Joseph Brant Memorial Hospital(JBMH)

Delirium in Critical Care

2

Background

• JBMH chose to participate in the ICU Collaborative in

January 2012 with the intent of learning best practices to

provide quality care when screening, assessing and

treating the critical care patient for delirium. Prior to this

JBMH did not have these processes in place for the

critical care patient

• Involvement of the inter-professional critical care team members was deemed necessary to identify these processes to achieve best patient outcomes and to sustain validated delirium prevention practices

3

Aim

• Develop education for ICU staff regarding delirium definition, prevention and management within 12 months

• Implement a delirium screening process for all ICU patients within 6 months

• Tabulate incidence of delirium within 6-8 months• Implement standardized delirium prevention

interventions for all ICU patients within 12 months• Implement standardized interventions for the

management of patients identified with delirium within 12 months

• Implement strategies to include families of patients with delirium within 12-18 months

4

Team Members

• Intensivist: Dr Stephanie Robbins• ICU Manger: Geoff Flannagan• JBMH Sponsor: Jill Randall Director Critical Care• Critical Care Educator: Jackie Adcock• RNs: Sandra Pagani, Ashley Robertson, Kristy Stouck• Pharmacist: Poobalan Nayiager• RT: Laurie Taplin• PT: Katie Williams• SLP: Kalen Paulson

5

Results

Screening for DeliriumEducation was provided about the definition

of delirium and the use of the Intensive Care Delirium

Screening Checklist (ICDSC) tool

The ICDSC is to be completed

each shift and prn for all ICU patients

Chart audits to determine whether ICDSC tools

were completed once a month over 4 months

The goal is for 100% of ICU patients to be screened

for delirium. The audit reveals an average of 80%

Increased frequency of audits is required to validate

findings

Strategies to improve consistency of completion

of ICDSC on all ICU patients need to be explored

1-Jul 1-Aug 1-Sep 1-Oct0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Intensive Care Delirium Screening Compliance Rate JBMH ICU 2012

% Compliance

Months

% C

om

pli

ance

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Results

1-Jul 1-Aug 1-Sep 1-Oct0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Positive ICDCS Score JBMH ICU 2012

Positive Score

Nu

mb

er

of

Pa

tie

nts

wit

h P

os

itv

e IC

DS

C S

co

re

Positive Delirium Scores

Positive delirium scores are determined by an ICDSC score of 4 or more

Charts were audited to discover how many patients had a positive ICDSC score

The audit reveals an average of just over 2 patients (out of 14) over the 4 months scoring positive for delirium

As the audits were only performed once a monthover 4 months a true picture for incidence of delirium likely was not realized

Availability of resources to provide more consistent auditing has been a challenge

We will continue to consider ways of procuring valid and consistent data collection and measurement

7

Changes to be Tested

• Delirium education has been provided to all ICU team members• Delirium posters are displayed throughout the ICU that define delirium, speak to

causes and the ABCDE bundle• ICDSC and RASS score templates are laminated on all ICU RN desks outside patient

rooms• RNs are to document the RASS and ICDSC on all ICU patient flow sheets each shift• The daily goal sheet used at rounds each day was revised to include RASS and

ICDSC scores• At daily patient rounds since May 2012 ICU patients are identified as being positive or

negative for delirium via the ICDSC tool• The team at rounds reviews the medications of the patient that is positive for delirium

with a view of eliminating deliriogenic medications such as benzodiazepines and considers adding Seroquel or Haloperidol as appropriate

• Other interventions to reduce delirium discussed at rounds are SBTs and mobilization goals for the day

• New ventilator orders have daily wake and wean interventions and eliminated Midazolam infusion

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Lessons Learned

• We need the participation of the whole Critical Care Team to promote consistency and sustainability of delirium strategies

• Some ICU staff do not complete the RASS and ICDSC scores each shift on their patients which prohibits identifying and treating those with delirium

• Increased frequency of audits is required to validate findings • Availability of resources to provide more consistent auditing has

been a challenge• It is difficult to mobilize our patients consistently as our PT

availability is only 5 hrs Mon-Tues-Thurs-Fri • It can be difficult to keep momentum for delirium with other

competing projects

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Next Steps

• We need to continue be more compliant with completing ICDSC on all ICU patients

• Audits for completion of ICDSC and incidence of delirium need to continue • Delirium status for all ICU patients must be discussed at daily rounds • Non-pharmacological delirium prevention interventions to be added to the

ICU admission orders• Patient orders set for delirium in critical care need to be explored• A mobilization protocol for ICU patients needs to be developed with

Intensivist, Educator, RN, RT and PT as leads• We need to create noise reduction awareness posters in the ICU for staff,

patients and families• We have a highly visible board in the ICU that provides education on

delirium and we will add data on delirium audits (ICDSC compliance and incidence of delirium)

• Continue to learn strategies for delirium prevention and treatment in critical care