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Nurse Practitioners taking a leadership role in improving the outcomes for older persons at risk of delirium

Delirium is an acute disorder of attention and cognition, often fatal, costing more than $164 billion per year in the USA. Delirium occurs across many specialties and settings: aged care, dementia, orthopaedics, surgery, palliative care and even paediatrics, albeit a dissimilar presentation and management. It is mostly recognized early in the presentation by nursing staff and requires a collaborative interdisciplinary team to manage the complexity of the symptoms. Skilled nursing care can deliver early recovery and reduction in mortality and morbidity.

The role of the Nurse Practitioner as the lead clinician in the detection and management of delirium was described by Burge et al. (2010). The Nurse Practitioner role was outlined as being well placed to provide thorough delirium screening, prevention, detection, and management by using highly developed assessment skills, the ability to prescribe medications and cease inappropriate ones, and to collaborate and consult with the treating team on the medical emergency that delirium can present. The Nurse Practitioner also has a powerful role in delirium diagnosis, management, research, and education, and may have the ability to generate an income stream with accurate diagnosis that can meet the costs of specifically tailored delirium management (Burge et al. 2010).

The delivery of excellence of Nurse Practitioner models of care is underpinned by high quality training, supervision, knowledge and experience which address the Australian National Competency Standards for Nurse Practitioners. Included in one of these standards is the Nurse Practitioner role in leadership and the ability to influence service delivery, sharing clinical knowledge, and improving patient outcomes.

Garrubba et al. (2011) identified the following themes in regard to clinical leadership:

• Influencing peers to act and enable clinical performance
• Providing peers with support and motivation
• Playing a role in enacting organizational strategic direction
• Challenging processes
• Driving and implementing the vision of delivering safety in health care
• Seeking to improve on current practice and using their influence to achieve this

Unfortunately, there is limited published literature on the leadership of Nurse Practitioners within the Australian context; however, a thesis prepared by Barraclough (2014) entitled “Nurse Practitioner Led Services in Primary Health Care in Rural NSW- Two Case Studies’” has described the role and model of service delivery of two established Nurse Practitioners and how they are reforming health care, practice and policy within the local, state, and national arenas. Barraclough’s paper contributes to the body of knowledge about Nurse Practitioners delivering leadership in the workplace.

The best possible outcome for the patient with delirium is guided by any number of Clinical Practice Guidelines. For the purpose of this paper, the American Geriatrics Society: Clinical Practice Guideline for Postoperative Delirium in Older Adults (2014) is referenced and included:

• Multicomponent nonpharmacological interventions delivered by an interdisciplinary team in order to prevent delirium in those older patients at-risk
• Ongoing educational programs provided to health care professionals
• Medical evaluation to identify and manage underlying contributors to delirium
• Pain management should be optimised
• Medications with high risk for precipitating delirium should be avoided
• Cholinesterase inhibitors should not be newly prescribed
• Benzodiazepines should not be used as first line treatment of agitation
• Antipsychotics and benzodiazepines should be avoided in treatment for hypoactive delirium

A number of countries have developed similar Delirium guidelines, for example the United Kingdom (NICE), Australia and Canadian.

Within the context of the Australian landscape, The Agency for Clinical Innovation, NSW Australia Ministry of Health is making an attempt to improve the outcome for patients at risk of delirium who are admitted to the public health system. A clinical redesign methodology is guiding the program and assisting the pilot sites in facilitating workplace change; a number of resources, information brochures, and education modalities are being developed. The model of service delivery is underpinned by seven key principles for the care of the confused older hospitalized person, which include: cognitive screening, risk identification and prevention, assessment, management, communication, education, and a supportive environment. These principles provide a reform platform on which to improve the experience and outcomes for older persons identified at risk for delirium on entering the acute care system. Nurse Practitioners are well placed to carry this reform forward.

Inouye et al. (1999), who has published extensively and made a major contribution to the recognition and management of delirium, reminds us “as a potent indicator of patient’s safety, delirium serves as a useful outcome measure to assess quality of care in hospitalized elderly persons. It is clearly an ‘outcome to be avoided considering that as much as 50% of cases may be preventable” (Inouye et al 1999).

References

Agency for Clinical Innovation 2014. Key Principles for Care of Confused Hospitalised Older Persons. PO Box 699 Chatswood NSW Australia 2057 www.aci.health.nsw.gov.au

American Geriatrics Society; 2014. Clinical Practice Guideline for Postoperative Delirium in Older Adults.

Australian Nursing Midwifery Council. National Competency Standards for the Nurse Practitioner. http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines/nurse-practitioner-standards-of-practice.aspx

Barraclough, F. 2014. Nurse Practitioner Led Services in Primary Health Care in Rural NSW- Two Case Studies. A thesis submitted to the Faculty of Medicine, School of Public Health University of Sydney Australia.

Burge, D; Kent, W; Verdon, J; Voogt, S & Haines, HM. 2010. ‘Nurse practitioners are well placed to lead in the effective management of delirium’, Australian Journal of Advanced Nursing (Online), vol. 28, no. 1, pp. 67-73.

Garrubba, M; Harris, C & Melder, A. 2011. Clinical Leadership : A literature review to investigate concepts , roles, and relationships related to clinical leadership. Centre for Clinical Effectiveness. Southern Health, Melbourne, Australia.

Inouye, S.K; Schlesinger, M.J; Lydon, T.J; 1999. ‘Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care’ American Journal of Medicine. 106(5): 565-73.

National Institute for Health and Clinical Excellence. Delirium: diagnosis, prevention and management; Clinical Guideline 103. London: NICE, 2010. 2. I

Anne Moehead, Nurse Practitioner, North Coast Area Health Service, New South Wales, Australia

Excerpted article as reprint from IPA’s newsletter, the IPA Bulletin, Volume 32, Number 2

Acknowledgements

Acadia Pharmaceuticals Otsuka Pharmaceuticals Cambridge University Press Avanir Pharmaceuticals
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