Delirium, Patient Outcomes, and Nursing Practice. Objectives

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1 Delirium, Patient Outcomes, and Nursing Practice Sharon Gunn, MSN, MA, RN, ACNS-BC, CCRN Clinical Nurse Specialist Critical Care Baylor University Medical Center Dallas, TX Objectives Describe the three delirium subtypes and potential causes of delirium. Recognize how delirium affects patient outcomes. Identify nursing practices to prevent /minimize duration of delirium.

2 Clinical Pearl What is Delirium? Altered LOC Inattention Disorganized thinking Acute onset with fluctuating course Delirium is characterized by sudden onset

3 How many types of delirium? Hyperactive agitated, restless, tries to remove lines/tubes, hitting, biting, etc. Hypoactive lethargic, withdrawn, apathy, flat affect Mixed may exhibit signs of both or fluctuate between hyper and hypoactive delirium Truman,B. & Ely, W. (2003). Monitoring delirium in critically ill patients: Using the confusion assessment method for the ICU. Critical Care Nurse. 23(2) Why Screen for Delirium? Delirium Increases length of stay, mortality, and cost Patients with delirium who survive have long term cognitive dysfunction. This affects quality of life and performance of daily activities Screening and treatment for delirium in hospitalized patients can help attenuate these adverse outcomes

4 So What? Delirium is directly associated with 1,2,3 : Increased morbidity and mortality (3.2 times more likely to die than pts who do not have delirium) Risk of death increases 10%/day for patients in ICU with delirium Increased hospital LOS as much as 11 days in some studies Increased Vent days So What? Nearly 1/3 of patients remain delirious 6 months later Of these patients, 39% will be dead within the year Patients who survive suffer long term cognitive decline 1. O Keefe, S. and Lavan, J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc. 1997; 45(2): Kiely DK, Markantonio ER, Inouye SK, et al. Persistent delirium predicts greater mortality. J Am Geriatr Soc. 2009;57(1): Jackson JC, Gordon SM, Hart RP, Hopkins RO, and Ely EW. The association between delirium and cognitive decline: A review of the empirical literature. Neuropsychol Rev. 2004; 14(2):87-98.

5 So What? Costs estimated at 39% higher per ICU stay 31% higher hospital stay $152 billion US healthcare costs Stuck et al. Preventing Intensive Care Unit Delirium. DIMENS CRIT CARE NURS. 2011;30(6):315/320 How common is delirium? Studies report anywhere from 20-90% of ICU patients have delirium Up to 30% of all hospitalized patients Up to 50% of hospitalized elderly Patients may have predisposing risk factors We may precipitate the occurrence of delirium Flagg, B., McDowell S. & Buelow, J. (2010). Nursing identification of delirium. Clinical Nurse Specialist. 24(5): The elderly are particularly vulnerable to developing delirium

6 Food for thought % Population >5 > % of the population has 5 or more chronic diseases and uses 30% of health care dollars Majority of cost is spent on the elderly % of Total COST Inspiration from Gawande, Atul: Hot Spots ; New Yorker, January 2011 # Chronic Diseases 11 Pathophysiology Not well understood Inflammation/sepsis? Imbalance of neurotransmitters? Reduced blood flow to brain? Metabolic disturbances? Bruno, J. & Warren, M. (2010). Intensive care unit delirium. Crit Care Nurs Clin North Am. 22(2):

7 Risk Factors for Developing Delirium Predisposing: Age Incidence increases Sensory impairment Hx of dementia, ETOH, smoking, depression Malnutrition, disease processes Polypharmacy and psychotropic meds Renal/liver impairment Sendelbach et al. Evidence-Based Guideline Acute Confusion/Delirium Identification, Assessment, Treatment, and Prevention. Journal of Gerontological Nursing (2009) 35:11, Risk Factors for Developing Delirium Precipitating Factors Dehydration Sleep deprivation Restraints/lines/tubes Excessive noise Day/night orientation out of whack Anticholinergic & Benzo medications Constipation O Mahony,R. Synopsis of the National Institute for Health and Clinical Excellence guideline for prevention of delirium. Ann Intern Med. 154(11): Faezah, S.K. The Prevalence and Risk Factors for Delirium Amongst the Elderly in Actute Hospital. Singapore Nursing Journal. 35(1):

8 Persistent delirium = lower survival Kiely et al. (2009). Persistent delirium predicts greater mortality. J Am Geriatr Soc 57:55-61, 2009.

9 Facts 4 In 2009 only 59% of hospitals screen for delirium 29% of hospitals use a standardized tool for screening Consider sensitivity and specificity and ease of use when selecting 4. Bruno JJ, and Warren ML. Intensive care unit delirium. Crit Care Nurs Clin North Am. 2010;22(2): You can t tell if someone has delirium just by looking at them! Delirium Screening Tools CAM CAM-ICU Mini Mental State Exam (MMSE) Delirium Observation Screening Scale Delirium Rating Scale Memorial Delirium Assessment Scale (MDAS) Nursing Delirium Screening Scale (Nu- DESC) Ali, S. et al.(2011). Insight into delirium. Innov Clin Neurosci. 8(10):25-34.

10 Role of Nursing Prevention & treatment is multidisciplinary but has specific nursing components Remember predisposing and precipitating factors! Nurses can make a huge difference! Screen patients on admission for risk factors and be proactive. Nursing and predisposing factors Sensory impairment: insure patient has dentures, hearing aids, glasses Hx of ETOH, smoking, depression: watch for alcohol withdrawal, nicotine patch, antidepressants Malnutrition: Monitor I and O and assist with feeding if necessary Polypharmacy and psychotropic meds: med reconciliation, discuss medication regimen with MD and pharmacy Lots of patients are admitted to hospital and are on antidepressants. Often these medications are overlooked during inpatient stay!

11 Nursing and precipitating factors Promote day/night orientation If possible allow uninterrupted periods of sleep (90 mins at a time) Keep environment quiet Remove unnecessary lines/tubes and reassess daily Sedate if agitated. Pain control. Bowel management Accurate and consistent Delirium screening Medical Treatment Haldol watch QT interval Seroquel Precedex Medical Treatment Avoid benzo s and anticholinergics Bowel regimen

12 What we did about it Prevention and treatment of delirium has nurse sensitive components We did not have a process in place to routinely screen patients for delirium Our goal was to implement delirium screening on all patients and standardize preventive nursing practices on our unit. Find staff nurse champions!! Implementing Practice Change Review of Literature: Identified screening tool, patient outcomes, and how to prevent/treat delirium Buy-in from key stakeholders nurse leaders/staff/physicians Educate the nursing staff Staff nurse super screeners on each shift were recruited to help implement and sustain the practice change.

13 Implementing Practice Change An initial pilot of approximately 2 weeks included delirium screening on all ICU patients twice daily by the super screeners. Rolled out daily screening to all staff members. Nursing practices were identified via the literature to prevent and treat delirium. An interdisciplinary team was formed and an order set was developed to prevent and treat patients with delirium. Inouye, et al. A Multicomponent Intervention To Prevent Delirium in Hospitalized Older Patients. The New Eng Jour of Med: 340(9) Vidan et al. An Intervention Integrated into Daily Clinical Practice Reduces the Incidence of Deliriurm During Hospitalization in Elderly patients. JAGS 57: , 2009.

14 Initial Outcomes The CNS tracked daily incidence of patients with delirium, nursing preventive practices, and use of the order set over a six month period. Our initial findings have been promising showing a decrease in daily incidence of delirium from 42% to 23%. Factoid: Decrease restraint use, decrease delirium, decrease falls, decrease LOS, decrease HAI s! Initial Outcomes Share results with stakeholders!

15 Screening Tool for Pilot Next Steps Delirium ICU order set developed Screening added to electronic health record Creating reports to track incidence of delirium via electronic health record Disseminated practice throughout critical care and healthcare system Piloting delirium screening on medicine floor

16 Delirium Order Set Delirium Order Set

17 Intensive Care Med (2009) 35: What s the difference?

18 Tips to promote staff buy-in Educate about delirium, risk factors and consequences Identify core group of innovators Use clinical ladder, projects, abstracts to conferences as motivator Share results and best practices Video with staff Plan ahead Be persistent Lessons learned Identify champions early in process Be persistent Track processes and outcomes to identify OFIs and successes

19 Questions?

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