Delirium Management in Critical Care. April 17, 2013

Transcription

1 Delirium Management in Critical Care April 17, 2013

2 Organizational Overview Founded in bed tertiary care facility Serves 650,000 people in five states 2,600 employees Major service lines: Cardiology Emergency/Trauma Neurosciences Obstetrics/Neonatology Oncology and Orthopedics 2

3 Goal To create a delirium policy and protocol for identification, documentation and initiation of a multidisciplinary approach to treat delirium and the risks it imposes for critically ill patients To include: >Early assessment for delirium >Early documentation of findings >Electronic consultations to interdisciplinary departments for prompt initiation of appropriate interventions >Electronic process for data management to monitor findings and conduct ongoing evaluation of interventions 3

4 Clinical Issue Delirium affects up to 80% of patients in Critical Care The longer ICU patients are delirious the higher the risk for: >Increased morbidity >Increased mortality >Prolonged hospital stays *Guidelines recommend that critical care teams address delirium as a standard of care for all critically ill patients. (Pun, 2011) 4

5 Clinical Issue Annual cost of ICU delirium in the U.S. is $4-6 billion Average costs for patients with delirium more than 2x the costs compared to patients without delirium Total costs estimates attributed to delirium range from $16,000-$64,000 per patient Leslie, Marcantonio, Zhang & Leo-Summers, 2008 Centers for Medicare & Medicaid Services (CMS) proposed delirium as one of 9 new conditions to be added to Non- Reimbursable Hospital Acquired Conditions. 5

6 Historical approach: Culture Change Long periods of immobility and bedrest to restore physiological stability >Sedation, long-term ventilation & bedrest >risk for delirium Current approach: ABCDE Bundle >Awakening & Breathing Trial Coordination (Critical Care & RT) >Careful sedation choices (Critical Care and Pharmacy) >Delirium monitoring & documentation (Critical Care) >Early exercise & mobility (PT) (Pun, 2011) 6

7 Delirium Team Key Clinical Leaders: Clinical Nurse Specialist: Coordinator of Delirium Project Cardiothoracic CNS Critical Care Educator Project Leader: Clinical Information Systems Delirium policy and protocol development, development of nursing assessment in McKesson system (CAM-ICU Assessment Tool), staff education, monitoring of delirium assessment by Critical Care staff nurses, utilization of McKesson products, Conscious Sedation Policy revision, and implementation of Richmond Agitation Sedation Scale (RASS). 7

8 Clinical Liaisons: Delirium Team Respiratory Therapy Manager: Spontaneous Breathing Trials and ventilator weaning Physical Therapists: Early mobility Pharm.D.: Medication review Critical Care staff nurses: Delirium assessment and subsequent documentation Governance Structure: Chief Nursing Officer (Vice-President of Patient Care) Critical Care Director Critical Care Unit Patient Care Managers 8

9 9 Process Phase 1: Clinical Nurse Specialist: >Reviewed scholarly evidence regarding delirium >Consulted with members of the ICU Delirium & Cognitive Impairment Study Group, Vanderbilt Medical Center (delirium.org) >Assembled a multidisciplinary team based upon evidence-based practice guidelines Phase 2: The Clinical Nurse Specialists and Critical Care Educator: >Met with each committee member to discuss their role Phase 3: >Reviewed current Policies and Procedures related to initiation of a new Delirium Policy (i.e. Conscious Sedation policy, Spontaneous Breathing Trial policy) >Delirium education presented to team members

10 Process Phase 4: Reviewed and implemented McKesson Clinical Solutions Conducted education of Critical Care staff Delirium Project initiated Clinical Nurse Specialists and Critical Care Educator received daily electronic reports of each positive delirium assessment Monthly progress reports were submitted to the Chief Nursing Officer (Vice-President for Patient Care) and Critical Care Director 10

11 IOM: Aims of Healthcare Improvement Safety CIT (Clinical Information Technology) provided clarity, accuracy and continuity for critically ill patients with delirium: Early assessment, documentation and multidisciplinary consultation minimized the risk of delirium >RASS Sedation Scale >Trauma Admission Orders >Critical Care Sedation Orders >Spontaneous Breathing Trial Coordination >Consultation Alerts expedited appropriate interventions Client satisfaction: >Brochure for patient & family education provided >Delirium management communicated across the trajectory of care following ICU discharge 11

12 Overview of McKesson Clinical Solutions Utilized to implement the Delirium Policy and initiate interventions for delirium management. Each Clinical Solution helped to expedite clinical workflow by implementing evidenced-based interventions to promote quality patient care and minimize costs. 12

13 McKesson Clinical Solutions HORIZON EXPERT ORDERS Incorporation of RASS Sedation Scale Following adaptation of the RASS Sedation Scale for the newly introduced Delirium Screening Policy, the RASS score was incorporated into the Horizon Expert Orders for the: (1) Trauma Admission Orders and the (2) new Critical Care Sedation Orders to determine the sedation level for trauma patients and all patients requiring chemical sedation. 13 HORIZON EXPERT DOCUMENTATION Newly created ICU Delirium Chartable Review (CRv) for Adult Nursing Assessment RASS Sedation Scale added to Adult Nursing Assessment under ICU Delirium Chartable Review (CRv) CAM-ICU Delirium Assessment Tool under ICU Delirium Chartable Review (CRv) Spontaneous Breathing Trial results under ICU Delirium Chartable Review (CRv)

14 McKesson Clinical Solutions HORIZON EXPERT DOCUMENTATION (cont.) Revised Nursing Interventions (NIC/NOC) added to Adult Nursing Assessment under ICU Delirium Chartable Review (CRv) and Plan of Care Chartable Review (CRv). *The preexisting Nursing Interventions required revision to adequately capture the current evidence-based interventions for delirium management HORIZON CARE ALERTS Automatic consults to Pharmacy, Respiratory Therapy and Physical Therapy for every positive delirium screen. Based upon the CAM-ICU (Delirium Screening Tool) results, automatic alerts are sent to each interdisciplinary consulting department. An is forwarded to designated printers in each Intensive Care Unit. BUSINESS OBJECTS Daily automatic reports of all delirium screens are sent to the Clinical Nurse Specialists and Critical Care Educator for evaluation. 14

15 Monitoring Process Clinical Nurse Specialists and Critical Care Educator: Receive daily reports containing patient name, diagnosis, age and delirium status Monthly reports reviewed jointly Monthly data summaries maintained > The initial reports included the following data: a. total number of patients b. number of patients + for delirium c. number of patients for delirium Identified the need for inclusion of the following data on current and future reports: a. fluctuating: (+) and ( ) while in the ICU b. unable to assess: i.e. brain injury c. no score: failure to score patient d. (+) for delirium on admission to ICU e. (+) for delirium after admission to ICU f. (+ ) for delirium when discharged from ICU 15

16 Results Within the first 10 months, 23% of all ICU patients had positive screens for delirium 100% received immediate multidisciplinary consultations and intervention Days on mechanical ventilation while receiving conscious sedation days 2.9 days = <.5 days *approx. savings of $ per patient <.5 days on mechanical ventilation = decreased risk for complications Decreased pain management for patients receiving conscious sedation: Medication order revision Earlier mobility

17 Implementation of Delirium Project Appoint an advanced-practice nurse as coordinator of the project Establish a multidisciplinary team Provide delirium education for the Delirium Team and Critical Care Nursing staff Review existing institutional policies that increase the risk for delirium i.e. Conscious Sedation, Spontaneous Breathing Trials, Mobility Orders for Critical Care Establish current Clinical Information Technology (CIT) capabilities to support the project 17

18 Implementation of Delirium Project Provide patient and advocate education materials regarding delirium Initiate daily rounding on all shifts, by Clinical Nurse Specialists and Critical Care Educator, with Critical Care nursing staff and multidisciplinary team to review, assist and confirm the presence of delirium and subsequent need for specific clinical interventions Share communication strategies for capturing more detailed information about delirium between team members and Critical Care nursing staff 18

19 19 Key Recommendations to Apply Initiative Delirium affects every patient admitted to critical care. The project s outcomes, and future development to identify the best interventional strategies for patients with delirium, will minimize the risk and long term complications it imposes. Quality of life can be improved for these patients while decreasing health care costs. The results are replicable throughout all patient populations. >Assessment tools, appropriate to each age group, must be implemented: >Geriatric syndromes require ongoing, comprehensive physical, functional, and psychosocial assessments tailored to older adults.

20 Complexity of delirium Challenges Continual education of Critical Care staff and multidisciplinary team Specificity of documentation to address clinical findings Incompatibility of various IT systems Transitional Care follow-up In the last 4 months of the 192 patients that had delirium in the ICU: 49.6% had delirium upon admission to the ICU 20