There is evidence of poor performance in the evaluation and management of geriatric conditions by clinicians, which suggests a need for changing clinician behavior (Levine et al., 2007
). Recently, there has been increased interest in finding methods to improve behavior patterns of physicians through models of knowledge translation (Levine et al., 2007
; Ward et al., 2002
). It is speculated that physician knowledge and attitudes are affected before there is change in clinical behavior and performance improvement (Ward et al., 2002
). This visiting professorship was designed to raise awareness, to better educate health care providers, and to help create and implement a program to address delirium.
The clinician education program utilized objectively designed pretest and posttest questionnaires to evaluate the impact of the CSI on knowledge among clinicians about delirium identification, diagnosis, and management. Concurrently, changes in the level of confidence and self-assessed capacity to identify a patient with delirium using the CAM were analyzed. It is anticipated that improvement in these parameters would translate into a change in practice and behavior toward delirium in general (Ward et al., 2002
). Novel aspects of this educational intervention included the needs assessment identifying a topic recognized as important on a large scale, obtaining administrative buy-in, generating a climate of change across the organization, and creating intensive interaction across disciplines through the intervention.
Overall, our analyses showed improvement in knowledge scores as a result of the intervention. Interestingly, cross-sectional analysis of Cohort 1 (attended one session) versus Cohort 2 (attended two or more sessions) revealed that the mean change in score was significantly higher in Cohort 2, with a p value of <.001. Also, three participants, all belonging to Cohort 2, achieved a perfect score of 17 on the posttest. These findings support the concept that a CSI with a multifaceted educational strategy can significantly enhance clinician knowledge around a particular subject in ways that a single-session attendance cannot.
It is noteworthy that the participants in Cohort 1 had a higher mean score on the pretest to begin with than the participants in Cohort 2. This could be attributed to higher baseline knowledge about delirium in this cohort, who thought that they may not benefit from attending more sessions. Also, despite increase in knowledge scores, the overall posttest scores remained low, with a mean posttest score of 10.8 of a maximum of 17 points. This may be attributed partly to our system of subtracting points for incorrect answers.
Another unique aspect of the CSI was the sequential patterning of educational activities. The systematic elucidation of the different facets of delirium through multiple sessions and educational formats (PowerPoint presentations, video clips, and case discussions) resulted in a significant increase in confidence among clinicians in identifying delirium in their hospitalized elderly patients (p < .001).
Although the goals of the program were to impact delirium prevention, identification, and management, the benefits of the CSI program extended to a broader context of improving geriatric care in the hospital. For example, it led to buy-in by administration for an expanded Geriatric Programming Agenda, including interest in a new model of care such as the Hospital Elder Life Program (HELP; Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000
). Furthermore, the CSI program helped to build bridges between hospital departments by focusing on a unifying patient care issue. This paved the way for the Emergency Department (ED) and Information Systems Department to take steps toward devising a novel interpretive cognitive screen and planning an ED delirium identification protocol that could be documented in the electronic medical records.
The CSI program also helped support employees by providing on-site CNE and CME to satisfy nurse and physician educational requirements. As a result of the CSI program, HELP concepts were integrated into periodic ACE Unit education days. Lastly, the large participant response to the didactic sessions coupled with the inherent limitations of the hospital’s meeting spaces led to novel use of multimedia to extend the reach of the program.
Several important limitations are worthy of comment. Use of remote locations, while allowing broadcast to a larger audience, prevented direct speaker interaction for some participants. Moreover, several pretest and posttest responses could not be used for analysis because of the lack of accurate matching parameters on the questionnaires. Also, there were no formal prospective evaluation or feedback systems in place for the small group sessions.
Another limitation is that data collection focused on improvements in knowledge rather than behavior change. While beyond the scope of the current study, measuring clinical impact and behavior change would be important for future investigations. Using coding data to identify physician recognition of delirium and pharmacy data to analyze prescribing practices could help to assess the impact on clinical practice.
In summary, the CSI strategy increased clinician knowledge about the characteristics and management of delirium and improved confidence and self-assessed capacity to identify delirium in the hospitalized elderly patients. This strategy, which incorporates multiple reinforcing modes of education, may be more effective in influencing clinician behavior when compared with traditional grand rounds. Based on the success of this program, the Geriatric Services Core Team plans to continue using the model to disseminate important medical and clinical quality initiatives to interdisciplinary hospital staff. Other institutions may be able to adopt a similar strategy to create change in geriatric care.