Patients in acute cardiac care units hold a high risk of developing delirium due to hardware-related immobility, cerebral hypoperfusion with a low cardiac output, status post transcatheter aortic valve replacement procedure, or status post-cardiac arrest.¹ The incidence of delirium in the cardiac intensive care unit varies depending on the screening tools and methods for assessment, but it ranges between 3% and 41.7%.^2,3 Multiple studies have shown that a patient-centered multicomponent approach is effective in delirium prevention and management.^4–6 However, application of such multicomponent care in a fast-paced specialized care unit like a cardiac care unit, may be challenging and impractical.

Recently, the Institute for Healthcare Improvement and the John A. Hartford Foundation launched Age-Friendly Health System (AFHS) 4Ms initiative.⁷ The AFHS 4Ms initiative promotes a framework addressing four key components called 4Ms: “What Matters,” “Medication,” “Mentation,” and “Mobility.” The rationale of the 4Ms is that by addressing each M, any healthcare system can provide high-quality and age-friendly care for older adults. Briefly, “What Matters” stands for patient-centered care aligning care plans to what matters most to older adults, “Medication” proposes healthcare providers avoid inappropriate medications, “Mentation” promotes screening, preventing, and managing delirium, dementia, and depression, and “Mobility” promotes older adults’ physical activities and avoids immobilization.

Given that the AFHS 4Ms framework intends to promote comprehensive care strategies and addresses delirium in its “Mentation” domain, AFHS 4Ms could be used for a patient-centered multicomponent approach in delirium prevention and management. Studies have reported the importance of medication management (“Medication”) or promoting mobility (“Mobility”) in optimal delirium prevention and management. Avoiding certain medications such as anticholinergics, antihistamines, or benzodiazepines is critical in preventing delirium.⁸ Physical rehabilitation has immediate benefits in older adults’ mentation and management of postoperative delirium.⁹ However, these 4Ms have only been studied individually, and there has not been a study assessing the effectiveness of AFHS 4Ms as a whole on delirium care. Furthermore, it has not been studied if AFHS 4Ms could be successfully implemented in a specialized care unit. Therefore, we conducted a quality improvement (QI) project implementing the AFHS 4Ms focusing on delirium detection and management and assessed its feasibility in acute cardiac care units.

We applied the AFHS 4Ms framework at two acute cardiac care units, cardiac intensive care unit (CCU) and cardiac intermediate care unit (CIMU) at a tertiary academic medical center (Memorial Hermann Hospital at Texas Medical Center) in Texas, U.S.A. These two units did not have a formal delirium screening process before the QI project, so we focused on delirium detection and proper management using the AFHS 4Ms framework and assessed its feasibility.

In this article, we report the results from a QI project applying AFHS 4Ms focusing on detecting and managing delirium in acute cardiac care units at a tertiary academic medical center. To our knowledge, this is the first study reporting the feasibility of AFHS 4Ms as a whole focusing on delirium detection and management. The high rate of delirium screenings administered authenticates the feasibility of the application of AFHS 4Ms in acute cardiac care units. Furthermore, although it was not statistically significant, the results showed a decreasing trend in the rate of positive delirium screening results over time.

One important aspect of the current study is that it showed that AFHS 4Ms are interconnected. The main concept of AFHS 4Ms^7,15,16 is that 4Ms are not mutually exclusive but are closely related and must work together to fulfill “What Matters.” Furthermore, AFHS 4Ms are specifically built so that addressing one M can assist in addressing another M simultaneously. For example, we observed reduced rates of prescriptions for potentially inappropriate medications,¹⁷ lorazepam and haloperidol, addressing the “Medication” domain, although our main focus was “Mentation.” Furthermore, we observed reduced use of physical restraints, which can potentially improve older adults’ “Mobility.” Physical restraint is one of the risk factors of immobilization,¹⁸ and in turn, immobilization is one of the precipitating factors of delirium.¹⁹

Although this QI project taught us the important aspects of 4Ms that are feasible to be implemented in acute cardiac care units holding its main concepts as stated above, it did not demonstrate significant changes in both primary and secondary outcomes. The rate of screening for delirium did not significantly increase during the study period. However, given that our units were not screening for delirium before the initiative, achieving an overall 79.6% of screening rate in four months can be considered a success. Regarding the rate of positive delirium screening results, it did not show a significant decrease over time. One of the explanations could be due to the short study time. Another explanation is that we did not deliberately evaluate the accuracy of CAM among the older adults in our cardiac care units, as well as with our nursing staff. Indeed, the accuracy of CAM screening is highly dependent on the training level of the performer.²⁰ Additionally, not excluding older adults with dementia in our analysis may have also affected the results. Our results showed relatively lower rates of delirium than other studies, possibly due to the inaccuracy of the screening, but also due to the confounding effect of the population with dementia. Nurses may have attributed “confusion” to dementia, not recording it as delirium on superimposed dementia.^21,22 Regarding the delirium-related orders, they were not significantly different before and after the initiative. We believe it is because we did not apply strict inclusion and exclusion criteria in selecting the delirium-related orders. Certainly, there are many other conditions that the four orders can be used, and also there are other orders that can be used for delirium management. Future studies with more accurate delirium screening tools for the specific population and more comprehensive outcome measures to capture appropriate delirium management are needed to fully assess the impact of AFHS 4Ms on delirium prevention and management.

The authors acknowledge that our QI project has several limitations. First, our QI project does not compare the screening rate and positive screening results before and after the initiatives but only shows the changes after the initiative was implemented. Second, to overcome the above-mentioned limitation, we used secondary outcomes as the proxy of delirium to indirectly compare the incidence of delirium before and after the initiative. However, we acknowledge that they are not a comprehensive list since other medications are frequently used for delirium. Third, although b-CAM and CAM-ICU are well-validated tests for screening for delirium, it requires training and education for accurate assessment. Their accuracy and inter- and intra- rater reliability in our unit were not assessed. Furthermore, positive screening results from CAM may not warrant the diagnosis of delirium since CAM is a screening test, not a diagnostic tool. Fourth, we only collected the data for five months after the QI project. Although we continued AFHS 4Ms in our units, data collection was heavily impacted by the COVID-19 pandemic, and unfortunately, we only had the data available until December 2019. Fifth, our QI project was conducted in a specialized cardiac care unit, which should be tested in other healthcare settings for better generalizability. Last, we also do not have sufficient data regarding the most important domain in AFHS 4Ms, the “What Matters” aspect, although patient-centered care is also critical in delirium management.

Despite several limitations, our QI project holds significant value. As the first report assessing the feasibility of applying AFHS 4Ms in delirium care, the results of our study suggest that it is feasible to implement AFHS 4Ms in highly specialized and fast-paced cardiac units. Future prospective studies with longer study periods and more detailed outcome assessments are strongly warranted.