title: A standardized, bundled approach to providing geriatric-focused acute care.
abstract: OBJECTIVE
  To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications.
  
  
  METHODS
  Pre-post interventional trial.
  
  
  METHODS
  Large academic medical center.
  
  
  METHODS
  Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls.
  
  
  METHODS
  The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults.
  
  
  METHODS
  Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous (IV) morphine in excess of 2 mg, and discharge disposition.
  
  
  RESULTS
  Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio (OR) for the difference of differences = 1.23 (95% confidence interval (CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol (OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine (OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities (OR = 1.18, 95% CI = 1.04-1.35, P = .01).
  
  
  CONCLUSIONS
  An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care.
authors.affiliation: Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Melissa L P
authors.initials: ML
authors.lastname: Mattison
authors.forename: Angela
authors.initials: A
authors.lastname: Catic
authors.forename: Roger B
authors.initials: RB
authors.lastname: Davis
authors.forename: Daniele
authors.initials: D
authors.lastname: Olveczky
authors.forename: Julie
authors.initials: J
authors.lastname: Moran
authors.forename: Julius
authors.initials: J
authors.lastname: Yang
authors.forename: Mark
authors.initials: M
authors.lastname: Aronson
authors.forename: Mark
authors.initials: M
authors.lastname: Zeidel
authors.forename: Lewis
authors.initials: L
authors.lastname: Lipsitz
authors.forename: Edward R
authors.initials: ER
authors.lastname: Marcantonio
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D003661:Decision Support Techniques; D003693:Delirium / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D003695:Delivery of Health Care / Q000592:standards*; D004305:Dose-Response Relationship, Drug; D005260:Female; D015577:Geriatric Assessment; D005853:Geriatrics / Q000379:methods*; D006220:Haloperidol / Q000008:administration & dosage*; D006760:Hospitalization / Q000639:trends; D006801:Humans; D007273:Injections, Intramuscular; D007275:Injections, Intravenous; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008609:Mental Status Schedule; D009020:Morphine / Q000008:administration & dosage*; D015995:Prevalence; D011379:Prognosis; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D009020:Morphine; D006220:Haloperidol
keywords: acute care; delirium; geriatrics; medication geriatrics safety
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