DASH Guidelines Improve Patient Care
In 2008, about 40 percent of BWH patients presented with delirium, alcohol abuse or dependence or a combination of both. And the number of patients who present with suicidal ideation has increased significantly for the past three years.
“To address these important issues, BWH launched a major interdisciplinary initiative to help improve outcomes and standardize the care we provide to these patients,” said Jackie Somerville, PhD, RN, senior vice president of Patient Care Services and chief nursing officer.
Somerville is an executive sponsor of the initiative, along with Stan Ashley, MD, chief medical officer, and David Silbersweig, MD, chief of Psychiatry. “Many clinicians across disciplines have partnered for several years to review and update policies, develop care guidelines and assessment tools for the purpose of improving the care we provide patients who have, or are at risk for, delirium, alcohol withdrawal, suicide and causing harm to others,” she said.
The initiative is called DASH, or Delirium, Alcohol withdrawal, and Suicide /Harm to others. Interdisciplinary teams of more than 60 clinicians developed care guidelines and revised policies for each area of the DASH, which officially rolled out across patient units this fall. Nurses, physicians, therapists, dietitians, care coordinators, pharmacists and chaplains examined scientific evidence and best practices in the care of these patient populations.
“These patient populations may be associated with significant morbidity or mortality if these issues go unrecognized or untreated,” said David Gitlin, MD, director of the Division of Medical Psychiatry. “The guidelines we have developed ensure that our care teams have the tools they need to quickly assess patients.”
The standardized assessment tools include the CAM-M (cognitive assessment method, modified) for delirium, the AUDIT-C for alcohol withdrawal and two questions to assess risk of suicide. If the assessment screens are positive, evidence-based interdisciplinary guidelines are available to assist clinicians in formulating the appropriate treatment plan.
The Audit-C, for example, is a set of three questions that are validated as a screening tool for patients at risk for alcohol withdrawal. This screening tool is included in the nursing assessment. A positive screen prompts a team discussion on next steps for the patient’s care, which includes a choice of two treatment protocols. The first institutes the CIWA-Ar protocol, which is a symptom-triggered regimen. A fixed dose regimen is instituted when the CIWA-Ar is contraindicated.
“The CIWA withdrawal assessment provides specific scores in different areas, like tremors, anxiety, agitation and other dimensions of withdrawal. Having this information enables us to develop the best plan of care,” said Adam Schaffer, MD, hospitalist. “A similar instrument is used at Faulkner Hospital, and it has worked very well.”
The use of these tools provides physicians, nurses and other members of the care team with a common language to talk about these issues. “These tools also make it more likely to prevent crisis situations for patients,” said Barbara Lakatos, DNP, PMHCNS-BC, program director for the Psychiatric Nursing Resource Service. “The guidelines provide a common terminology for interdisciplinary discussion of care, increasing opportunities for early intervention.”
The confusion assessment method, or CAM-modified, enables care providers to assess patients and provides non-pharmacologic and pharmacologic interventions for delirium management. Nursing interventions focus on assessing mental status, decreasing agitation, improving sleep patterns, decreasing stimulation and improving communication for the cognitively impaired patient. Patient and family education booklets are also available for delirium, alcohol withdrawal and suicide/harm.
Specific order sets for suicide/harm prevention include a bundle of precautions to take if patients are at risk for self harm or harming others. “These order sets cover fine points you might not always think about,” Schaffer said.
The feedback from nurses and physicians on the usefulness of these guidelines has been “very positive,” according to Lakatos. “We’re hearing stories from staff on the units about how the use of these guidelines is improving patient assessment, team discussions and patient care.”
As the interdisciplinary implementation steering committee, Gitlin, Lakatos and Schaffer have provided the leadership for the DASH roll out. Andrea Shellman from the Center for Clinical Excellence is also on the steering committee.
Updated information for each area of the DASH is available via the Partners Handbook.