Department of Critical Care MedicineCalgary

Delirium Assessment and Treatment

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Background

• Calgary DCCM comprised of 4 adult critical care sites• Mix of medical, surgical, neurological, and cardiovascular

surgery patients• Disciplines involved:

• Intensivists, RNs, RTs, Pharmacists, Nurse Educators, Physiotherapists, Occupational Therapists

• The literature has demonstrated that delirium is a strong predictor for patient morbidity and mortality

• We currently do not have a standardized assessment tool or treatment algorithm in place for recognition and management of delirium

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Aim

• Determine baseline incidence/prevalence of delirium with in 3-6 months.

• Implement processes to screen 100% of all ICU patients for delirium within 12 months.

• Develop education and support for staff regarding delirium awareness, prevention, and management within 12 months.

• Implement standardized delirium prevention interventions in all ICU patients within 12 months.

• Implement standardized interventions for the management of delirium within 12 months.

• Implement strategies to support families of patients with delirium within 18 months

Team Members• Intensivists/Nurse Practitioner

– Dr. Terry Hulme, Dr. Sid Viner, Nicki Johal• Nursing Management

– Rebecca Eldridge• RNs/Educators

– Melissa Redlich, Joan Harris, Joanne Xu, Deborah Banack, Heather Sartison, Laura Sullivan, Alana

• RTs– Suzanne Boyd

• Pharmacists– Barry Kushner, Diana Callfas

• PT/OT– Megan Hudson PT / Alanna Cunningham OT

Apr 21, 2023 4Delirium and Med Rec Collaborative

Collaboration sur le delirium et le BCM

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Changes Tested

• Implemented the RASS scale in 4 adult ICUs as replacement for RIKER in anticipation of using CAM-ICU for delirium assessment.

• Trialed use of CAM-ICU in 2 adult ICUs• Trialed use of ICDSC in 2 adult ICUs• ICU Physiotherapist developed an Intensive Care

Patient Mobility protocol.• PDSA trials regarding new mobility protocol

completed in 1 adult ICU.

Changes Tested continued…

• Trialed ICDSC with head injury patients at 1 adult ICU. • ICU Pharmacist and 2 ICU Intensivists reviewing and

revising Sedation protocol to include in our delirium management protocol.

• ICU OT , 2 ICU RNs and CNE working on the non-pharmacological algorithm for delirium management protocol.

Apr 21, 2023 6Delirium and Med Rec Collaborative

Collaboration sur le delirium et le BCM

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Results

• RASS successfully implemented at all 4 adult ICUs. Incorporated into the provincial electronic critical care documentation system.

• CAM-ICU trial results demonstrated strong interrater reliability and ease of use for novice practitioners.

• ICDSC trial demonstrated difficulties with how to measure some of the indicators, how to reliably interpret and assess indicators.

• ICDSC trial demonstrated difficulties with education regarding how to correctly use the tool. Required extensive educational component.

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Results continues..

• PDSA trials of mobility protocol provided in-depth feedback for ICU PT.

• PDSA trial of using ICDSC with head injury patients resulted in further questions of reliability with this patient population and how to apply this assessment tool with this population.

• Current sedation guidelines and protocols will require minor revisions to accommodate delirium management recommendations.

• Non-pharmacological processes require a visible, defined area/ focus in the ICU unit.

Lessons Learned

• Strong educational component will be required to address diverse learning needs associated with utilization of the ICDSC.

• Current sedation practices will change and education will need to occur to address changes.

• ICU staff are looking forward to more structure and education around delirium assessment and management.

• Early mobilization process has been initially well accepted by bedside staff.

Apr 21, 2023 9Delirium and Med Rec Collaborative

Collaboration sur le delirium et le BCM

Lessons Learned continued…

• Some hesitation regarding mobilization of “drowsy” (RASS -1) patients with mobilization protocol.

• Delirium Management Protocol will require comprehensive education and engagement of whole interdisciplinary team.

Apr 21, 2023 10Delirium and Med Rec Collaborative

Collaboration sur le delirium et le BCM

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Next Steps

• To test our newly developed sedation guidelines and delirium treatment algorithm

• PDSA cycles for the ICDSC– Start with Delirium Collaborative participants– Then to roll out to core group of bedside practitioners

• Audit of ICDSC accuracy and completeness• Comparison of delirium incidence before and after

the implementation of standardized assessment and treatment tools

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EXAMPLE – DELETE BEFORE SAVING

Title

Background

Aim

Team Members

Results Changes Tested

Lessons Learned

Next Steps