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Delirium

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Evan Mahakian

on 23 February 2015

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Transcript of Delirium

Delirium
Is an acute change in consciousness accompanied by inattention and
either
a change in cognition
or
a perceptual disturbance.
Best Practice
AACN Practice Alert 2011:
Implement delirium assessment
Create strategies to reduce risk factors
Be cautious with use of benzodiazepine
Consider adopting an ABCDE bundle
Delirium Positive
-Now What???
No drug is FDA approved to treat delirium
Is this the tip of the iceberg?
Metabolic Disturbance / Dehydration
Organ failure
Infection
Electrolyte Imbalances
Medication Interactions
Hypercapnia / Hypoxemia
Immobilization
What has changed in MICU?
In 2012 the Sedation Policy / Protocol was revised to:
1. Hyperactive
Delirium assessment & Management
Implementing CAM-ICU In A Medical ICU
Evan Mahakian RN, CCRN
(DSM IV, 1994)
Types of Delirium
2. Hypoactive
3. Mixed
Cost
$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)
Who's Delirious?
10-30% General Hospital Population

30-50% Hospitalized Older Adults

30% Open Heart Surgery

25-50% Cancer

50% Hip Fracture

60% Institutionalized Older Adult

83% Terminally Ill

(Ryan et al. 2009; Solai, 2009)
Mortality Rates
22-76% for General Hospital Population

35-40% One Year Mortality Rate

ICU patients particularly at risk
(Solai, 2009)
Delirium Affects
70-87%
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.
(Ely, 2014)
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
(Ely, 2014)
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.”
(AACN, 2014)
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

CAM-ICU Components
Is the RASS greater than -4 ?
1. Has there been a change in Mental status at any time during the past 24 hrs?
Inattention
2. Indicate when you hear the letter "A"
S-A-V-E-A-H-A-A-R-T
-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?
Disorganized Thinking
-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?
Risk Factors
Advanced Age

Advanced Acuity

Polypharmacy
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
Early mobility
Sensory aids
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)
Order Sets
In 2013 the MICU sedation order set was modified to include a physician order for CAM-ICU per the policy
PRISM (EHR)
Added to Critical Care Flowsheets

Includes Computer Based Decision Support
Hands On Education, 2014
Individual to Small group

Personal demonstration

Pocket Reference Card

Paper Copy of Teaching Plan

Unit CAM-ICU Reference Binder

Added to MICU New Hire Education
Challenges
Addition to other order sets

Fatalistic approach to delirium

Education

Victims of our own success?
References
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
Introduced, 2013
Presented by Ryan Clouser MD durring MICU Education Day

Initial PRISM design underway

Educator Updates
Full transcript