Royal Columbian Hospital Intensive Care Unit Delirium Quality

Improvement Initiative

Breakout session #G8 Sandy White, RN BSN Sharon Hickin, RN BSc, CNCC(C)

Prolonged duration of mechanical ventilation and length of stay

Three fold higher 6 month mortality

Financial impact of $4 to $16 billion annually

Delirium Fast Facts to Ponder

“Is a syndrome characterized by the acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status, inattention, and either disorganized thinking or an altered level of consciousness”(Barr et al. 2013, p282)

Whatever the cause, delirium is an ACUTE and WIDE-SPREAD BRAIN DYSFUNCTION

Delirium

Pain, Agitation, Delirium (PAD) Why Care?

Understanding the impact that delirium can have on hospitalized patients makes prevention and optimal treatment

of this organ dysfunction a priority

Our Mission:

To develop a cohesive interdisciplinary delirium mitigation strategy aimed at improving patient

outcomes.

Analyzing Assumptions

1. Everyone understood delirium and the impact it had on patient outcomes

2. Delirium management relied primarily on pharmacological interventions

3. Providing education would help ICU staff recognise the significance of delirium and thus lead to a change in practice

The Starting Point: Needs Assessment of Delirium

Created ICU Delirium Working Team

Explore current research and gold standards of practices

Review current RCH ICU delirium management and gaps in practice

Assess/measure baseline knowledge of ICU RNs

Dual-pronged Approach

Multifaceted Education Roll-out

Development of discipline specific Clinical Practice Guidelines (CPG) for non-pharmacological aspects of delirium management

Team Rounds: Communication is Key in Delirium Management

Differentiate Analgesic versus

Sedation

Use Objective Language

Report & discuss Pain, Agitation & Delirium using Validated Scoring

Tools

Sleep Habits

Date: RN: RT: Physio: Doctor:

Understanding Delirium Brings Change in Culture

Pet Therapy

Family Engagement

Routines

Early Mobility

ICU Nursing Kardex

Spring 2012- Fall 2013:

• Whiteboards in rooms

• Family journals

• Ear plugs at bedside

• Encourage sensory aids

• Using proper language

• Delirium added to rounds

checklist

Spring 2012: Delirium

Management Working Group

formed

Dec 2012: First draft of

Interdisciplinary CPG

Baseline

Assessment

October 2013: Nursing

Education Roll Out

Follow-Up

Assessment

May 2014: Regional CC

Ed Days

Winter Surge Winter Surge

Sustained Education Gap Analysis Engagement

Family Empowerment

December 2014

Program team

approval of CPG

Winter 2014/ Spring 2015

• Brain Cards

• Quiet signs

• Quick ref for Doctors

• Ed Roll Out CPG/PAD

Long-term

Follow-Up

Education Matters Most

• Engagement: Delirium champions, families • Sustained Education: Incorporate into unit

orientation for all disciplines including students and residents

• Interdisciplinary Delirium QI Team: New

initiative to examine rates of delirium within unit • Leadership: Commitment to action plan Health

Authority wide

What Lies Ahead

Self Preservation… Understanding the Impact of Delirium

Take-Away Delirium Fast Facts

34% experience cognitive impairment similar in severity to patients with moderate traumatic brain injury

Pandharipande PP, et al. N Engl J Med. 2013 Oct 3;369(14):1306-16

References Barr, J., Fraser, J., Puntillo, K., Ely, E., Gélinas, C., Dasta, J., . . . Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in

adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263-306. doi:10.1097/CCM.0b013e3182783b72

Bergeron, N., Dubois, M.-J., Dumont, M., Dial, S., & Skrobik, Y. (2001). Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive

Care Medicine, 27, 859-864. doi:10.1007/s001340100909

Brummel, N., Vasilevskis, E., Han, J., Boehm, L., Pun, B., & Ely, E. (2013). Implementing delirium screening in the ICU: Secrets to success. Critical Care Medicine,

41(9), 2196-2208. doi:10.1097/CCM.0b013e31829a6f1e

Carolinas Medical Center. (2008). Evaluation of delirium in critically ill patients at Carolinas Healthcare System: Nursing education.

Devlin, J., Brummel, N., & Al-Qadheeb, N. (2012). Optimising the recognition of delirium in the intensive care unit. Best Practice & Research Clinical

Anaesthesiology, 26, 385-393. doi:10.1016/j.bpa.2012.08.002

Ely, E., Siegel, M., & Inouye, S. (2001). Delirium in the intensive care unit: An under-recognized syndrome of organ dysfunction. Seminars in Respiratory and Critical

Care Medicine, 22(2), 115-126.

Gesin, G. R. (2012). Impact of a delirium screening tool and multifaceted education on nurses’ knowledge of delirium and ability to evaluate it correctly. American

Journal of Critical Care, 21(1), e1-e11. doi:10.4037/ajcc2012605

Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med.

2010;38(7):1513-1520.

Law, T., Leistikow, N., Hoofring, L., Krumm, S., Neufeld, K., & Needham, D. (2012). A survey of nurses' perceptions of the intensive care delirium screening checklist.

Dynamics, 23(4), 18-24.

Macfarlane, K. (2012, Feb). The wakeful brain: Analgesia, sedation & delirium.

Pandharipande PP1, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK,

Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW; BRAIN-ICU Study Investigators. (2013, Oct) N Engl J Med; 369(14):1306-16. doi:

10.1056/NEJMoa1301372.Long-term cognitive impairment after critical illness.

Pun, B., & Ely, E. (2007). The importance of diagnosing and managing ICU delirium. Chest, 132, 624-636. doi:10.1378/chest.06-1795

Pun, B., Gordon, S., Peterson, J., Shintani, A., Jackson, J., Bernard, G., . . . Ely, E. (2005). Large-scale implementation of sedation and delirium monitoring in the

intensive care medical centers. Critical care Medicine, 33(6), 1199-1205. doi:10.1097/01.CCM.0000166867.78320.AC