ICU Delirium

By Brooke Gowey, Whitney Mudd, Andrea Trillo, Macy

Dailey, Ali Schlichting, Karen Gudino, Minli Huang, and
Audrey Goh

In adult ICU patients (P), who have been in the

ICU for more than 24 hours (T), does the
implementation of a delirium protocol (I) decrease
delirium symptoms (O) as compared to units
without an established protocol (C) ?

Introduction of issue
Delirium is an acute brain dysfunction
characterised by an alteration or
fluctuation in baseline mental status
combined with inattention and either an
altered level of consciousness or
disorganised thinking

Introduction of Issue

60-80% of adult patients that have stayed 24 hours or

greater in the ICU were shown to experience delirium.

ICU delirium is associated with increased patient

mortality rates, persistent cognitive decline, extended
hospital and ICU stays, and increased healthcare costs.

Summary of
Current Practice

ABCDE Bundle

Interprofessional, evidenced based

Vanderbilt University Medical
Centers Delirium and Cognitive
Impairment Study Group

PAD Guidelines

Revised and Published in 2013 by

the Society of Critical Care
Medicine (SCCM)

Limited information of which

current protocols are being
incorporated and where
Lack of knowledge amongst
bedside critical-care nurses and
other healthcare professionals

Summary of Current Practice

The Awakening and Breathing Coordination, Delirium

monitoring/management, and Early exercise/mobility (ABCDE) bundle

reducing sedation exposure

reducing duration of mechanical ventilation
managing ICU-acquired delirium & weakness

Pain, Agitation, and Delirium (PAD) Guidelines

Detecting, monitoring, and preventing delirium

Screening tool: Confusion Assessment Method in the ICU (CAM-ICU)
Early mobility and physical therapy
Daily interruption of sedation
Promotion of sleep

Summary of Current Practice

St Josephs Hospital:
Critical-Care Pain Observation
Tool (CPOT)
CAM-ICU Tool

UAMC Banner:
CAM-ICU Assessment Tool
ABCDE Bundle

TMC:
CAM-ICU

National Practice:
CAM-ICU is a widely used
instrument tool for detection
of delirium worldwide
5,000 original articles to date
Translated into 16 languages

Summary of Current Practice

Careful use of medications

Early mobilization

Wean patients off ventilator

Avoidance of physical

quicker
Soften the environment
shutting off lights
minimizing noisy alarms

restraints
Removal of unnecessary
invasive tubes

Synopsis of current
literature research
findings

Research Relating to Delirium Protocols

Studies:
Observational study
Randomized controlled trial
An Interdisciplinary Quality Improvement Project
2 cohort studies
Mixed-methods study
Descriptive qualitative and a Descriptive quantitative study

Each article researches the delirium protocol

The research found delirium of the older population much more significant

Significant Findings

Requirement of RASS score and CAM-ICU documentation every 4 hours

Constant reassessment of the patients sedation

Staff awareness of early symptoms/progression delirium

Implementation of the delirium protocol found a decrease in 7-day

mortality

No difference in incidence of delirium, only a difference of the duration of

the delirium

Strengths of current
research

Summary of strengths
Populations of participating individuals are clearly identified
and consistent
Measurement tools for delirium status are consistent
Levels of evidence are relatively high

Summary of strengths
Studies were performed in varied geographical settings
(U.S., Irish, Korea)
Studies have multifaceted focus for recommendation
(pharmacological, non-pharmacological and psychosocial)

Limitations of the
current research

Summary of limitations
Sample sizes are relatively small
Use of self-reporting questionnaires
No long-term follow-up
Some studies lack randomization

Evidence Based
Nursing
Recommendations
Supporting Best
Practice

Implementation of ABCDE Bundle

ABC: Awakening and Breathing Coordination
Spontaneous Awakening Trials (SATs)
Spontaneous Breathing Trials (SBTs)
Coordination of the two
D: Delirium monitoring/management
Routine sedation/agitation screening
E: Early exercise/mobility
Early progressive mobilization

Richmond Agitation-Sedation Score (RASS)

Perform three times a shift

Confusion Assessment Method (CAM-ICU)

Pharmacologic & Non-pharmacological Protocols

Limit delirium associated drugs
Daily medication reconciliations
to discuss necessity of
deliriogenic medications

Sleep enhancement
Promote sleep that would
occur during normal sleepwake cycles
i.e. turning off lights,
decreasing
volume/brightness of
monitors

Application/Implementation
to Nursing Practice

Plan to Implement Delirium protocol care bundle

1)

Have senior leaders such as Chief Nurse Officer and Chief

Medical professionals meet and discuss delirium prevention
bundle

2) Committee identifies leaders for each interdisciplinary

fields
3) Interdisciplinary team meet and determine:
i) Identify existing institutional policies
ii) Identify advantages and disadvantages
iii) Sub committee including ICU nurse educator and
individuals from the other fields to develop
didactic training

Plan to Implement Delirium protocol care bundle part II

4) Committee Identify Unit-level leaders that will be in charge of the implementation
process
i. provide unit leader-level protocol bundle information and didactic
training
5) Critical care nurse educator provides didactic training to individuals working at the
floor level
i. Educator provides didactic training

Plan to Implement Delirium protocol care bundle part III

6) Implementation and training of all staff should be completed in
18 months and delirium protocol should be part of hospital policy
7) Continued Education interventions every 6 months
i. Provide in-service
ii. Provide online accesses to content offered in didactic training

Formal Didactic Training

Formal didactic training has been shown :
- Didactic training program for ICU nurses can result in increased
awareness and knowledge of ICU delirium
- It will adequately prepare them for how to properly screen and treat
patients
- Is a feasible means to institute an ICU delirium care program in
hospitals

Implementation of Didactic training

- Live lecture format
- Information on what is ICU delirium
- What current Evidence-based recommendations
- Specific instructions on how to use screening tools
- Supplemental handout material
- Patient Case studies should be included
- case study facilitate group discussion on how to apply
delirium protocols to a clinical scenario

Implementation of Didactic training

Didactic training sessions should be made available to all staff:
- 8 educational session of 1- hour increments
- spaced over 4 weeks
Communication:
- Via emails
- Word of mouth reminders by Charge Nurses and Unit Directors
- Paper posters posted in the Staff lounge areas

Timeline
Senior Leader's
Professional meet

Committee Identifies leaders for

each interdisciplinary fields

1 to 2 months
Training of Unit-level
leaders

1 to 2 months

2 to 3 months

1 to 2 months
Didactic Training of
Floor level
individuals who
implement protocol

Interdisciplinary
team meet and plan

Implementation of
Bundle protocol
consider part of
hospital policy

1 month

Continued
Education

every 6 months
6 months

Cost Analysis

Cost Analysis of an established delirium protocol

Costs saved by patient and hospital:

$4-16 billion ICU costs associated with delirium
Ventilation
4.5 days less on the ventilator
$6.5-20.4 billion annually ($600-1,500 per day)
$600-1,500/day x 4.5 days= $2,700-6,750/patient
Medication costs saved is variable

Cost Analysis of an established delirium protocol

Costs acquired by hospital:

Education
$32/hour/ICU nurse
$41/hour x 8 hours= $328 cost
for critical care nurse manager
Clinical educator= no cost

Benefits > Cost

Risks vs. Benefits

Risk vs. Benefits

Risk to patients:

Benefits to patients:

-Patient distress.

-Infused sedatives dramatically

decreased.

-Decreased rest.
-Unnecessary delays in extubation.

-Patients more frequently

mobilized.
-Decreased cost to patient.
-Overall quality of life.

Risk vs. Benefits

Risk to nurse:

Benefits to nurse:

-Increased workload.

-Simple and straightforward.

-Increased documentation.

-Feeling more empowered and

autonomous.

-Ethical dilemmas.
-Lack of time (75% of nurses).

-Overall better patient outcomes.

Risk vs. Benefits

Risk to agency:

Benefits to agency:

-Not sufficient evidence stating

risks to the agency.

-Decreased overall cost.

-Decreased accreditation related to

decreased sedation.

-Decreased overall stay.

-Increased accreditation related to
decreased sedation.

Evaluation

Evaluation/Outcomes
Patient:
Patients will experience no more than 3 consecutive days of delirium during
their ICU stay while on the ABCDE protocol.
Nurse:
Nurses will successfully perform and implement ABCDE protocol once a shift
and RASS or CAM-ICU assessments 3 times during their shift on all their
assigned qualifying ICU patients.
Protocol:
The local facility that initiates this protocol will have the training and
implementation of all staff completed in 18 months and the delirium protocol
will be a permanent part of the hospital policy within 2 years of the initiation of
the protocol.

Summary

Implementation of a delirium protocol assists in

preventing and decreasing symptoms associated with
delirium.

Cost of implementing protocol reduces cost to patient

and healthcare system/agency.

Overall benefit to all parties.

References
American Association of Critical Care Nurses. (2015). Delirium Assessment and Management. Retrieved from
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References
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References
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