A Population-Based Care Improvement Initiative for Patients at Risk for Delirium, Alcohol Withdrawal, and Suicide Harm

Background: In a population-based approach, a hospital-wide interprofessional care redesign at Brigham and Women's Hospital (BWH; Boston), was conducted to provide optimal evidence-informed care for patients at risk for delirium, alcohol abuse, and suicide harm (DASH). The initiative involved enhanced screening and the introduction of new care management guidelines and order sets pertaining to the DASH diagnoses. Methods: An interprofessional group from medicine, nursing, and psychiatry jointly led a hospitalwide effort for the improvement of care and outcomes of patients presenting with a DASH diagnosis (delirium, alcohol withdrawal, and suicide harm). The care improvement process consisted of four phases: (1) development of guidelines, (2) implementation/rollout, (3) integration into practice, and (4) sustainability, including ongoing practice development and evaluation. Results: Implementation outcomes were evaluated using eight parameters-acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. Internal billing data and ICD-9-CM [International Classification of Diseases, Ninth Revision, Clinical Modification] diagnostic codes were used to identify the DASH population. Patients were compared pre- and postprogram implementation for fiscal years 2010 through 2013. The average length of stay, reported as the number of midnights in the hospital, remained consistent for DASH patients-9.3-10.0 days (versus 5.3-6.0 days for BWH overall). The DASH readmission rate decreased by 9%-from 15.1% to 13.7%, approaching the overall BWH rate of 13.3%. Conclusion: Close nurse-physician collaboration, including joint leadership and simultaneous rollout for nurses and physicians, contributed to the initiative's effective implementation.