Beyond Grand Rounds: A Comprehensive and Sequential Intervention to Improve Identification of Delirium

Traditional medical grand rounds have been considered the standard for physician training and continuing medical education (CME). Grand rounds originated in postgraduate medical training as the primary means of imparting new information (Hull, Cullen, & Hekelman, 1989). This time-honored model of education was patterned after undergraduate medical education and based upon a belief that gains in knowledge lead to improvement in physician practice and, in turn, to improvement in patient outcomes (Davis et al., 1999). More recently, the idea of using solely didactic CME activities to effect practice improvement has been called into question (Davis et al., 1999; Van Hoof, Monson, Majdalany, Giannotti, & Meehan, 2009a). Although they may change elements of competence, such as knowledge, clinical skills or attitudes, didactic interventions alone consistently fail to change performance of health care providers or improve health outcomes (Bellolio & Stead, 2009; Forsetlund et al., 2009; Greene et al., 2004). A recent Cochrane Review indicated that interventions using an interactive educational format had greater effects than those using a didactic format, and multifaceted interventions were better than single interventions (Forsetlund et al., 2009). Also, combining didactic and interactive interventions was found to be more effective than either component alone. Other factors can play a role in educational program success. For instance, buy-in from senior management in health care can play a monumental role in the success or failure of such endeavors. Hospital leadership is pivotal in promoting and sustaining educational programs directed at continuous quality improvement (Bradley et al., 2003; Van Hoof, Monson, Majdalany, Giannotti, & Meehan, 2009b). One study indicated that senior management support (or lack thereof) was viewed as the most important factor determining whether their intervention program was successfully implemented and sustained (Bradley, Webster, Schlesinger, Baker, & Inouye, 2006). Furthermore, the success of the innovation depended on administrative understanding, belief, and support. Recently, issues of patient safety and quality of care have been brought to the forefront and highlighted by the Centers for Medicare and Medicaid Services, as well as by private insurance providers, through the development of reimbursement initiatives that tie payment to quality performance (Bradley et al., 2006). These issues have motivated senior hospital administrators to become actively engaged in improving clinical quality programs. Delirium, defined as an acute decline in attention and cognition, is a common, life-threatening and potentially preventable clinical syndrome in older adults. The development of delirium often initiates a cascade of events culminating in the loss of independence, increased risk of morbidity and mortality, and higher health care costs. Nationally, reported prevalence of delirium on hospital admission ranges from 14% to 24%, whereas incidence during hospitalization can be as high as 56% (Inouye, 2006). Delirium complicates hospital stays for more than 20% of hospitalized patients aged 65 years and older each year and increases hospital costs by $2,500 per hospital stay (Van Hoof et al., 2009a). Importantly, delirium is often unrecognized by physicians and nurses, is often not coded as a diagnosis, and is not adequately managed in the clinical setting. The perceived need to address a clinical topic, along with an assessment of the possibility of change and improvement, is critical to set the stage for an effective intervention. The overall goal of this initiative was to impact the knowledge of clinicians caring for elderly patients through comprehensive education on delirium prevention, recognition, and management. With this aim, the Geriatrics Services Core Team, along with a leading content expert, developed a novel educational strategy as part of an effort to improve the outcomes of hospitalized geriatric patients experiencing delirium. Going beyond the traditional grand rounds format, the educational methods incorporated five evidence-based criteria demonstrated to be effective for CME with a goal of changing clinician practice (Van Hoof et al., 2009a). These criteria were needs assessment, commitment to change, multifaceted intervention strategy, sequencing of educational activities, and interaction. Based on the innovative aspects of this education program, the interdisciplinary focus (involving nurses, physicians, and administrative staff among others), as well as the multicomponent approach in dissemination of information (sequential didactic sessions interspersed with interactive small group sessions), this was named by the authors as a comprehensive and sequential intervention (CSI).