Reducing Low-Value Delirium Care Using Behavioral Design in the Electronic Medical Record

Delirium is associated with increased morbidity, mortality, and healthcare costs. Despite best practice guidelines recommending non-pharmacological treatment strategies, delirium is frequently sub-optimally managed with reliance on antipsychotics or benzodiazepines. To optimize delirium management at our institution, we implemented a clinical decision support tool embedded within our Epic electronic medical record (EMR). Our team developed an Our Practice Advisory (OPA) triggered by a positive delirium screening result to alert hospitalists to patients at high risk for delirium. An accompanying order set emphasized high-value management, such as frequent re-orientation, and de-emphasized antipsychotics through embedded education and "collapsing" the antipsychotic section by default upon opening the order set. Mechanical restraint options were also intentionally excluded from the order set. We conducted a quasi-experimental pre-post study (December 2023 - November 2024), across two hospitals, measuring medication use, restraint use, bowel regimen orders, and provider engagement. Restraint use decreased significantly (35.4% to 23.4%, p<0.001). Antipsychotic and bowel regimen use showed no improvement. Provider engagement with the order set was robust, with 76.4% of providers reviewing the order set and 40.7% placing orders. This study demonstrates that EMR-embedded clinical decision support tools can influence clinician behavior and encourage concordance with evidence-based guidelines for delirium management. Additional refinements are needed to further promote provider adherence and translate changes in provider behavior into improvements in patient outcomes.