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.

Public Health Relevance

Nurses play a critical role in medication management through their responsibilities for medication administration, reviewing orders, and monitoring for therapeutic effectiveness and adverse effects. Acute mental status changes are high priority clinical condition that requires an integrated team approach. Cognitive support for nurses and for a shared situation awareness of the patient is lacking. This proposal aims to design and implement a 4-pronged intervention designed to enhance shared awareness and support nursing information needs, including electronic white board displays, text extractions of mental status narrative from notes, an alert mechanism to guide staffing and assignment decisions and info-buttons available to nurses at the point of medication administration. Methods will start with qualitative assessment of information needs to design and implementation.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Special Emphasis Panel (HCR3)
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VA Salt Lake City Healthcare System
Salt Lake City
United States
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