Why Target Delirium for Surgical Quality Improvement? Tom Robinson MD FACS thomas.robinson@ucdenver.edu July 22, 2018
Disclosures Tom Robinson has no disclosures.
Who Cares About the Brain? Acute Organ Dysfunction Commonly Recognized by Surgeons Delirium (Acute Brain Dysfunction) 1.Disturbance of Consciousness 2. Change in Cognition 3. Acute Onset 4. Coexisting Physiologic Disturbance Diagnostic and Statistical Manual of Mental Disorders DSM IV - Fourth Edition (1994)
The Importance of Post-Operative Delirium Incidence (%) 15 10 5 0 NSQIP Geriatric Pilot Collaborative Marcantonio ER et al. JAMA (1994) 272: 1518
The Importance of Post-Operative Delirium Death CLOSE TIES Serious Morbidity Functional Decline DELIRIUM is closely associated with adverse healthcare outcomes. Longer Hospital Stay Delirium Increased Healthcare Cost Impaired Cognition Marcantonio ER et al. JAMA (1994) 272: 1518
Post-Operative Delirium and Adverse Surgical Outcomes 60% 50% % Patients 40% 30% 20% 10% 0% Post-acute care discharge Serious morbidity* 30-day mortality No Delirium (N=4,704) Delirium (N=614) Berian J, et al. Annals of Surgery 2017, *Leslie DL, Inouye SK, J Am Geriatr Soc, 2011
Post-Operative Delirium and Adverse Surgical Outcomes 40% Total 30% cost estimates $16 to $64K per patient* % Patients 60% 50% 20% Potential $38 to $152 billion burden 10% 0% Post-acute care discharge No Delirium (N=4,704) Serious morbidity* 30-day mortality Delirium (N=614) Berian J, et al. Annals of Surgery 2017, *Leslie DL, Inouye SK, J Am Geriatr Soc, 2011
The Importance of Post-Operative Delirium SHEAR NUMBERS Preventable Up to 40% of Delirium Is Preventable 10,000 people turn 65 years old every day 40% 60%
Delirium The Perfect Candidate for a Quality Project Delirium Is: Deleterious Common Improving the Surgical Care of Older Adults Modifiable Ideal for Quality Initiative thomas.robinson@ucdenver.edu
Hospital Odds Ratio for Postoperative Delirium Low Outlier High Outlier Odds Ratio with 95% Confidence Interval 6 5 4 3 2 1 0 (n=4) (n=7) Geriatric Pilot Hospitals, Arranged Low to High Outliers Berian J, et al.. Ann Surg (2017)
Delirium Risk Factors Intrinsic Risk Factors Impaired Cognition Impaired Function Age Multi- Morbidity Poor Nutrition Polypharmacy Frailty Psychiatric Prior Diagnosis Delirium Marcantonio ER et al. JAMA. 1994; 271:134 Dasgupta M et al. J Am Ger Soc. 2006; 54:1578 Robinson TN et al. Ann Surg 2009; 249:173
Defining the At-Risk Population for Delirium ICU Delirium and Age Delirium (%) 50 40 30 20 10 0 < 50 50-59 60-69 70 Age (Years) Robinson TN. Ann Surg (2009) 249:173
Preventing Delirium Across the Surgical Service Healthcare systems and hospitals should implement multicomponent nonpharmacologic intervention programs delivered by an interdisciplinary team for the entire hospitalization in at-risk older adults undergoing surgery to prevent delirium Strength of recommendation: strong
Supportive Interventions to Prevent Delirium Multi-Component Interventions To Prevent Delirium Risk Factor Cognitive Impairment Sleep Deprivation Immobility Visual Impairment Hearing Impairment Dehydration Intervention Orientation protocol Sleep enhancement Early mobilization Early vision correction Hearing protocol Change BUN/Cr ratio Inouye et al. NEJM (1999) 340(9):669.
Preventing Delirium in the Hospitalized Elderly STUDY GROUP Intervention Usual Care p value Incidence Delirium 9.9% 15.0% p=0.02 Total Days Delirium 105 161 p=0.02 Episodes of Delirium 62 90 p=0.03 Inouye et al. NEJM (1999) 340(9):669.
Supportive Interventions to Prevent Delirium cognitive reorientation nonpharmacologic sleep protocol early mobility and/or physical rehabilitation adaptations for visual and hearing impairment nutrition and fluid repletion engage family members pain management promote sleep / wake cycle appropriate medication usage avoid restraints remove lines and tubes Blair GJ et al. J Int Care Med (2018) epub
Delirium Prevention Orderset
Pneumonic Reversible Causes of Delirium E R U Drugs (anticholinergics, polypharmacy) Eyes, Ears (sensory deficits) Low O 2 states (MI, PE, anemia, CVA) Infection (sepsis) Retention (urine or stool) Ictal state Underhydration/undernutrition Metabolic (sodium, glucose)
Pneumonic Reversible Causes of Delirium E R U Drugs (anticholinergics, polypharmacy) Eyes, Ears (sensory deficits) Low O 2 states (MI, PE, anemia, CVA) Infection (sepsis) Retention (urine or stool) Ictal state Underhydration/undernutrition Metabolic (sodium, glucose) Most Common Reversible Causes of Postoperative Delirium Infection Medications Pain Hypotension Acute blood loss anemia Metabolic acidosis Hypoxia / Hypercarbia **Substance withdrawal
Medications That Promote Delirium Meperidine (Demerol) Pain Indomethacin (Indocin) Pentazocine (Talwin) GI Stress Ulcer Prophylaxis Nausea Insomnia Miscellaneous Cimetidine (Tagamet) Ranitidine (Zantac) Scopolamine Promethazine (Phenergan) Benzodiazepines Diphenhydramine (Benadryl) Cyclobenzaprine (Flexeril) Postoperative Delirium in Older Adults: Best Practices Statement from the American Geriatrics Society JACS (2015) 220: 136.
The Scope of Delirium Care Delirium Screening Delirium Risk Factors Diagnosing Delirium Non-Pharmacologic Prevention of Delirium Pharmacologic Prevention of Delirium Medical Evaluation of Delirium Intra-Operative Measures to Prevent Delirium Pharmacologic Treatment of Delirium