Evidence-Based Practice Implementation Plan: A Nurse-Led Multicomponent Delirium Prevention Program for Older Adults on an Orthopedic Unit
[Student Name]
University of Phoenix
NSG/509: Research and Applied Statistics for Quality Improvement
Week 6 Summative Assessment
[Instructor Name]
[Date]
The hospital, unit and figures are a composite written for a model paper.
Trigger and Priority
The Iowa Model begins with a trigger, a problem or new knowledge that prompts a question about practice, and then asks whether the organization considers that problem important enough to act on (Iowa Model Collaborative, 2017). On a composite 28-bed orthopedic unit, a review of the past year found that 26% of patients aged 70 or older admitted with hip fracture developed delirium, as documented by the Confusion Assessment Method. These patients had longer stays, more falls and more discharges to skilled nursing facilities than patients without delirium. The hospital's strategic plan includes reducing hospital-acquired complications in older adults, and the chief nursing officer agreed that delirium prevention was a priority.
PICOT Question
In adults aged 70 or older admitted with hip fracture (P), does a nurse-led multicomponent nonpharmacological delirium prevention program (I), compared with usual care (C), reduce the incidence of delirium (O) during the hospital stay (T)?
Team
The team includes the unit's clinical nurse specialist as project lead, two staff nurses from days and nights, a nursing assistant, a physical therapist, a pharmacist, an orthopedic hospitalist, a volunteer services coordinator and a family member of a former patient. The mix covers the components of the intervention and the people who will carry it out.
Evidence Synthesis
The evidence for multicomponent prevention is strong. Inouye et al. (1999), in a controlled clinical trial among older medical patients, found that the Hospital Elder Life Program, which targets cognitive impairment, sleep deprivation, immobility, visual and hearing impairment and dehydration through standardized protocols, significantly reduced the incidence of delirium compared with usual care. Pooling trials of nondrug prevention bundles, Hshieh et al. (2015) showed that these programs reduced delirium incidence and falls across studies and settings, including surgical populations. Martinez et al. (2012) showed that a family-delivered component of reorientation, familiar objects and extended visits reduced delirium in older inpatients in a randomized trial.
Applying a standard hierarchy of evidence, the body includes randomized and controlled trials and a meta-analysis with consistent findings, which supports practice change (Melnyk & Fineout-Overholt, 2023). The team judged the evidence sufficient to design and pilot the practice change, the next step in the Iowa Model.
The Practice Change
The program has six components, each assigned to a role and built into the unit's workflow.
1. Orientation and cognitive engagement. Nurses orient patients at each shift change using a whiteboard with the date, the nurse's name and the day's plan; trained volunteers provide conversation and cognitive activities twice daily.
2. Sleep protection. Lights are dimmed and noise reduced after 10 p.m.; overnight vital signs and medications are clustered; a warm drink and quiet music are offered in place of sedative-hypnotics.
3. Early mobility. Physical therapy begins on the day after surgery; nurses and assistants walk patients three times daily as tolerated.
4. Sensory aids. Glasses and hearing aids are located on admission, labeled and kept within reach.
5. Hydration and nutrition. Assistants offer fluids each hour while awake and help with meals.
6. Family partnership. Families receive a one-page guide and are invited to stay longer, including overnight when the patient is at high risk.
The pharmacist reviews each patient's medications on admission for drugs that increase delirium risk, and the hospitalist agrees to avoid them where possible.
Pilot Design and Timeline
The Iowa Model recommends piloting a change before adopting it widely (Iowa Model Collaborative, 2017). The pilot will run for six months on the orthopedic unit.
Months 1 and 2: baseline data collection, staff education in 30-minute sessions on each shift, volunteer training and preparation of materials.
Months 3 through 8: pilot implementation, with weekly team huddles in the first month and monthly meetings afterward.
Month 9: evaluation and decision on adoption.
Evaluation Plan
Outcome measure: the incidence of delirium among patients aged 70 or older admitted with hip fracture, assessed with the Confusion Assessment Method each shift by trained nurses. The baseline is 26%; the target is 16% or lower.
Process measures: the percentage of eligible patients who receive each component daily, audited on ten random patients per week; staff completion of education.
Balancing measures: falls, length of stay and staff time per shift for the program, since additional work could affect other care.
Analysis plan: the proportion of patients with delirium before and during the pilot will be compared with a chi-square test, with significance set at .05 and the absolute difference and its 95% confidence interval reported. Since comparing periods cannot exclude other causes of change, delirium incidence will also be plotted monthly on a run chart to see whether a change coincides with the start of the pilot. Length of stay, which is typically skewed, will be compared using medians and a nonparametric test.
Barriers and Strategies
The team anticipates three barriers. Staffing pressure may make daily mobility and hourly fluids hard to deliver; the plan assigns specific tasks to assistants and volunteers and tracks staff time as a balancing measure. Night staff may resist clustering care or reducing overnight checks; night nurses are on the team and will help design the sleep protocol. Volunteer availability may be limited on weekends; families are invited to fill that role, and the volunteer coordinator will recruit weekend volunteers.
Sustainability and Spread
If the pilot meets its targets without harm, the team will ask the nursing practice council to adopt the program as unit standard work, embed its components in the electronic health record as an order set and nursing care plan, add delirium incidence to the unit's quality dashboard and include program training in orientation. The Iowa Model's final steps include integrating and sustaining the practice change and disseminating results (Iowa Model Collaborative, 2017). The team will present results to other surgical and medical units and at a regional nursing conference, and will plan spread to the general surgery unit first, since its population is similar.
Conclusion
One in four older adults with hip fracture on this unit developed delirium, a preventable complication with serious consequences. Following the Iowa Model, this plan moves from a local trigger to a focused question, synthesizes strong evidence for multicomponent prevention, designs a nurse-led program with clear roles, pilots it with prespecified measures and analysis and plans for sustainability. If successful, the program will reduce delirium for the unit's most vulnerable patients and provide a model for the rest of the hospital.
References
Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: A meta-analysis. JAMA Internal Medicine, 175(4), 512-520. https://doi.org/10.1001/jamainternmed.2014.7779
Inouye, S. K., Bogardus, S. T., Jr., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney, L. M., Jr. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340(9), 669-676. https://doi.org/10.1056/NEJM199903043400901
Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223
Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and Ageing, 41(5), 629-634. https://doi.org/10.1093/ageing/afs060
Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing & healthcare: A guide to best practice (5th ed.). Wolters Kluwer.
How this NSG 509 Week 6 example is structured
Course materials list the NSG/509 Week 6 Summative Assessment as an Evidence-Based Practice Implementation Plan. The plan follows the Iowa Model's sequence because a named model gives each section a reason for its place: trigger, question, team, evidence, pilot design, evaluation and sustainability. The evaluation section specifies measures, data sources and statistical tests before the pilot starts, drawing the course's statistics weeks into the final plan. Students search this week as NSG 509 Week 6, NSG509 Wk 6 or NSG/509 Wk 6; all three are the same assignment.
NSG/509 Week 6 questions, answered
What does NSG/509 Week 6 usually ask for?
Course materials list the Week 6 summative assessment as an evidence-based practice implementation plan. Many sections expect a PICOT question, an evidence summary, an implementation model, stakeholders, a timeline and an evaluation plan with measures. Check your rubric for required headings.
Which implementation model should I use?
Use the one your course names, or one suited to hospital practice change, such as the Iowa Model, the Johns Hopkins model or the ACE Star model. What matters is applying the model's steps to your project, not only naming it.
How detailed should the evaluation plan be?
Detailed enough that someone else could carry it out: name each measure, how and when it will be collected, the baseline, the target and how the results will be analyzed. Deciding the analysis before collecting data is part of good evidence-based practice.
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