaboration. Now when a patient is admitted to the CCU, we assess their risk of delirium. By identifying patients at risk for the condition upfront, we can assess and document the condition, and provide immediate interdisciplinary consultation and treatment. Delirium assessment continues for all patients throughout their length of stay in the CCU.

An automatic consult is sent to the Pharmacy, Respiratory Therapy and Physical Therapy departments for every positive delirium assessment. We also provide patients’ families with an educational brochure to promote their active participation in the process. As a result, we have experienced fewer complications and delirium-related consequences and costs.

Upon transfer from the CCU, we communicate essential information regarding the patient to the transitional site of care. This communication promotes care continuity and improved patient outcomes.

Tools to Support the New Process for Delirium Management

To support the improvement program, we implemented multidisciplinary tools and processes:

  • Richmond Agitation Sedation Scale (RASS) scores for critical care patients were incorporated into our clinical documentation system to assist caregivers in determining sedation levels.
  • We created an ICU Delirium Chartable Review (CRv) for nursing assessments, and we added revised nursing interventions, RASS scales and spontaneous breathing trial results. Improved communication between the CCU nurse and the respiratory therapist during the trial for patients receiving sedation enabled us to wean them from the ventilator in a safe, timely manner.
  • Real-time care alerts generated automatic consults to Pharmacy, Respiratory Therapy and Physical Therapy departments for every positive delirium screen.
  • Interdisciplinary care team members worked collaboratively at the patient bedside, and through advanced notifications at their workstations, we minimized the risk and potential complications of delirium for our most critically ill patients.


Tangible results

Since the project has been implemented, we have improved clarity, accuracy and continuity for the detection and management of delirium. Within the first 10 months, 23% of all Intensive Care Unit (ICU) patients had positive screenings for the condition, and of those, 100% received immediate interdisciplinary consultations and interventions.

Our efforts have resulted in a reduction of 0.5 days on mechanical ventilation while receiving conscious sedation, which can reduce the length of stay in the ICU. Prompt review of medications revealed the fact that some patients on conscious sedation received minimal pain medication, which led to the revision of the Spontaneous Breathing Trial and Conscious Sedation Policies. Patients achieved mobility earlier due to the improved timing of physical therapy consultations.

We believe our evidence-based, standardized approach will be repeatable for other patient populations. The approach reinforces the importance of providing ongoing and comprehensive physical, functional, and psychosocial assessments that are unique to every age group.

Early detection, combined with multidisciplinary interventions for delirium can minimize the risk of complications for critically ill patients. As a result, Saint Francis has improved patient safety and outcomes, and we’ve reduced costs by reducing length of stay. Promoting quality of life for patients and their families also helps to protect the business health of the hospital.

1Delirium in the Intensive Care Unit: Assessment and Management, Pun, Brenda T.; Boehm, Leanne, AACN Advanced Critical Care. 22(3):225-237, July/September 2011.
2 Ibid.
3 Ibid.

Saint Francis Medical Center was a finalist for McKesson’s 2013 Distinguished Achievement Award for Clinical Excellence. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.

Results Achieved in First 10 Months with Delirium Protocol

  • 23% of all ICU patients had positive screens for delirium
  • 100% received immediate interdisciplinary consultations and interventions
  • Reduction of .5 days on mechanical ventilation while receiving conscious sedation, which can reduce ICU length of stay
  • Patients achieved earlier mobility 
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About the author

Linda Heitman is a professor of Nursing and an Advanced Practice Nurse consultant. Her areas of expertise focus on adult health issues (cardiovascular) and critical care. In her Nursing faculty role, she teaches critical care to undergraduate students and pathophysiology to graduate students preparing for an Advanced Practice Nursing role. She also serves as a reviewer for The Journal of Cardiovascular Nursing. Dr. Heitman has a PhD in Nursing from Saint Louis University. She is certified as an Adult Health Clinical Nurse Specialist with the American Nurses Credentialing Center (ANCC).

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About the author

Barbara Mueller, RN, BSN, CCRN, CSC, has been with Saint Francis Medical Center for more than 30 years. Currently she is project leader for the Clinical Information Systems department and for Saint Francis’s initiative to improve delirium management. Previously, she received the Leader of the Year Award from Saint Francis and served as the ICU and inpatient acute dialysis manager. In her role, she is responsible for managing its use of McKesson’s clinical software solutions.

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About the author

Lisa M. Job, RN, MSN, ACNS-BC, is the Clinical Nurse Specialist in the Cardiac Intensive Care Unit at Saint Francis Medical Center. Lisa also has served on the faculty of the Medical-Surgical Department at Southeast Missouri State University in Cape Girardeau, Mo. She graduated with a Master’s Degree in Nursing, Clinical Nurse Specialist in Medical-Surgical Nursing. Lisa is a Board-certified Clinical Nurse Specialist in Adult Health by the ANCC.