Juliana Barr, MD, FCCM

Juliana Barr, MD, FCCM Staff Anesthesiologist and Intensivist, VA Palo Alto Health Care System Associate Professor, Anesthesiology, Perioperative, and Pain Medicine Stanford University School of Medicine

Faculty Disclosures: Lead Author, SCCM s ICU Pain, Agitation, and Delirium Guidelines 1 Member, SCCM ICU Liberation Committee Faculty, SCCM ABCDEF Bundle Collaborative Advisory Board Member, Medasense Biometrics, Ltd. 1 Barr J, et al. Crit Care Med 2013 41(1):263-306

Learning Objectives: To be able to: Describe risk factors, outcomes associated with ICU delirium. Diagnose delirium in ICU patients. Know the elements of the ABCDEF Bundle. Implement the ABCDEF Bundle in your ICU.

Acute onset of cerebral dysfunction, characterized by 3 features*: A change or fluctuation in baseline mental status. Inattention. and either disorganized thinking, or an altered level of consciousness. *In: DSM-V, American Psychiatric Association, 2013

Symptoms of ICU Delirium Hallucinations, delusions Sleep disturbances Abnormal psychometric activity (e.g., agitation, lethargy) Emotional disturbances (e.g., fear, anger, depression, apathy)

Subtypes of ICU Delirium Mixed (9%-54%) Hyperactive (1-2%) Hypoactive (44%-90%) (Easy to identify!) (Worse outcomes!) Pandharipande, IntCareMed (2007) 33:1726 1731 Peterson, J Am Geriatr Soc (2006) 54:479 484

Epidemiology of ICU delirium Incidence: Risk factors: 60-80% of Mech. Ventilated ICU patients 20-50% of non-mv ICU patients Baseline: dementia, HTN, ETOH, acuity ICU acquired: deep sedation, coma, benzodiazepines Outcomes: ICU/Hospital: duration of MV, LOS, mortality Post-D/C: PTSD, cognitive dysfunction, physical disability, SNF placement, mortality Costs: 39% ICU costs, 31% hospital costs* $6.5 - $20.4 billion annually** *Milbrandt EB, et al. Crit. Care Med. 32 (4):955-962, 2004 **Chang B, et al. Anesthesiology Clin 33:753-770, 2015

ICU Delirium Duration & 1 yr. Mortality ICU delirium duration P<0.001 Fig. 2 K-M curve, 1-yr mortality post ICU admission vs. ICU delirium duration Pisani MA, Am J Respir Crit Care Med. 2009 Dec 1;180(11):1092-7.

ICU Delirium - What ICU Survivors Say I saw outlines of skeletons on the wall, heard strange sounds, etc. I believed I had been moved into various parts of the hospital, including the basement. I misinterpreted environmental cues and attempts to help me were interpreted as meanness. I actually saw body bags with my children's names on them! I tried to help them and I tried to communicate this to others, but with the tracheostomy tube I was unable to do this. After I was extubated and sedation was discontinued, I continued to have paranoid delusions about the nurses wanting to harm me. I repeatedly told my family that when I was dead, the nurses were going to put my body in a large trash can at the foot of my bed.

Causes of ICU Delirium Cholinergic activity Genetic predisposition Dopaminergic activity Primed microglial cells / Serotonergic activity Cavallazzi R, Annals of Intensive Care 2012, 2:49 GABA/NMDA receptor imbalance

Delirium goes undetected in most ICU patients. Validated delirium assessment tools ICU delirium dx. CAM-ICU, ICDSC are the most valid, reliable tools.* Delirium assessments should be performed >Q shift in all pts.* Routine delirium assessments are feasible in clinical practice.** *Barr J, Crit Care Med 2013; 41:263 306 **Vasilevskis EE, J Am Geriatr Soc 2011; 59 (Suppl 2):S249 S255

ICU Delirium Detection Rates Delirium goes undetected in 72% of ICU patients. Hypoactive delirium is harder to diagnose without using a validated assessment tool. Only 25-59% of ICU MDs screen ICU pts. for delirium (2/3 use clinical judgement). Use of a validated ICU delirium assessment tool RN delirium detection rates (27% 92%).* *Mistarz R, Aust Crit Care. 2011 May;24(2):126-32

CAM-ICU Delirium Assessment Tool Sensitivity and Specificity >90%, = 0.91 Ely EW, www.icudelirium.org

The Confusion Assessment Method for the ICU (CAM-ICU) training manual [http://www.icudelirium.org/delirium/cam-icutraining.html]

Within past 24 hr S A V E A H A A R T (>2 Errors) Inappropriate responses to questions or commands (>1 Error) CAM Positive RASS other than zero The Confusion Assessment Method for the ICU (CAM-ICU) training manual [http://www.icudelirium.org/delirium/cam-icutraining.html]

Intensive Care Delirium Screening Checklist (ICDSC) Delirium Assessment Tool Delirious if ICDSC > 4 (sensitivity = 99%, specificity = 64%, κ = 0.92) Bergeron N. Intensive Care Med 2001, 27:859-864 Neziraj M, Acta Anaesthesiol Scand. 2011 Aug;55(7):819-26

HALDOL

ICU Delirium Management Strategies Non- Pharmacologic Delirium Rx

What are Non-Pharmacologic ICU Delirium Management Strategies?

Non-Pharmacologic ICU Delirium Management Strategies 1. Optimize pain management 2. Avoid deep sedation 3. Eliminate deliriogenic medications 4. Facilitate ventilator weaning 5. Remove lines and tubes 6. Avoid restraints 7. Reorient patients 8. Promote normal sleep-wake cycles 9. Mobilize patients early 10. Engage ICU patients and families

Optimize ICU Pain Management Assess pain Q2hr, prn: NRS = 0 10 (self-report) CPOT (0 8) or BPS (3 12) (non-self report) Treat significant pain first before sedating pts (analgosedation): NRS 4 CPOT 3, BPS 6 Pain management: Non-neuropathic pain: IV opioids Neuropathic pain: PO gabapentin, carbamazepine Adjunctive: IV acetaminophen, NSAIDs, ketamine Thoracic epidurals: rib fractures, s/p AAA repair Barr J, et al. Crit Care Med 2013 41(1):263-306

Postoperative Pain Management Multimodal Pain Management Chou R, et al. The Journal of Pain 2016; 17(2): 131-157

Avoid Deep Sedation Deep Sedation: risk of ICU delirium (3x), MV, mortality! Tanaka LMS, et al. Critical Care 2014; 18:R156 Ouimet S, et al. Intensive Care Med 2007; 33:66 73 Hager DN, et al. Crit Care Med 2013 Jun; 41(6):1435-42

Avoid Deep Sedation Assess sedation Q2hr, prn: RASS (-5 to +4) SAS (1 to 7) Target light sedation: Definition: Patients are able to perform a variety of simple commands (i.e., RASS = 0 to -2, SAS = 3 to 4) Exceptions: ICP, status epilepticus, severe resp. failure, NMB Use sedation protocols sedative exposure: IV gtt: Targeted sedation strategy (TSS) constant light sedation Daily sedative interruption (DSI) deep to light sedation IV bolus dosing prn Barr J, et al. Crit Care Med 2013; 41(1):263-306 Shehabi Y, et al. AJRCCM 2012;186(8):724-731 Hager DN, et al. Crit Care Med 2013;41(6):1435-1442

Deep Sedation In-Hospital Mortality (P = 0.004) Depth of Sedation On Day #2 Tanaka LMS, et al. Critical Care 2014; 18:R156

Deep Sedation Long-term Mortality Survival (%) Day #2 of sedation Shehabi Y, et al. AJRCCM 2012; 186:724 731

Eliminate Deliriogenic Medications Sedatives (e.g, benzodiazepines >> propofol, DEX) Opioids (e.g, MSO4, meperidine) Anticholinergics (e.g., H2 blockers, atropine, diphenhydramine, amiodarone, ophthalmic medications) Corticosteroids (e.g., dexamethasone, methylprednisolone, hydrocortisone) Antibiotics (e.g., quinalones, cefepime) Hayhurst CJ, et al. Anesthesiology 2016; 125(6):1299-41. Devlin JW, et al. (2012) In Papadopoulos J, et al. (Eds) Drug-Induced Coma and Delirium. In Drug-induced complications in the critically ill patient (pp 107-16). Mount Prospect, IL: SCCM.

Sedation and Mechanical Ventilation DEX VERSED

Facilitate Ventilator Weaning: SAT + SBT Trials MV duration ICU LOS Control Intervention Difference P Control Intervention Difference P SAT 1 7.3d 4.9d 2.4d 0.004 9.9d 6.4d 3.5d 0.02 SBT 2 6d 4.5d 1.5d 0.003 9d 8d 1.0d NS SAT + SBT 3 11.6d* 14.7d* 3.1d 0.02 12.9d 9.1d 3.8d 0.01 *Vent free days 1 Kress JP, et al. NEJM 2000; 342:1471-7. 2 Ely EW, et al. NEJM 1996; 335:1864 69. 3 Girard T, et al. Lancet 2008; 371:126-34.

SAT-SBT Protocol SAT + SBT Trials www.iculiberation.org

Remove Lines and Tubes http://www.icudelirium.org/delirium/management.html

Remove Lines and Tubes Chen Y, et al. Am J Crit Care 2013;22(2):105-114 Halm MA. Am J Crit Care 2008; 17(6):577-580

Avoid Restraints Micek ST, et al. Crit Care Med 2005; 33:1260 1265

Avoid Restraints The use of physical restraints before the onset of delirium showed a very high risk (OR 33.84). Van Rompaey B. Intensive and Critical Care Nursing 2008; 24:98 107

Avoid Restraints

Reorient ICU Patients N = 314 med-surg ICU patients (excluded neuro, psych pts.) DSI CAM-ICU assessments BID (when RASS = -3 to +3) Intervention group: daily reorientation (5Ws + H), stimulation (wall clock, reading, favorite music), hearing aids/eyeglasses prn during DSI minimal light, noise at night Results: delirium incidence (35% 22%, P=0.02) Colombo R, et al. Minerva Anestesiol 2012; 78:1026-33

Promote Normal Sleep-Wake Cycles

ICU Patient Sleep-Wake Cycles Cooper AB, et al. CHEST 2000; 117(3):809-18.

Sleep Deprivation in ICU Patients Causes: Round-the-clock environmental stimuli (e.g., noise, light, interactions) Pain Medications (e.g., sedatives, opioids, etc.) Mechanical ventilation Underlying acute illness Delirium Kaplow R. CCCNA 2016; 28(2):169-182

ICU Nighttime Care Interactions N = 50 ICU pts., 147 nights Average of 42.6 interactions/night; only 6% of nights with no interactions x 2-3 hr! Tamburri LM, et al. AJCC 2004; 13:102-115

Sleep Deprivation and ICU Delirium??

ICU Sleep Hygiene Programs Create a protected nighttime sleeping period (i.e., 2200 hr 0600 hr): Minimize, cluster patient care activities. Decrease light and noise in the patient s room. Have patients wear earplugs, eye masks. Use relaxation techniques (e.g., soothing music, massage, aromatherapy) Avoid sedatives, caffeinated beverages (i.e., nighttime sedation sleep promotion) Increase daytime activity: Increase mobility Open window shades Avoid daytime naps Oral melatonin Qhs? (Huang H, et al. Trials 2014;15:327, Burry L, et al. BMJ Open 2017; 7(3), Martinez FE, et al. Trials 2017;18(1):4) ICU sleep hygiene programs* incidence, duration of ICU delirium >50% *Alway A, et al. AACN 2013;22(4):357-360 *Van Rompaey B, et al. Critical Care 2012;16(3):R73 *Kamdar BB, et al. Anaesthesia 2014;69(6):527-531 *Patel J, et al. Anaesthesia 2014;69(6):540-549. Shaw R. AJCC 2016; 25(2):181-4.

Mobilize ICU Patients Early ICU Acquired Weakness*: Multifactorial syndrome myopathy &/or polyneuropathy Risk factors: sepsis, inflammation, MOSF, MV, BG, steroids, NMB agents >48h, F>M, immobility Incidence: 25% 100% Outcomes**: risk of MV wean failure (30%), ICU mortality (30%), hospital mortality (31%); hospital $$, 1 yr mortality, 50% of pts. fail to return to previous level of function! *Kress JP, et al. NEJM 2014; 370(17):1626-1635 **Hermans G, et al. AJRCCM 2014; 190(4):410-420 **Needham DM, et al. BMJ (Clinical research ed) 2013; 346:f1532 **Herridge MS, et al. NEJM 2003; 348(8):683-693.

Mobilize ICU Patients Early Mobility is Medicine. - Heidi Engel, PT, UCSF ICU/hospital LOS, sedative use, deep sedation, delirium Functional status at d/c Schweickert WD, et al. Lancet 2009; 373(9678):1874-1882 Morris PE, et al. Crit Care Med 2008; 36(8):2238-2243 Needham DM, et al. Topics in Stroke Rehab 2010; 17(4):271-281.

Mobilize ICU Patients Early Deep Sedation No Sedation

Engage ICU Patients and Families Davidson JF, et al. Crit Care Med 2017; 45:103 128

Engage ICU Patients and Families ICU family presence 24h visitation, ICU rounds, resuscitations. ICU family support education, how to assist in pt. care, ICU diaries. Communication with ICU family members routine family conferences, using VALUE tool, provider education. Palliative Care involvement ICU patients with poor prognosis. Family /Staff Goals-of-Care conflicts Ethics consults, Social Work, Spiritual support Create ICU Policies EOL sedation/analgesia, create sleep promoting environment for ICU patients, families. Davidson JF, et al. Crit Care Med 2017; 45:103 128

Engage ICU Patients and Families Family Members ICU Team

Medications Used to Treat Refractory ICU Delirium Sedatives Benzodiazepines: Midazolam Lorazepam Propofol Dexmedetomidine* Antipsychotics Haloperidol Atypical antipsychotics: Risperidone Ziprasidone Quetiapine Olanzapine No clear evidence for safety and efficacy in the treating delirium in ICU patients! *Reade, et al. JAMA 2016 Apr 12;315(14):1460-8

Provider Survey of Medications Used to Treat ICU Delirium Mo Y, et al. J Pharm Pract. 2017 Apr;30(2):162-171

Design: RCT Enrollment: 600+ Med-Surg ICU pts. dx. with delirium Rx: Haldol vs. Ziprasidone vs. Placebo 14d Outcomes: DCFD; side effects; ICU LOS; LTCD; 30d, 90d, 1yr survival

Treating ICU Delirium in the Substance Abuse Patient

Treatment of Withdrawal Symptoms Withdrawal From Alcohol Nicotine Opioids Benzodiazepines Dex, clonidine, gabapentin Illicit drugs (e.g., meth, PCP) Treatment* 1 st line: benzodiazepines; 2 nd line: phenobarbital, haldol, [chlomethiazole], clonidine? 3 rd line: propofol, Dex gtt (adj.) transdermal nicotine patch??? replacement rx, slow wean replacement rx, slow wean slow wean symptom management *Treatment should be symptom triggered, prn dosing, titrated to effect. (Few studies in ICU patients demonstrating safety, efficacy!) Awissi D, et al. Crit Care Med. 2013; 41:S57-S68.

ABCDEF Bundle* A Assess, Prevent and Manage Pain B Both SATs and SBTs C Choice of Sedation D Delirium: Assess, Prevent and Manage E Early Mobility and Exercise F Family Engagement and Empowerment *www.iculiberation.org

ABCDEF Bundle Objectives Optimize pain management. Break the cycle of deep sedation and prolonged mechanical ventilation. Reduce the incidence, duration of ICU delirium. Improve short, long-term ICU patient outcomes. Reduce health care costs! *www.iculiberation.org

Why a Bundle? Standardize Care Processes Reduce Practice Variation Better Outcomes! Improve ICU Team Communication Every Patient, Every Time Resar R, Pronovost P, et al. JQPC 2005;31(5):243-248 http://www.ihi.org/resources/pages/improvementstories/whatisabundle.aspx

ABCDEF Bundle Implementation Create multidisciplinary team Identify clinical champion Perform Gap Analysis Develop ABCDEF Bundle implementation plan PLAN Educate stakeholders Trial interventions Collect process, outcome data (EMR) ACT ABCDEF Bundle DO Tweak interventions Prepare to retest STUDY Analyze data Share results Get staff feedback *Pun BT, et al. Semin Resp Crit Care Med 2013;34:223 235.

How to implement the ABCDEF Bundle in Your ICU HELP! VS. Where to begin????

Implementing ABCDEF Bundle Elements Seven Steps to Success! STEP 1: Implement Pain, Sedation, Delirium assessment tools. STEP 2: Incorporate PAD assessments into daily ICU care plan. STEP 3: Create ICU specific PAD management protocols. STEP 4: Integrate PAD protocols w/ SATs, SBTs, EM protocols. STEP 5: Engage ICU patients and families. STEP 6: Measure Bundle Compliance, Performance. STEP 7: Measure Bundle impact on ICU patient outcomes. *Pun BT, et al. Semin Resp Crit Care Med 2013;34:223 235.

Step 1: Implement ICU Pain, Sedation, and Delirium Assessment Tools Pain, coma, & delirium = barriers! You don t know what you don t measure! SAT-SBT, Mobility, Family Engagement HOUSE OF PAD ICU PAD Protocols PAD Assessment Tools Assessments without protocols won t change practice!

Step 2: Incorporate PAD Assessments Into the Daily ICU Care Plan What is the patient s current pain score and their analgesia regimen? What is the patient s current and target sedation scores, and their current sedation regimen? What is the patient s current delirium score and what are their delirium risk factors? How do these PAD assessment influence our ICU care plan for today?

Step 3: Create ICU Specific Pain, Agitation, and Delirium Management Protocols Make protocols specific to your ICU culture, formulary. Use opt out rather than opt in protocol designs. Protocol benefits: Help transfer EBM best practices to the bedside. Limit practice variation. Reduce treatment delays. Improve ICU patient outcomes. Link to quality assurance efforts.

Step 4: Integrate PAD Management Early Mobility Pain Management SATs Sedation/ Agitation Management Delirium Management SBTs

Step 5: Engage ICU Patients and Families

Step 6: Measure ABCDEF Bundle Compliance and Performance* How do you know if your Bundle elements are working???

Bundle Element A Step 6: Measuring ABCDEF Bundle Compliance and Performance* Process Measure Chart NRS or CPOT Q2h Compliance Target Outcome Measure Performance Target >90% NRS 4 or CPOT 3 <30% B Daily SAT-SBT 1 >90% Extubated <60 min >80% C Chart RASS Q2hr >90% RASS > 0 or < -2 <30% D E F Chart CAM-ICU Q12h Chart mobility level Q24h Chart ICU Family Engagement QD >90% CAM-ICU positive <30% >90% >90% Standing or walking by ICU d/c >80% Family Satisfaction Survey 2 >80% 1 Mechanically ventilated ICU patients only, who passed SAT, SBT safety screens. 2 Satisfied or very satisfied responses *VA Palo Alto Medical Surgical ICU

Step 6: Measuring ABCDEF Bundle Compliance and Performance* VA Palo Alto Medical Surgical ICU

STEP 7: Measure ABCDEF Bundle Impact on ICU Patient Outcomes How do you know if your Bundle implementation is making a difference???

STEP 7: Measuring Impacts on ICU Patient Outcomes Outcome HRET Performance Target ICU Outcomes: Duration of MV N/A LOS N/A Mortality N/A Hospital Outcomes: LOS N/A Mortality Mobility status at D/C N/A N/A HAI Rate (CLABSI, CAUTI, VAE) <20% SSI Rate <20% VTE Rate <20% HAPU Rate <20% Fall Rate <20% Discharge Outcomes: D/C to home N/A 30d Readmission Rate <12% Post D/C Mortality (6 mo, 1 yr) N/A

STEP 7: Measuring Bundle Impact on ICU Outcomes CMS Medicare Reimbursement SGR Fee for Service Volume-based reimbursement MACRA MIPS Value-based reimbursement

ABCDEF Bundle: Improving ICU Patient Outcomes How do we know this works???? Barnes-Daly, et al. Crit Care Med 2017; 45:171 178

ABCDEF Bundle: Improving ICU Patient Outcomes Hospital Survival Delirium, Coma Free Days Total Bundle Compliance N = 5,471 OR = 1.12 (95% CI, 1.07-1.17; P <0.001) N = 5,581 IRR N = 1.02 (95% CI, 1.01 1.04; IRR =, P P = 0.004) Partial Bundle Compliance N = 5,471 OR = 1.23 (95% CI, 1.14-1.32; P <0.001) N = 5,581 IRR = 1.15 (95% CI, 1.09 1.22; P = 0.001) Bundle Dose-Response Effect! Barnes-Daly, et al. Crit Care Med 2017; 45:171 178

ICU Liberation Collaborative Andrea Saito, ACNP (Team Leader) ABCDEF Bundle Team VA Palo Alto Health Care System Palo Alto, CA Goal: Implement the ABCDEF Bundle over 20 months (2015-2017). ICUs: 77 U.S. ICUs (69 adult, 8 pediatric), 3 Regions (SE, MW, West) Tools: meetings, webinars, list serve, REDCAP database. QI strategies: Bundle adoption, compliance, and improve outcomes. Enrollment: Total N = 17,069 ICU pts. Pre-Bundle: 1,982 pts. (6 mo.) Post-Bundle: 15,087 pts. (14 mo.)

VAPAHCS* ABCDEF Bundle Compliance and Performance Bundle Element A B C D E F Process Measure Assess NRS or CPOT <Q2h Assess SAT/SBT Daily Assess RASS Q2hr Assess CAM-ICU Q12h Assess Mobility QD Chart ICU Family Engagement QD Compliance Outcome Performance Pre Post Measure Pre Post 100% 100% NRS 4 or CPOT 3 38% 47% 13%/ 14% 54%/ 100% Perform Daily SAT/SBT 16%/ 54% 31%/ 100% 96% 98% RASS -4 or -5 >1d 42% 30% 71% 97% CAM-ICU + >1d 21% 19% 0% 12% 65% 60% Active transfer, standing, or walking 44% 59% Family Satisfaction Survey N/A N/A *VAPAHCS Pre: (Retrospective = 6 mo.) N=33; Post: (Prospective = 14 mo.) N = 238

VAPAHCS Overall ABCDEF Bundle Performance VAPAHCS Post Bundle = 86% Pre Bundle = 68% 27% increase!

VAPAHCS* ABCDEF Bundle Collaborative Patient Outcomes Outcome Pre Bundle 1 Post Bundle 1 Duration of MV 2 21 hours 22 hours ICU LOS 7.3 days 5.0 days Hospital LOS 21 days 19 days ICU Mortality Rate 6% 5% Hospital Mortality Rate 3 0% 5% *VAPAHCS Total N = 271 Pre N = 33 (Retrospec. = 6 mo.), Post N = 238 (Prospec. = 14 mo.) 1 Results reported as Medians, P Values TBD 2 MV pts: Total = 116 (19 pre, 97 post) 3 Died during hospitalization after ICU discharge.

ICU Liberation Collaborative

ICU Liberation Collaborative

ICU Liberation Collaborative

ICU Liberation Collaborative

ICU Liberation Collaborative

ICU Liberation Collaborative NEVER Delirious! Increased 41% to 56%

ICU Liberation Collaborative

ICU Liberation Collaborative Active Mobility Mean Increase: 20% to 24%

ICU Liberation Collaborative

ICU Liberation Collaborative

ICU Liberation Collaborative Patient Outcomes Outcome Pre-Bundle 1 Post-Bundle 1 Duration of MV 2 65 hours 55 hours ICU LOS 3.5 days 3.0 days Hospital LOS 8.5 days 8.0 days ICU Mortality Rate 13% 11% Hospital Mortality Rate 3 4% 3% Total N = 17,069, Pre Bundle N = 1,982, Post Bundle N = 15,087 1 Results Reported as Medians, P Values TBD 2 MV pts: Total = 16,735 (Pre N = 1,905, Post N = 14,830) 3 Died during hospitalization after ICU discharge.

ABCDEF Bundle

The ABCDEF Bundle Redefining ICU Outcomes Immobility Deep Sedation Mechanical Ventilation

The ABCDEF Bundle Redefining ICU Outcomes Not just surviving, but thriving!

Thank You!

Questions?