Implementation of a Delirium Screening Tool in a Pediatric Intensive Care Unit

Transcription

1 Implementation of a Delirium Screening Tool in a Pediatric Intensive Care Unit BY: ABBY WACHHOLTZ, BSN, RN, PEDIATRIC ACUTE CARE DNP STUDENT Disclosures I have no disclosures. 1

2 Objectives 1. Recognize symptoms, risk factors, and consequences associated with delirium. 2. Understand the implementation process for delirium screening in the PICU population. 3. Understand the prevalence of delirium in one Midwestern PICU. Definition Delirium is a disturbance of both consciousness and cognition with the cardinal features of acute change or fluctuation in mental status and inattention 2

3 Delirium Subtypes Hyperactive Agitation, restlessness, attempting to remove catheters, emotional lability Hypoactive Flat affect, withdrawal, apathy, lethargy, decreased responsiveness Mixed Combination of hypoactive and hyperactive symptoms Why should we care? Underdiagnosed Misdiagnosed (withdrawal) Received incorrect treatment Inconsistent use of appropriate diagnostic and screening tools Lack of understanding of delirium by healthcare professionals 3

4 Why should we care? Adult screening tools not reliable for pediatric use Recent development of the Cornell Assessment of Pediatric Delirium (CAPD) American Association of Critical-Care Nurses (AACN) released a Practice Alert in November 2016 Risk Factors Age <2 years 3 Developmental Delay 3 Pre-existing medical condition 3 Severity of illness 3 Mechanical Ventilation 3 Receipt of benzodiazepines, corticosteroids, anticholinergics, and vasoactive medications 3 4

5 Current Literature >20% prevalence rate in pediatric ICUs 5 PICU length of stay 2x longer in delirious patients (median 7 vs 3 days, p<0.001) 3 Hospital length of stay longer in delirious patients (median 8 vs 3 days, p<0.001) 3 Hospitalization is 3.5x more expensive 4 In-hospital mortality is greater (5.24% vs 0.94%, p<0.001) 3 Why should we care? Early delirium diagnosis associated with: Decreased ICU LOS Decreased hospital LOS Decreased days of mechanical ventilation Decrease in amount of sedative and analgesics administered DECREASE IN MORTALITY!! 5

6 Implementation Process: Nurses Chart RASS score with each set of vitals Screen for delirium using CAPD once each shift 0600 and 1800 Notify provider with positive CAPD score Use prevention strategies with every patient What is the RASS? Richmond Agitation-Sedation Scale 10-point scale (-5 to +4) Measures agitation or sedation 6

7 Source: NYPH Benefits of the RASS +1 to +4 = hyperactive delirium 0 to -3 = hypoactive delirium -4 to -5 = persistently comatose Scores crossing zero = Mixed-subtype delirium 7

8 What is the CAPD? Cornell Assessment of Pediatric Delirium 8 item tool Uses non-verbal behaviors to capture changes affected in patients with delirium Orientation Arousal Cognition 8

9 Benefits of the CAPD Reliable and valid tool to assess pediatric delirium 5. Can reliably distinguish between pain, agitation, residual sedation, and delirium 3. Applicable to nearly every patient, including the developmentally delayed 5. Uses developmental anchor points for appropriate screening 6. Takes less than 2 minutes to administer. High degree of inter-observer and intra-observer reliability. Implementation Process Education session for nurses Education session for providers Interrater reliability Complete 2 CAPDs in presence of delirium champion Go-live 9

10 Screening Process RN charts RASS score with each set of vitals If RASS score -4 or -5, STOP here. If RASS greater than -4 (-3 to +4), continue with CAPD assessment. RN screens for delirium using CAPD once each shift 0600 and 1800 RN notifies provider of positive CAPD score ( 9) Use prevention strategies with every patient 10

11 Results: Demographic Data Demographic Details (n=total 171) Characteristic n(%) Gender Male 95(56) Female 76 (44) Age 0-24 months 82(48) 2-5 years 34(20) 6-12 years 20(12) years 35(20) Results: Demographic Data Admission Diagnoses (n=total 171) Characteristic n(%) Diagnoses Cardiac 48(28) Genetic disorder 1(0) Hematologic/Oncologic 3(2) Infectious/Inflammatory 15(9) Metabolic 5(3) Neurologic 9(5) Neurosurgical 20(12) Respiratory Insufficiency 43(25) Postoperative/other 27(16) 11

12 Results: Delirium Characteristics Delirium Characteristics Characteristic n(%) Delirium Incidence n=171 Ever delirious 54(31.6) Never delirious 117(68.4) Delirium Subtype n=374 Hypoactive 146(39) Hyperactive 12(3) Mixed 215(57) Results: Delirium Outcomes Selected Outcomes Entire Cohort Ever Delirious Median (Q1, Q3) Median (Q1, Q3) Age 2 (0, 10) 0 (0, 3.75) Hospital LOS 6 (3, 11) 10 (6, 20.75) PICU LOS 2 (1, 5) 6 (3, 15) 12

13 Results Children s Hospital and Medical Center Incidence rate: >30% Age: <3 years Longer hospital LOS Longer PICU LOS Days to delirious: 3 Current Literature Prevalence rate: >20% Age: <2 years Longer hospital LOS Longer PICU LOS Days to delirious: 3 Discussion Delirium is common in critically ill children Children s results are consistent with the current literature Can lead to negative patient outcomes There is a need for a delirium pathway/protocol in our institution Prevention Treatment Next steps 13

14 Appreciation PICU providers and nurses for their dedication, especially Amanda Hinkel and Vannessa Ramos Alex Hall (Creighton University) for Statistical Support Children s Hospital and Medical Center IT department for EPIC support Meghan Potthoff (Creighton University) for course support References 1. Schieveld, J., & Janssen, N. (2014). Delirium in the pediatric patient: On the growing awareness of its clinical interdisciplinary importance. JAMA Pediatrics, 168(7). 2. American Association of Critical-Care Nurses (AACN). (2016). AACN practice alert: Assessment and management of delirium across the life span. Critical Care Nurse, 36(4), e14-e Traube, C., Silver, G., Gerber, L.M., Kaur, S., Mauer, E.A., Kerson, A., &... Greenwald, B.M. (2017). Delirium and mortality in critically ill children: Epidemiology and outcomes of pediatric delirium. Critical Care Medicine. 4. Traube, C., Mauer, E. A., Gerber, L. M., Kaur, S., Joyce, C., Kerson, A.,... Greenwald, B. M. (2016). Cost Associated With Pediatric Delirium in the ICU. Critical Care Medicine, 44(12), e1175-e Traube, C., Silver, G., Kearney, J., Patel, A., Atkinson, T., Yoon, M.,... Greenwald, B. (2014). Cornell assessment of pediatric delirium: A valid, rapid, observational tool for screening delirium in the PICU. Critical Care Medicine, 42(3), Silver, G., Kearney, J., Traube, C., & Hertzig, M. (2015). Delirium screening anchored in child development: The cornell assessment for pediatric delirium. Palliative and Supportive Care, 13(4), Joyce, C., Witcher, R. W., Herrup, E., Kaur, S., Mendez-Rico, E., Silver, G.,... Traube, C. (2015). Evaluation of the safety of quetiapine in treating delirium in critically ill children: A retrospective review. Journal of Child and Adolescent Psychopharmacology, 25(9),