Prevention of Unbearable Situations and Harms Protocol: A Quality Improvement Initiative in Neurological Delirium

Hyperactive delirium in neurological wards frequently results in patient harm, falls, device removal, and caregiver injuries, alongside significant staff burnout. To address inconsistent management practices, we developed the Prevention of Unbearable Situations and Harms (PUSH) protocol, a structured multidisciplinary approach to proactively manage hyperactive delirium. This study evaluated the effectiveness of the PUSH protocol in reducing delirium-related adverse events (primary outcome), and improving clinical workflow, staff burnout, and satisfaction (secondary outcomes).

We conducted a pre-post study in three phases: pre-implementation (November 2021-May 2022), pilot testing (June-August 2022), and post-implementation (September 2022-March 2023). The PUSH protocol includes Standard Care (routine delirium prevention), Preparation (anticipatory medication planning for patients at risk, Nursing Delirium Screening Scale ≥2), and Action (rapid response for escalating delirium) phases. Outcomes included delirium rates, hyperactive delirium episodes, adverse event incidence, medication response times, and staff burnout and satisfaction surveys. We compared pre- and post-implementation data using Poisson regression.

Among 2,457 patients, 174 developed delirium during 2,958 observed person-days. Unbearable situations or harms decreased from 5.6 to 4.2 events per 100 person-days, with a fully adjusted incidence rate ratio of 0.539 (95% confidence interval: 0.368-0.788, p=0.001). Response times to sedative medication administration improved markedly (16 to 0 min; p<0.001). Staff burnout significantly decreased (32 to 27; p<0.001), and satisfaction notably increased (3 to 4; p=0.009).

The PUSH protocol significantly reduced delirium-related harms, enhanced clinical workflow efficiency, decreased staff burnout, and increased satisfaction, supporting its broader implementation in neurological settings.