Cognitive Support Informatics for Nurse Medication Stewardship

Va Salt Lake City Healthcare System, Salt Lake City UT

Investigators

Abstract

DESCRIPTION (provided by applicant): ABSTRACT Anticipated Impacts on Veteran's Health Care Nurses play a critical role in medication management through their responsibilities for medication administration, reviewing orders, and monitoring for therapeutic effectiveness and adverse effects. Enhancing evidence-based practice and patient safety is a priority of the VA Office of Nursing Service (ONS). One of the most common adverse drug events (ADE) is an acute change in mental status, including delirium, somnolence and psychosis. In older hospitalized adults, acute mental status changes can be as high as 25%. Monitoring for changes in mental status, initiating preventative actions and mitigating harm requires effective coordination between clinical roles. Project Background Delirium may impact an estimated 14-56% of all hospitalized elderly patients. Because of its fluctuating nature, delirium is particularly difficult to detect and requires increased monitoring and comprehensive documentation. Undiagnosed delirium has been cited to be as high as 32- 67% on general medical wards, 65% in emergency wards and as low as 86% in nursing homes. In one review, nurses' recognition of delirium symptoms ranged from 26% to 83%. Cognitive support for nurses and for an integrated team approach is lacking. Project Objectives AIM 1: Characterize nurses' medication management information needs, documentation and communication processes associated with identifying and monitoring acute mental status changes (AMSC) in inpatient settings. AIM 2: Create a predictive model that integrates AMSC predictors and text descriptors of AMSC with staffing data, to support therapeutic decision-making, resource planning and collaboration AIM 3: Design and test three cognitive support interventions: 1) Info-button decision-support for nurses provided through BCMA (bar-coded medication administration); 2) alerts imbedded in white board display; 3) display of documented mental status changes from the narrative electronic notes. AIM 4: Implement and assess the impact of a comprehensive program for AMSC at two vanguard sites. This program will focus on the: 1) quality of nursing monitoring and documentation, 2) quality of communication between nurses and physicians, 3) rates of delirium, and 4) appropriateness of physician prescribing patterns. Project Methods Aim 1 involves observation, interviews and phone surveys of nurses, charge nurses, physicians and pharmacist as well as chart review to identify medication management information needs. Aim 2 involves developing an ontology, natural language processing methods and a risk model from national data to link risk for delirium with medication and staffing decision-making. Aim 3 consists of design and usability testing. Aim 4 will be a feasibility implementation study assessing the impact of the interventions on two sites and four medical/surgical units.