Healthcare Practice Improvement Plan: Addressing Hypoactive Delirium

This healthcare improvement plan focuses on addressing the challenges of delirium, particularly hypoactive delirium, within a healthcare setting. The report identifies gaps in early detection, management, and staff education, emphasizing the need for a person-centered care approach. It outlines an action plan utilizing the Plan-Do-Study-Act (PDSA) cycle to improve practices, including interventions for early detection, creating enriching environments, and educating staff. The plan assesses the clinical practice context using the PARIHS framework to evaluate the readiness for change. The report highlights the importance of recognizing delirium, reducing risk factors, and providing prompt interventions. The plan aims to improve patient outcomes, reduce hospital stays, and enhance the overall quality of care for delirium patients, with the support of family and community involvement.

Running head: HEALTHCARE PRACTICE IMPROVEMENT 1
Healthcare Practice Improvement Plan
Name
Institutional Affiliation
Date

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Introduction
Delirium is a common yet often under-diagnosed or mismanaged disorder. As a result of
the aging population, the disorder is becoming more prevalent (Martins & Fernandes,
2012).Delirium is characterized by an inability to focus, change in cognition, reduced awareness
clarity, and distractibility(Martins & Fernandes, 2012).Delirium, which affects up to 50% of
elderly patients, can be clinically categorized as either hyperactive or hypoactive delirium. This
healthcare improvement plan will concentrate on hypoactive delirium.
Under hypoactive delirium, patients are usually withdrawn and quiet (Schuurmans,
Duursma& Shortridge, Baggett, 2001). Although there existstrategies to detect and diagnose
delirium, the disorder is oftenmisdiagnosed as dementia or not detected at all (Cole, 2005).
Studies by Fick, Agostini & Inouye (2002) emphasize the importance of recognizing and
consequently preventing delirium. Better knowledge and understanding of delirium among
professionals in the healthcare sector can lead to early detection,reduction of risk factors, and
better management in the acute phase (Saxena & Lowley, 2009). It is important to give attention
to the identification of delirium because more than half of the cases are potentially reversible.
Immediately delirium is detected, prompt management and intervention arecritical. Early
patient mobilization, removal of precipitating factors and environmental changes are all
warranted as soon a delirium is recognized. Once detected, delirium should be treated as an
emergency. It’s important to note that delirium causes a lot of distress to the patient, his or her
family, the healthcare staff and even the medical institution.The families delirium patients
describe the behavior and emotional manifestations as disturbing(Mailhot et al., 2014). Proper
care is necessary especially for patients with hypoactive dementia. The hospital and staff should
care for these patients so as to prevent the patient’s prolonged stay or more adverse effects.

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Gaps
Research and treatment gaps exist in the early detection and management of hypoactive
delirium. Hypoactive delirium is characterized by a quiet and withdrawn behavior, and although
its presentation is more common than hyperactive delirium, the disorder is usually
overlooked(Hosker & Ward, 2017). Most of the patients with delirium are therefore often
undertreated or underdiagnosed. It is assumed that delirium is not a problem on its own but
merely a clinical symptom of other pathologies. Furthermore, although there is growing research
on hypoactive delirium, there is no conclusive evidence regarding symptom association and
presentation (Peritogiannis, Bolosi, Lixouriotis & Rizos, 2015 ). A lot of research focusing on
the primary care setting is needed. It is important to regularly assess all patients diagnosed with
delirium for signs of hypoactive delirium. Diagnosing delirium earlyon is necessary so as to
enable the patient and supporters to understand and accept the changes soas to plan for the
future.
Providing an enriching environment to patients with hypoactive delirium is
important.Delirium is usually treated through combining the treatment of presumed underlying
cause and by optimizing the patient's conditions. This treatment of deliriumshould, however,be
supplemented by initiating therapy and person-centered care(Hosker & Ward, 2017).To facilitate
their recovery, the patients need support from both their families and healthcareprofessionals.
Due to the symptoms of their disorder, patients with delirium are often stigmatized.
Another critical gap in relation to hypoactive delirium manifests in the educating the
medical staff. Professionals and care staff who deal with delirium related cases quite
oftenmisdiagnose delirium patients. Measures must be taken to sensitize the staff on ways to
detect the onset of delirium at the early stages. Patients with hypoactive delirium due to their

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characteristic withdrawal are easily ignored. Without proper care mechanisms, these patients
may end up staying in hospital longer or even agitating their symptoms.
Person-centered care
In relation to delirium patients, person-centered care is an approach by a medical
institution that treats the staff, patients and their family as partners in developing and
administering care to meet their needs. It involves considering what the people desire and want.
Person-centered care is a term associated with high-quality care (Brooker, 2003). By utilizing a
person-centered approach, organizations can provide flexible, responsive and accessible services
that meet the preferences and needs of the community. With the demographic shift in Australia
and New Zealand whereby the number of old population is rapidly increasing, a person-centered
approach is important to provide support in managing delirium(Australian hospital statistics
2008-09, 2010).
A person-centered care approach enables patients and staff to make their own decisions
and control the services their lifestyle ( Richard, Coulter & Wicks, 2015). The medical care staff
will have a sense of responsibility for the people they take care. The organization will also be
well placed to provide responses that are culturally appropriate especially to patients with
delirium. A person-centered approach in treating patients with delirium will consequently help in
alleviating issues related to the identification and diagnosis of patients with delirium. The
personalized care with also contribute to reducing adverse effects of delirium that often result in
a prolonged stay in hospitals ( Brooker & Latham, 2015). This approach will especially be
significant to patients with hypoactive delirium. Such patients are often ignored because of their
‘undemanding’ nature. Since the approach is community-based involving friends and family, it
enables a wholesome health care system. Therefore, person-centered care can have significant

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effects on the well-being of dementia patients by helping in the prevention of delirium, its early
detection, response, and management. (Dewing, 2009)
Action plan.
Delirium is an overlooked yet pressing concern in our health care system. It is necessary
to identify the existing gaps relating to the detection, management and care services provided to
the patients. Gaps in the early detection and management of delirium, environmental factors
relating to delirium and the level of awareness and education exhibited by the health care
practitioners need to be addressedso as to improve delirium care. This healthcare improvement
plan utilizes a Plan-Do-Study-Act (PDSA) cycle conducted by a focus group to analyze and
provide possible courses of action to address issues the gaps identified.
Focus groups are commonly used to discuss a specified topic in a short period.A focus
group allows a range of opinion to be discussed in a short period and provides a chance to mingle
with others, the group’s composition may inhibit some member (Whittaker, 2012). A PDSA
cycle is often used to turn an idea into action and in turn connect the action to a learning
experience (Langley et al., p. 97).In relation to delirium, the health care improvement plan will
provide a plan to improve the healthcare practices and culture, implement the plans, determine
their effectiveness in solving the issue and finally refine the procedure based on the findings. By
utilizing the PDSA cycle, the first step in the action plan will be to define and design the
intervention into the gaps in delirium health care. After planning how to mitigate the gaps, the
actual changes will be implemented and documented. The documented information on the
intervention process will then be analyzedafterwhich the finding will be used to identify
additional gaps or improve on the existing delirium healthcare improvement plan.

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Early detection and management of hypoactive delirium
Hypoactive delirium, whichis characterized by a quiet and withdrawn behavior is usually
overlooked (Hosker & Ward, 2017). To further complicate its early detection and subsequent
management, studies into hypoactive delirium have provided inconclusive evidence regarding
symptom association and presentation. These characteristics have resulted in people, and
healthcarepractitioners having an assumption that delirium is not a problem on its own but
merely a clinical symptom of other pathologies. With the number of people with delirium
expected to increase as a result of an aging population, it is prudent to improve on the detection
and management of hypoactive delirium(Hosker & Ward, 2017).
Interventions to increase early detection and management of hypoactive delirium include
reducing the time between the onset of delirium symptoms and communication of diagnosis,
improving on research related to identification and management and, improving the approach of
health care practitioners’ to treating delirium.These interventions will be implemented by
improving the quality of healthcare services offered in theinstitution. This will be achieved by
improving the processes involved in assessing a potential case of delirium and admitting the
diagnosed patient for care(Spiller & Keen, 2006). An efficient system will facilitate the quick
and accurate communication of diagnosis making the management of delirium easier. The
support staff should also be educated on the appropriate methods of taking care of patients. To
properly manage delirium, all parties involved should have all the relevant information on how
to identify symptoms of hypoactive delirium and how to handle affected patients.The success of
the intervention will be assessed based on the number of newly detected cases together with the
amount of time spent in the institutions. The core limitation to this intervention is the lack of
conclusive evidence on symptom association and presentation (Spiller & Keen, 2006).

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Providing enriching environment
Most patients portraying symptoms of hypoactive delirium are often misunderstood and
even discriminated. An enriching environment comprises of relevant, psychological, physical,
and sensory support (Bridges, Flatley & Meyer, 2010). Since patients with delirium need a
supportive environment of family, friends, and carers, it is necessary to design a plan that
facilitates this kind of enriching environment. An enriching environment should also be safe,
comfortable, and sensitive to the needs of the diagnosed patient. After discussions in the focus
group, a possible strategy to mitigate risks associated with the environmental conditions
surrounding delirium patients is to incorporate a comprehensive person-centered care system into
the health institutions and community. The relevant institutions should provide a personalized
care system that incorporates the patients, their family, and the community. The key objective in
delirium management is maintaining the patient’s and carer’s quality of life(Young, Murthy,
Westby, Akunne & O'Mahony, 2010). This can be done by sensitizing the community and carers
on the importance of knowing the characteristics of a patient with possible hypoactive delirium
and why/how to respond to diagnosed patients. This strategy is expected to create awareness and
bring the whole community together to tackle the delirium issue.To improve community care
especially in care homes, it is important to reduce the inappropriate use of antipsychotic drugs.
With a successful campaign, family, friends, and carers will have the necessary knowledge and
understanding of how to take care of patients. The strategy may, however, be limited by the
complex nature of hypoactive delirium in that it is characteristically hard to detect and manage.
Educating staff
The support staff of patients with hypoactive delirium have oftenbeen accused of
ignoring the patients due to the reasoning that the patients are ‘un-demanding.' It is therefore

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important to educate the staff on ways of managing and taking care of patients diagnosed with
delirium.To improve the patient and staff’s quality of life, an intervention to educate the
healthcare staff is necessary. There exists a service delivery gap between the actual services
offered by staff and what is appropriate.Patients are often misdiagnosed due to lack of crucial
information. Educating the staff will help in early detection of delirium and its management. The
healthcare improvement action plan will employ a comprehensive educational package that
delivers information on delirium, preventive measures, treatment, and management.This will be
done using small group presentations, formal presentations, and guidelines on how to detect,
prevent and manage hypoactive delirium coupled with follow-up lessons (Law, Connelly,
Prentice, & Rooke, 2009)
Evaluation of clinical practice context
PARIHS is a conceptual framework that postulates the important elements influencing
the successful application of evidence-based practices (Helfrich et al., 2010). To evaluate the
clinical practice context’s readiness for the suggested changes, the healthcare improvement plan
used the PARIHS framework. The framework explains interactions between the context of a
study, the evidence available, and facilitation of the change (Kitson et al., 2008). This tool was
embedded in the evaluation because it provided a relevant guide to help in the development of
the healthcare improvement plan and evaluation of the implementation process. The PARIHS
tool was used to guide decisions on the design of the intervention, collection of data and the
analysis of the processes while focusing on early detection and management of hypoactive
delirium, providing the enriching environment and educating employees. So as to fully
understand the process of implementation and the impacts to the management of delirium, a
process evaluation embedded with PARIHS was designed.

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Strategies for the implementation of the three evidence-based recommendations were
designed. The guidelines include that institutions should adopt a person-centered care approach,
the health care staff should be educated and trained on effective ways of caring for delirium
patients, and effective ways of detecting and managing delirium.The core purpose of the
evaluation is to determine how the interventions will be received in a delirium healthcare setting,
impacts observed, and how the changes played out.
In relation to the evaluation framework, the hypoactive delirium interventions can
function at multiple levels within healthcare organization’s context based on an assessment of
the readiness using PDSAcycle.Data will be collected pre-intervention and post-intervention
from healthcare institutions managing patients with hypoactive delirium.This will be obtained
from pre-existing case studies, focus groups and interviews conducted afterward. Interview
topics for both staff and patient interviews will be developed based on the framework and hence
will include questions on early detection and management of delirium, staff education and
provision of an enriching environment. The inductive and deductive analysis will be used based
on Ritchie and Spencer’s (2002) approach to analysis. The influence that contextual factors such
the individual patient (micro), the care staff (meso) and healthcare institutions(macro) will have
on the implementation of the changes mustbe considered(Rycroft-Malone et al., 2013). These
themes usually interact with each other in a practical setting.Finally, facilitation is necessary to
make implementation easier
To enhance the chances for successful implementation of the initiatives, the suggested
changes may be aligned with existing initiatives related to improving the health care of patients
with hypoactive delirium. For the successful implementation of this healthcare practice
improvement plan, the recommendations highlighted will need to be used in practice and

HEALTHCARE PRACTICE IMPROVEMENT 10
impacton the management of delirium and related issues(Rycroft-Malone et al., 2013).Findings
will be presented based on the main criteria of the PARIHS framework: context, evidence, and
facilitation. In a practical clinical setting, it is expected that there will be dynamism and
complexity underlying the findings.
Quality Plan
According to Donabedian (2005), the quality of health care should be measured by taking
the processes, structure, and outcomes into account. Under process, we measure thedelivery of
services by providers. Structure is concerned with the availability, accessibility, and quality of
resources. The outcome indicates the resulting effect of the healthcare process and includes
factors such as patient satisfaction, mortality, or improved health status. The healthcare
improvement plan will adopt a collaborative approach to come up with a change framework to
support improvements.
Confusion Assessment Method (CAM) is a harmonized evidence-based method, which
gives health practitioners not trained in the psychiatry field the ability to detect and correctly
diagnose delirium at an early stage in research and clinical settings (Waszynski, 2004). The
method utilizes four steps that collectively provide delirium healthcare practitioners the best
ability to differentiate delirium from other types of disorders. The main advantages of the CAM
method are that the hospital staff can adopt it in their normal day-to-day evaluation of patients.
The method can also be translated into different languages so that as many patients as possible
can be treated correctly regardless of the language they understand. Due to its short
administering period, this delirium diagnosis and assessment tool can help in the early detection
and management of hypoactive delirium. Implementing CAM, therefore, results in an
improvement of delirium health care but only if the staffs are properly trained (Ely et al., 2001).

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Nurses from other wards can be trained on how to identify and care for deliriumpatients
so that incase they encounter one as they are treating patients, they know how to handle the
situation effectively.This will help solve the healthcare gap relating to staff education. Training
the nurses the fellow nurses on skills that will help in the early detection and management of
hypoactive delirium will contribute to the overall mitigation of delirium in the hospital and
community.This will contribute towards bringing about change in the diagnosis and treatment of
hypoactive delirium in the long run.
An online training course for staff on identifying and managing delirium can be done
regularly so that the healthcare practitioners are upto date with the effective ways of preventing,
identifying, and managinghypoactive delirium. An online training program is an appropriate
tool,especially where the medical staff are on busy schedules or need reference material as and
when they suspect manifestations of hypoactive delirium symptoms. This activity will facilitate
change in the healthcare system by educating employees on how to detect the onset of delirium
and manage diagnosed patients.
Although most health carepractitionersare trained on identification and management of
delirium, new studies are being conducted to improve our understanding and response to this
clinical diagnosis (O'hanlon et al., 2013). Therefore, to facilitate the implementation and success
of the suggested interventions into delirium health care, the staff need to be re-trained. While
staff members are re-trained on delirium care practices, the training sessions should be well
documented so that future groups can reference and learn from them.This will ease the process of
conducting similar re-training activities. It is, however, important to note that training activities
are costly and time-consuming. Re-training session should, therefore,be conducted on a need

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basis. This activity will facilitate the reinforcement of existing knowledge while updating the
medical staff on recent developments or approaches to hypoactive delirium.
To help enforce the changes suggested, being part of the delirium representatives in the
ward will provide a field experience on the conditions present in a real-world setting. The best
way to ensure that the suggested changes are implemented is by personally facilitating their
implementation. By being part of the delirium representatives in the ward, it will be easier to
monitor, evaluate and enforce necessary adjustments aimed at implementing changes in the
hypoactive delirium health care system in the particular health facility. It will make it possible to
contribute towards providing an enriching environment, educate fellow staff members on
important issues related to delirium, and improve the detection and management of hypoactive
delirium in a clinical setup.
According to Rudolf et al., (2011) delirium does not have a single causal pathway.A
basicdeliriummanagementpathwaystarts from determining the risk factors for delirium based on
a patient’s history, a clinical assessment to diagnose delirium symptoms, measures to manage the
underlying causes, admission, and supervision if it’s determined to be an emergency, reduction
of delirium, and finally managing the diagnosed patient.
A person-centered collaborative care system that incorporates the patients, their family,
and the community, with help in the management of delirium patients. According to Young,
Murthy, Westby, Akunne & O'Mahony (2010), the key objective in deliriummanagement is
maintaining the patient’s and carer’s quality of life. This can be donethrough the collaboration of
the patients, their family, hospital staff and thegeneral community on the importance of knowing
the characteristics of a patient with possible hypoactive delirium and why/how to respond to
diagnosed patients. This care system is expected to create awareness and bring the whole

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community together to tackle the delirium issue.A successful care plan with becharacterized by a
situation where the family, friends, and carers will have the necessary knowledge and
understanding of how to take care of patients
The effectiveness of this health care improvement plan with be evaluated using a survey
on the healthcare facility staff. The survey with collect and evaluate information so as to
determine whether there was a significant improvement in early detection of hypoactive delirium
and the management of diagnosed cases. This information will be collected from statistics
relating to the number of new delirium patients admitted, the gap between the onset of symptoms
and diagnosis and the length of stay by hospitalized delirium patients. Information related to the
intervention on staff education will be collected by randomly surveying the retaining delirium
knowledge.
Conclusion
In conclusion, hypoactive delirium remains a clinical diagnosis that needs to be critically
evaluated and managed. Its presence should be approached as a medical emergency. The overall
approach when dealing with delirium should start with assessment using appropriate tools or
methods. Once hypoactive delirium is detected, the next step is to identify and remove the
underlying cause.The only strategy that conclusively improves outcomes is the early
mobilization of delirium patients. It is also important to note that patients without delirium
posses the risk of developing delirium in the course of their hospitalization. The examination of
delirium provides a chance for us to improve health care service towards the elderly(Inouye,
Schlesinger, & Lydon, 1999).

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Fueled by an aging demographic structure, there has been an increased need to focus on
effective methods of detecting delirium early so as to better manage the disorder. The healthcare
staff overseeing patients with delirium have often misdiagnosed, mistreated or ignored patients
with hypoactive delirium. Therefore, it is necessary to formulate and implement changes that
will assist in the early detection and management of hypoactive delirium, provide an enriching
environmentconducive for delirium patients, and to educate the healthcare staff on matters
pertaining to hypoactive delirium. Evaluation of the interventions aimed to ensure the changes
had a positive impact and that they helped mitigate the existing service delivery gaps in
hypoactive delirium healthcare. This healthcare improvement plan emphasized on the
importance of a person-centered care approach.

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