Fighting the Fog A Collaborative Approach to Decreasing ICU Delirium

Transcription

1 Fighting the Fog A Collaborative Approach to Decreasing ICU Delirium Kimberly Scherr NP Jennifer Barker RN Misericordia Hospital ICU Edmonton, AB CACCN Dynamics Sept 21, 2014

2 Delirium Delirium is an acute change in LOC accompanied by inattention and either a change in cognition or perceptual disturbance Hyperactive vs Hypoactive Affects up to 80% of ICU patients with increased length of ICU/hospital stay, time on ventilator, mortality, and long term neuropsychological deficits (Ely et al, JAMA, 2004)

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5 Yasuda M et al. Neurology 2000;55: American Academy of Neurology

6 Delirium Risk Factors Pre-existing dementia History of hypertension Alcoholism High severity of illness at admission (ie. APACHE score)

7 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU (SCCM, 2012) Maintain light levels of sedation Utilize a reliable sedation assessment tool (RASS/SAS) Utilize a non-bzp sedation strategy (ie. Propofol/Dexmedetomidine) Monitor delirium scores routinely (CAM-ICU or ICDSC) BZP use may be a risk factor for the development of delirium Dexmedetomidine may be useful in decreasing delirium in ventilated patients Mobilize patients early

8 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU (SCCM, 2012) No evidence to support use of haloperidol or atypical antipsychotics to prevent delirium Atypical antipsychotics may reduce the duration of delirium; no evidence for haloperidol Do not suggest using antipsychotics in patients at significant risk for torsades Dexmedetomidine rather than BZP infusions should be considered for sedation to reduce duration of delirium in non ETOH withdrawal patients Target light levels of sedation or daily sedation interruption Promote sleep No recommendation for specific modes of ventilation to promote sleep Recommend interdisciplinary team approach to facilitate use of guidelines

9 Collaborative Approach to Decreasing ICU Delirium Misericordia Hospital Strategy Aim and Objectives : Develop and deliver education and support for staff regarding delirium awareness, prevention, and management within 12 months. Determine baseline incidence of delirium within 3-4 months. Implement processes to screen 100% of all ICU patients for delirium within 6 months or less. Identify and implement standardized delirium prevention interventions in all ICU patients within 12 months or less. Implement standardized interventions for the management of delirium within 12 months or less. Implement strategies to support families of patients with delirium within 18 months or less. Establish ongoing education parameters.

10 Goals To decrease the incidence of delirium in the Misericordia ICU by: a) Reducing the utilization of analgesic and sedation infusions b) Reducing the utilization of restraints c) Decreasing ventilation days of ICU patients d) Improving mobilization of ICU patients e) Improving consecutive hours of sleep for patients and noise reduction

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14 ICU Delirium Outcomes Percent of ICU Patients Screened % 80.00% 60.00% 40.00% 20.00% 0.00%

15 Delirium Incidence Misericordia ICU 70.00% Peak Incidence of H1N % 50.00% 40.00% 30.00% Mean = 34.92% 20.00% 10.00% 0.00%

16 ICU Sedation Usage By Year Number of Patients MORPHINE HYDROMORPHONE FENTANYL MIDAZOLAM PROPOFOL DEXMEDETOMIDINE

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19 Average Number of Mobilizations per patient per 24 hours 3 Goal Early Mobilization Education Blitz Aug 15/12 Aug 24/12 Oct 19/12 Oct 26/12 Feb 15/13 Aug 23/13 Jan 17/14

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21 ICU Ventilator Days Number of Patient Self extubations Average Number of Ventilator Days Peak Incident H1N

22 Number of Days ICU Length of Stay

23 ICU Admission Orders

24 ICU: Visual Analog Scale Aim for total score of 0 3 If total score > 3, treat with analgesic as ordered Adapted with approval from Wong-Baker Faces, Pain Rating Scale, 1983

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26 Treatment Approach to Agitated/ Delirious Patient Prevention is the KEY!!!!! Utilize narcotics as first option (IV Opioids) for non-neuropathic pain; add Gabapentin/Carbamazapine for neuropathic pain Pre-treat procedural pain

27 Treatment Approach to Agitated/ Delirious Patient Clinical Pearls Atypical anti-psychotics (quetiapine, olanzapine, risperadone) Haloperidol no evidence to suggest that haloperidol decreases length of delirium Dexmedetomidine infusion (bolus 1mcg/kg or 0.5mcg/kg/hr; range mcg/kg/hr). For delirium unrelated to ETOH/BZP withdrawal, dexmedetomidine infusion should be considered for sedation to reduce the duration of delirium Propofol

28 Treatment Approach to Agitated/ Delirious Patient the Patient with ETOH Withdrawal Benzodiazepines (ATC prn dosing) Symptom triggered therapy vs scheduled therapy associated with shorter duration of treatment, decreased BZP dose (Crit Care Med, 2010,38(9 Suppl):S ) -Infusions of BZPs associated with increased drug dosage, increased LOS, and increase in incidence of VAP GABA A receptors may become saturated with high dose BZPs therefore increasing doses will be ineffective Propofol/Barbiturates may modify withdrawal by an alternative pathway Clonidine α2 agonist ( mg po/ng BID) Dexmedetomidine - α2 agonist (IV bolus 1mcg/kg then infusion at mcg/kg/hr) may be utilized as an adjunct to BZPs Baclofen GABA B agonist (20mg po/ng BID-TID Ethanol (from the intensivist s office )

29 Accomplishments We have developed and implemented a delirium screening tool in our ICU with > 90% compliance with screening. Our delirium incidence is 15-40% with a goal of < 20%. We have significantly reduced our utilization of narcotic and benzodiazepine infusions, while increasing our use of dexmedetomine. We have significantly reduced the use of restraints. Mobility has improved from an average of 1.2 to 2.3 mobilization episodes per patient/day. We have developed a current set of ICU Admission Orders which reflect our ICU delirium strategy. We have implemented a pain assessment and treatment strategy.

30 Next Steps Development and implementation of a Family Centered Care strategy including: Distribution of ICU Family Satisfaction Survey to all patients/families Use of All About Me tool to learn more about each individual s unique needs Development and implementation of a Noise Reduction and Sleep Promotion Strategy

31 ALL ABOUT ME My Name is: You should also know: I Like To be Called: My favorite things: My Family and Friends are: My work before I got sick was: Pets: Music: Song: Books: Sports: T.V. show: Channels: I am stressed when: Glasses At home use: Hearing Aides Other Dentures Contact Lens Adapted from MGH presentation 2009

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