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Transcript of Delirium
Is an acute change in consciousness accompanied by inattention and
a change in cognition
a perceptual disturbance.
AACN Practice Alert 2011:
Implement delirium assessment
Create strategies to reduce risk factors
Be cautious with use of benzodiazepine
Consider adopting an ABCDE bundle
No drug is FDA approved to treat delirium
Is this the tip of the iceberg?
Metabolic Disturbance / Dehydration
Hypercapnia / Hypoxemia
What has changed in MICU?
In 2012 the Sedation Policy / Protocol was revised to:
Delirium assessment & Management
Implementing CAM-ICU In A Medical ICU
Evan Mahakian RN, CCRN
(DSM IV, 1994)
Types of Delirium
$4 to $16 Billion per Year
(Pisani et al., 2007; Pandharipande et al. 2008; Ely et al. 2001; McNicoll et al. 2003; Milbrandt et al. 2004)
10-30% General Hospital Population
30-50% Hospitalized Older Adults
30% Open Heart Surgery
50% Hip Fracture
60% Institutionalized Older Adult
83% Terminally Ill
(Ryan et al. 2009; Solai, 2009)
22-76% for General Hospital Population
35-40% One Year Mortality Rate
ICU patients particularly at risk
of Patients in ICU
(Ryan et al. 2009; Solai, 2009)
We have learned that duration of delirium in ICU patients is one of the strongest independent predictors of death, length of stay in the hospital (even after adjusting for acuity), cost of care, and long-term cognitive impairment.
Less than 5% of Delirium is Hyperactive
Hypoactive Delirium is Generally Associated With A Worse Prognosis
Than Hyperactive Delirium
Hypoactive delirium is missed in 75% of circumstances in the absence of active monitoring
For many years, critical care nursing and medical teams have considered delirium to be a benign problem, often even saying,
“It will clear when we get them out of the ICU.”
Is this what you think of...
when you think delirium?
Society of Critical Care Medicine 2013:
Differentiation of pain, agitation, delirium
Recommends use of reliable tools
Greater emphasis on delirium
Is the RASS greater than -4 ?
1. Has there been a change in Mental status at any time during the past 24 hrs?
2. Indicate when you hear the letter "A"
-If they correct your spelling they
are not delirious
-An inability to perform suggests a positive finding for inattention
Altered Level of Consciousness
-Is the RASS anything other than zero?
-Will a stone float on water?
-Can you use a hammer to pound a nail?
-Are there fish in the sea?
-Does one pound weigh more than two pounds?
3 days longer in ICU (5 vs 8 days)
Higher ICU cost ($22,000 vs $13,000)
Increased Ventilator Days (9 vs 4 days)
Longer hospital stay (21 vs 11 days)
Antipsychotics have limited evidence
Choose analgesia before sedation
Provide sleep periods
Dexmedetomidine or Propofol
Family presence / reorientation measures
Represent the A,B,C,D,E approach
Discourage routine use of benzos
Specify use of CAM-ICU at set intervals (three times per day, including before and after sedation interruptions)
In 2013 the MICU sedation order set was modified to include a physician order for CAM-ICU per the policy
Added to Critical Care Flowsheets
Includes Computer Based Decision Support
Hands On Education, 2014
Individual to Small group
Pocket Reference Card
Paper Copy of Teaching Plan
Unit CAM-ICU Reference Binder
Added to MICU New Hire Education
Addition to other order sets
Fatalistic approach to delirium
Victims of our own success?
American Association of Critical Care Nurses. (2011). Practice alert: Delirium assessment and management. Retrieved from http://www.aacn.org/WD/practice/docs/practicealerts/delirium-practice-alert-2011.pdf
Ely W. & Vanderbilt University Medical Center. (2014). Confusion Assessment Method for the ICU: Training Manual. Retrieved from http://www.icudelirium.org/docs/CAM_ICU_training.pdf
Ely et al. (2001). Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 286(21), 2703-10. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11730446
ICU Delirium and Cognitive Impairment Study Group. (n.d.). For medical professionals. Retrieved from http://www.icudelirium.org/medicalprofessionals.html
Society of Critical Care Medicine. (2013). Agitation and delirium clinical practice guidelines. Retrieved from http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/SCCM-Releases-New-Pain,-Agitation-and-Delirium-Clinical-Practice-Guidelines.aspx
Woten, M. (2012). Confusion Assessment Method (CAM) of screening test for delirium. CINAHL Information Systems.
So What is the Common Denominator Behind What is Improving Our Care?
A Miracle Medication?
A High Tech Device?
...Or Good Fundamental Bedside
Care & Communication?
It Is Very Important For Nurses To Remember That This Is A Multidisciplinary Problem
Presented by Ryan Clouser MD durring MICU Education Day
Initial PRISM design underway