SPECIAL ARTICLE

A Clinical Pathway to Standardize Care of ChildrenWith Delirium in Pediatric Inpatient SettingsGabrielle H. Silver, MD,a,* Julia A. Kearney, MD,b,* Sonali Bora, MD,c Claire De Souza, MD,d Lisa Giles, MD,e Sophia Hrycko, MD,f Willough Jenkins, MD, FRCPSC,g

Nasuh Malas, MD,h Lisa Namerow, MD,i Roberto Ortiz-Aguayo, MD,j Ruth Russell, MD,k Maryland Pao, MD,l Sigita Plioplys, MD,m Khyati Brahmbhatt, MD,n

PATHWAYS FOR CLINICAL CARE WORKGROUP

A B S T R A C T Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that haslacked a consistent approach for detection and management. A clinical pathway (CP) was developedto address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs ofinpatient care of medically ill children and adolescents. Screening for delirium in hospital settingswith validated tools is feasible and effective in reducing delirium and improving outcomes; however,multidisciplinary coordination is required for implementation. The workgroup, composed ofinternational experts in child and adolescent consultation psychiatry, reviewed the literature anddeveloped a flowchart for feasible screening and management of pediatric delirium. When evidencewas lacking, expert consensus was reached; stakeholder feedback was included to create the finalpathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1)“Prevention and Identification of Pediatric Delirium” emphasizes the need for systematic preventivemeasures and screening, and (2) “Diagnosis and Management of Pediatric Delirium” recommendsan urgent and ongoing search for the underlying causes to reverse the syndrome while providingsymptomatic management focused on comfort and safety. Detailed accompanying documentsexplain the supporting literature and the rationale for recommendations and provide resources suchas screening tools and implementation guides. Additionally, the role of the child and adolescentconsultation-liaison psychiatrist as a resource for collaborative care of patients with delirium isdiscussed.

aNewYork-Presbyterian/Weill

Cornell Medical Center, Weill

Cornell Medicine, Cornell

University, New York, New York;bMemorial Sloan Kettering

Cancer Center, New York, New

York; cChildren’s Healthcare of

Atlanta, Atlanta, Georgia;dHospital for Sick Children,

University of Toronto, Toronto,

Ontario, Canada; eDepartments

of Pediatrics and Psychiatry,

School of Medicine, The

University of Utah, Salt Lake City,

Utah; fDepartment of Psychiatry,

University of Ottawa, Ottawa,

Ontario, Canada; gDepartment of

Psychiatry, School of Medicine,

University of California, San

Diego, La Jolla, California;hDivision of Child and Adolescent

Psychiatry, Departments of

Psychiatry and Pediatrics, C.S.

Mott Children’s Hospital, Medical

School, University of Michigan,

Ann Arbor, Michigan; iInstitute of

Living and Hartford Hospital,

School of Medicine, University of

Connecticut, Hartford,

Connecticut; jChildren’s Hospital

of Philadelphia, Philadelphia,

Pennsylvania; kMcGill University

Health Centre and Montreal

Children’s Hospital, Montréal,

Canada; lNational Institute of

Mental Health, National

Institutes of Health, Bethesda,

Maryland; mDepartment of

Psychiatry and Behavioral

Sciences, Ann and Robert H.

Lurie Children’s Hospital of

Chicago, Northwestern

University, Chicago, Illinois; andnDepartment of Psychiatry,

Langley Porter Psychiatric

Institute, Weill Institute for

Neurosciences, Benioff Children’s

Hospital, University of California,

San Francisco, San Francisco,

California

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2019-0115Copyright © 2019 by the American Academy of Pediatrics

Address correspondence to Gabrielle H. Silver, MD, NewYork-Presbyterian/Weill Cornell Medical Center, 470 West End Ave, Suite 1AA, NewYork, NY 10024. E-mail: dr.gabriellesilver@gmail.com

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by the Abramson Fund of the American Academy of Child and Adolescent Psychiatry and the Intramural ResearchProgram (ZIA MH002922-10) of the National Institute of Mental Health of the National Institutes of Health.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Drs Silver and Kearney organized and led pathway development, drafted sections and assembled the initial manuscript, and coordinatedall edits and revisions; Drs Bora, De Souza, Giles, Hryko, Jenkins, Malas, Namerow, Ortiz-Aguayo, and Russell participated in pathwaydevelopment, drafted sections of the initial manuscript, and reviewed and revised edits; Drs Pao and Plioplys conceptualized anddesigned the overall pathway project and critically reviewed the manuscript; Dr Brahmbhatt conceptualized and designed the overallpathway project, participated in pathway development, drafted sections of the initial manuscript, and reviewed and revised edits; andall authors approved the final manuscript as submitted.

*Contributed equally as co-first authors

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Delirium is a well-described syndrome ofacute brain dysfunction1 associated withunderlying physical illness. It involves anacute change in baseline awareness, andonset of altered behavior or cognition, witha fluctuating course.2 Currentpathophysiologic models explain deliriumsymptoms as the result of disturbanceswithin the neuroendocrine andinflammatory pathways triggered by anunderlying physiologic disturbance, such asa systemic or neurologic medical condition,or iatrogenic causes, such as use ofsedatives, substance intoxication, orwithdrawal.2–4 Current understanding ofpediatric delirium is extrapolated fromrobust adult literature and supported byexpanding pediatric literature.5–10

Delirium can occur in any setting but ismost prevalent in the inpatient setting,predominately in the critical care setting,because of worsening clinical disease andexposure to pharmacologic agents that canexacerbate delirium, such asbenzodiazepines or anticholinergics.10–15

Prevalence rates are ∼20% to 44% in PICUsettings, according to US studies.16–20 Theinpatient environment can confer risks forthe development of delirium due to noiseand overstimulation, causing frequentdisruptions in rest and sleep.21 Validatedscreening tools have recently becomeavailable and are feasible for implementationin detecting pediatric delirium. Tools includethe Pediatric Confusion Assessment Methodfor the ICU (pCAM-ICU), the PreschoolConfusion Assessment Method for the ICU(psCAM-ICU), and the Cornell Assessment ofPediatric Delirium (CAPD).17,18, 20, 22–25

Pediatric delirium can have significantimpacts on morbidity, mortality, andfinancial costs. Delirium increases length ofstay in pediatric critical care settings andlength of mechanical ventilation by 2 to3 days26 and is an independent predictor ofmortality (adjusted odds ratio 4.39; P ,.001).16 Hospital costs of youth with deliriumare .4 times the cost of similar youthwithout delirium ($18 832 vs $4803; P ,.0001), with incremental increases in costseen with each day a child remainsdelirious. Controlling for age, sex, severity ofillness, and pediatric critical care length of

stay, delirium is associated with an 85%increase in hospitalization costs.26 Beyondshort-term effects on hospital outcomes,delirium studies in adults show significantcognitive, emotional, and behavioral impactsbeyond the hospital stay.25,27–29 In asystematic review and meta-analysis of5280 adult patients with delirium, there wasan association between the presence ofdelirium and a decline in cognitiveoutcomes.30 Long-term outcome research inpediatric delirium is needed. A significantminority (nearly one-third) of pediatricpatients with delirium describeposttraumatic stress symptoms up to3 months after hospitalization.31 A recentstudy of cognitive function in PICU survivorsdid not find an association betweendelirium and impaired cognition, althoughthe survivors did have lower IQ as a groupcompared with the normal population, andthe study was limited by design, usingnormative scales only and lacking controlsor baseline evaluations for subjects.32

Despite the negative outcomes associatedwith pediatric delirium, there is a lack ofstandardization of prevention, evaluation,and management.33 For problems likedelirium, clinical pathways (CPs) can be aneffective means of standardizing care bytranslating current literature and expertconsensus into clinical practice.34,35 Althoughthey have been increasingly used inpediatric diseases ranging from community-acquired pneumonia to cystic fibrosis, therehas been limited use of CPs to addresscomplex conditions at the interface ofpediatric medicine and psychiatry, such asin the case of delirium.36–38 CP use hasresulted in decreased length of stay,reduced health care use and costs, reduceduse of unnecessary diagnostic practices andinterventions, reduced recidivism, andimproved quality of care.36,39 They anchorthe interdisciplinary care teams, as well asfamilies, to aligned expectations andprinciples for care. They also allow forclinician judgment and do not provide arigid, overly prescriptive approach.40 Factorsthat predict successful CP implementationinclude high disease prevalence, significantdisease impact on patient outcomes, highpractice variability, and broad,multidisciplinary care involvement.40

The goal of standardizing pediatric deliriumcare in this way is to improve outcomes,prevent delirium, decrease length of stayand invasive interventions (such asprolonged mechanical ventilation orextended sedation use), reduce cost,improve quality of life, and enhance patient,family, and provider satisfaction with care.39

The current study describes the processand content development of a CP forinpatient pediatric delirium care developedthrough evidence-based review, broadstakeholder feedback, and expertconsensus by a representative group ofchild and adolescent consultation-liaisonpsychiatrists in the United States andCanada.

METHODS

The Pathways for Clinical Care (PaCC)Workgroup has described the overallprocess of developing 3 pediatricconsultation-liaison CPs41,42 using anestablished model for CP creation.43

Identifying the Need for a CP

Factors that may make a conditionappropriate for successful pathwaydevelopment include the following. (1)Either high-volume, common conditions or iflow-volume condition is high risk: Deliriummeets both conditions when it is prevalentin inpatient settings, namely critical care,and when not as prevalent (generalpediatric hospitalized population), it mayindicate new-onset central nervous systemcomorbidities or be a harbinger of criticalsystemic complications (eg, sepsis). (2)Strong evidence base: There is strongevidence for screening and a fair evidencebase for management from adult researchwith growing pediatric evidence. (3) Highvariation in practice: This was affirmed bythe varied experiences the authors hadwhen implementing best practices forpediatric delirium at their own institutionsand stakeholder feedback obtained frommultiinstitutional inpatient pediatric careproviders. A lack of standardized screening,institutionally based patterns of prescribingdrugs (deemed either useful or taboo) forpediatric patients with delirium, and evencross-disciplinary differences in diagnosticlanguage and recognition of delirium

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further this as a compelling target forstandardization through pathwaydevelopment. (4) Traverses differentsettings: Delirium, although most commonin critical care, often occurs in otherinpatient medical and surgical settings andinvolves many disciplines caring for1 patient. These factors all point to theurgent need for a pathway for pediatricdelirium screening and management.

Assembling a Team of Experts

The subgroup coleaders has an establishedclinical and research expertise in pediatricdelirium as authors of the CAPD and otherseminal peer-reviewed publications.* The13 subgroup members practice in a varietyof consultation-liaison settings in 7 USstates and 2 Canadian provinces, workmainly in medium or large academic acutemedical centers, and have some variation inresources and practice patterns. Allmembers volunteered to participate in thepathway development initiative.

Starting in 2016, the subgroup met regularlyover 2 years, primarily throughteleconferences (∼28 calls and 4 in-personmeetings). Work was conducted byindividual members and shared with thegroup for discussion and consensusgeneration. To establish a shared baselinelevel of knowledge and understanding, thecoleaders facilitated telephone-basedtraining and dialogue on screening andmanagement of delirium based on a reviewof the literature and the leaders’ previouswork.55–57 Ilana Waynik, MD, a pediatrichospitalist and clinical educator withexpertise in CP generation, providedongoing guidance about pathwaydevelopment over the 2 years.

Compiling and ReviewingBackground Research

The literature on pediatric delirium wascompiled, reviewed, and used to inform andstructure steps in the pathway. Subgroupmembers shared current practices,guidelines, and protocols (as available)from their individual institutions, whichfurther influenced the common,foundational elements of the pathway. When

evidence was limited, consensusdiscussions by subgroup expertscontributed to elaboration of some pathwayrecommendations.

Developing the CP

On the basis of literature review andclinical consensus discussions, thesubgroup drafted an outline of the keypathway steps and drafts of the pathwaydocuments. Feedback and revisions weredone iteratively at 3 key points withdifferent audiences: (1) The initial draftswere shared with the members of thelarger PaCC Workgroup and Dr Waynik, theCP expert, at a face-to-face workshopretreat made possible by an AmericanAcademy of Child and AdolescentPsychiatry (AACAP) Abramson Fund grantobtained for the initiative. (2) The pathwaywas then presented and discussed at theAACAP October 2017 Annual Meeting andMember Services Forum in Washington,District of Columbia. Audience responseson language, format, and implementationstrategies informed further refinementof the suite of documents.41 (3) Finally,the pathway was shared withmultidisciplinary stakeholdersrepresenting a range of fields, includingpediatric critical care, advanced practicenursing, bedside nursing, physiotherapy,and pharmacy, and a parent frommembers’ hospitals by using aquestionnaire devised by the subgroupto elicit feedback. Responses weresummarized, considered by members, andincorporated into the pathway documentsif consistent with the pathway goals andevidence base.

RESULTS

The products of the described consensusprocess are a suite of complementarydocuments including 2 flowcharts(Figs 1 and 2) and two text documents:“Introduction to the Delirium Pathway” and“Guide to the Delirium Pathway”(Supplemental Information). Many aspectsof the intervention are flexible to localpreferences and practice, which may varyaccording to resources. The flowchartsintentionally include detailed information onnonpharmacologic prevention and

intervention so that these documents couldserve as stand-alone clinical or educationalresources with end-user ease in mind.

DISCUSSION

Delirium is a disabling and prevalentcondition among hospitalized children.Increasing recognition of pediatric deliriumby clinicians reveals concerns aboutappropriate assessment and treatment. Topromote a more standardized approach tocare, we present a consensus-driven,evidence-based CP on the detection andmanagement of pediatric delirium ininpatient settings.

When possible, empirical evidence wasincluded to inform each pathwayrecommendation. When no evidence wasfound, the rationale supporting theinclusion of each consensusrecommendation is described in the guide.Consensus discussions took into accountvalues and priorities such as patient safety,illness prevention, early identification,patient-centered care, family systemsinterventions, and multidisciplinary and/orteam-based practice.

Given that inpatient care, and thus deliriumevaluation and management, ismultidisciplinary by nature, documentswere created with input frommultidisciplinary stakeholders and writtento acknowledge the different audiences,such as nursing, physician specialists (eg,critical care and neurology), rehabilitation,pharmacy, and administration. Thisinclusive approach recognizes thatsuccessful implementation of a new CPrequires education, participation, and buy-infrom all relevant disciplines. Thecomplementary pathway documents weredesigned to address the varying needs ofthe stakeholder groups. For example, thepathway flowchart is a simplified, easy-to-read, bedside reference tool (Figs 1 and 2),whereas the accompanying narrative,“Guide to the Pathway” in the SupplementalInformation, presents a morecomprehensive, in-depth description of eachstep and its underlying rationale.

The pathway is designed to provide anoverall guide, not a prescriptivemethodology, for pediatric institutions*Refs 10, 12, 13, 16, 17, 22, 26, and 44–54.

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FIGURE 1 Pediatric Delirium Pathway I: Prevention and Identification. OT, occupational therapy; PT, physical therapy.

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focused on improving delirium evaluation

and management. It was challenging to

ensure the “best” balance between

standardization of recommendations and

potential for setting-specific customization

of recommendations. Because institutions

have heterogeneous needs, resources, and

populations, the pathway is amenable to

modification and refinement by local care

FIGURE 2 Pediatric Delirium Pathway II: Diagnosis and Management. OT, occupational therapy; PT, physical therapy.

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teams and institutional workgroups. Thepathway indicates when and where it isrecommended to engage psychiatry; whenand how this occurs may become settingspecific because of the availability ofconsultation-liaison psychiatry in differenthospitals. Another example of adaptationpotential is the promotion of the use ofwhichever validated delirium screening toolbest meets an institution’s needs.Additionally, pathway elements may berevised for discipline-specific policies (eg,nursing policies may be written to includeparameters for bedside screening, andenvironmental interventions nursescan implement for prevention andmanagement).

Implementation of the pathway can be ledby leadership in child and adolescentconsultation-liaison psychiatrists, pediatricintensivists or hospitalists, or pediatricnurses and requires champions in alldisciplines. As child and adolescentconsultation-liaison psychiatrists, webelieve this clinical area offers a uniqueleadership opportunity for members of ourfield. Through the process of successfulimplementation of the Pediatric DeliriumPathway, the psychiatrist can offer valuableexpertise toward an education and trainingprogram, the development of delirium ordersets, and the identification of quality metricsfor ongoing review and improvement.43 Theinsights a psychiatrist brings to thedifferential diagnosis of delirium, thedevelopmental presentation of symptoms inchildren, and the appropriate use ofantipsychotics in medically ill children willhelp ensure safe and meaningfulimplementation of the pathway. An addedbenefit of leading these initiatives in ourown institutions has been the fullerintegration of consult-liaison psychiatryteams into the PICU and other medical units.

One limitation in the process of pathwaydevelopment was the lack of publishedevidence for many recommendations.Although the quality of evidence wasconsidered, a formal Preferred ReportingItems for Systematic Reviews and Meta-analysis systematic review was not completedfor this study. Another limitation is the lack ofa systematic, blinded approach to reach

expert consensus for clinical management,such as the Delphi method. Additionally,because a review of quality metrics has notyet been done, there is no assurance thatadherence to these recommendationswill bring improved outcomes for deliriumcare.

Future steps for this pathway initiativeinclude the design of multiinstitutionalstudies to examine implementationprocesses and the impact on patient,provider, and system outcomes. Examinationof rates of adherence to the pathway mayhelp us better understand barriers to andfacilitators of pathway implementation.Studying outcomes such as changes indelirium prevalence, sources of delirium,delirium interventions used, length of stay,morbidity, and mortality may help elucidatethe clinical benefits and drawbacks ofpathway implementation. Revisions to thispathway based on emerging research are tobe expected and will require ongoingcollaboration between pediatrics, nursing,and child and adolescent psychiatry. Theconcept of CPs is still relatively new inpsychiatry, especially when it targetspsychiatric or behavioral problems inhospital-based pediatric medical and/orsurgical contexts. This delirium pathwayrepresents a promising example of howpsychiatric CPs may promote improvementof quality of care in inpatient pediatrichospital settings.

CONCLUSIONS

We propose a CP representing a distillationof current literature and expert consensusin screening, evaluation, and managementof pediatric delirium. This pathway isdesigned to be adapted to fit individualinstitutions and foment a multidisciplinaryapproach while encouraging consultation-liaison child and adolescent psychiatryleadership and integration. Ongoingresearch regarding pathwayimplementation, outcomes, and continuedprocess improvement is warranted.

Acknowledgments

In addition to the authors of this article, thePaCC Workgroup includes Patricia Ibeziako,MD, Lisa Horowitz, PhD, Andrea Chapman,MD, Shanti Gooden, MD, Finza Latif, MD,

Petra Steinbuchel, MD, Khalid Afzal, MD, KyleJohnson, MD, Elizabeth Kowal, MD, andBrian Kurtz, MD. The authors thankgraphic designer Kathleen Saminy for herinvaluable collaboration in this pathwaydevelopment.

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DOI: 10.1542/hpeds.2019-0115 originally published online October 29, 2019; 2019;9;909Hospital Pediatrics 

PATHWAYS FOR CLINICAL CARE WORKGROUPOrtiz-Aguayo, Ruth Russell, Maryland Pao, Sigita Plioplys, Khyati Brahmbhatt and

Sophia Hrycko, Willough Jenkins, Nasuh Malas, Lisa Namerow, Roberto Gabrielle H. Silver, Julia A. Kearney, Sonali Bora, Claire De Souza, Lisa Giles,

Inpatient SettingsA Clinical Pathway to Standardize Care of Children With Delirium in Pediatric

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PATHWAYS FOR CLINICAL CARE WORKGROUPOrtiz-Aguayo, Ruth Russell, Maryland Pao, Sigita Plioplys, Khyati Brahmbhatt and

Sophia Hrycko, Willough Jenkins, Nasuh Malas, Lisa Namerow, Roberto Gabrielle H. Silver, Julia A. Kearney, Sonali Bora, Claire De Souza, Lisa Giles,

Inpatient SettingsA Clinical Pathway to Standardize Care of Children With Delirium in Pediatric

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