Joseph Brant Memorial Hospital (JBMH)

1. Joseph Brant Memorial Hospital(JBMH) Delirium in Critical Care

2. Background • JBMH chose to participate in the ICU Collaborative in January 2012 with the intent of learning best practices to provide quality care when screening, assessing and treating the critical care patient for delirium. Prior to this JBMH did not have these processes in place for the critical care patient • Involvement of the inter-professional critical care team members was deemed necessary to identify these processes to achieve best patient outcomes and to sustain validated delirium prevention practices

3. Aim • Develop education for ICU staff regarding delirium definition, prevention and management within 12 months • Implement a delirium screening process for all ICU patients within 6 months • Tabulate incidence of delirium within 6-8 months • Implement standardized delirium prevention interventions for all ICU patients within 12 months • Implement standardized interventions for the management of patients identified with delirium within 12 months • Implement strategies to include families of patients with delirium within 12-18 months

4. Team Members • Intensivist: Dr Stephanie Robbins • ICU Manger: Geoff Flannagan • JBMH Sponsor: Jill Randall Director Critical Care • Critical Care Educator: Jackie Adcock • RNs: Sandra Pagani, Ashley Robertson, Kristy Stouck • Pharmacist: Poobalan Nayiager • RT: Laurie Taplin • PT: Katie Williams • SLP: Kalen Paulson

5. Results Screening for Delirium Education was provided about the definition of delirium and the use of the Intensive Care Delirium Screening Checklist (ICDSC) tool The ICDSC is to be completed each shift and prn for all ICU patients Chart audits to determine whether ICDSC tools were completed once a month over 4 months The goal is for 100% of ICU patients to be screened for delirium. The audit reveals an average of 80% Increased frequency of audits is required to validate findings Strategies to improve consistency of completion of ICDSC on all ICU patients need to be explored

6. Results Positive Delirium Scores Positive delirium scores are determined by an ICDSC score of 4 or more Charts were audited to discover how many patients had a positive ICDSC score The audit reveals an average of just over 2 patients (out of 14) over the 4 months scoring positive for delirium As the audits were only performed once a month over 4 months a true picture for incidence of delirium likely was not realized Availability of resources to provide more consistent auditing has been a challenge We will continue to consider ways of procuring valid and consistent data collection and measurement

7. Changes to be Tested • Delirium education has been provided to all ICU team members • Delirium posters are displayed throughout the ICU that define delirium, speak to causes and the ABCDE bundle • ICDSC and RASS score templates are laminated on all ICU RN desks outside patient rooms • RNs are to document the RASS and ICDSC on all ICU patient flow sheets each shift • The daily goal sheet used at rounds each day was revised to include RASS and ICDSC scores • At daily patient rounds since May 2012 ICU patients are identified as being positive or negative for delirium via the ICDSC tool • The team at rounds reviews the medications of the patient that is positive for delirium with a view of eliminating deliriogenic medications such as benzodiazepines and considers adding Seroquel or Haloperidol as appropriate • Other interventions to reduce delirium discussed at rounds are SBTs and mobilization goals for the day • New ventilator orders have daily wake and wean interventions and eliminated Midazolam infusion

8. Lessons Learned • We need the participation of the whole Critical Care Team to promote consistency and sustainability of delirium strategies • Some ICU staff do not complete the RASS and ICDSC scores each shift on their patients which prohibits identifying and treating those with delirium • Increased frequency of audits is required to validate findings • Availability of resources to provide more consistent auditing has been a challenge • It is difficult to mobilize our patients consistently as our PT availability is only 5 hrs Mon-Tues-Thurs-Fri • It can be difficult to keep momentum for delirium with other competing projects

9. Next Steps • We need to continue be more compliant with completing ICDSC on all ICU patients • Audits for completion of ICDSC and incidence of delirium need to continue • Delirium status for all ICU patients must be discussed at daily rounds • Non-pharmacological delirium prevention interventions to be added to the ICU admission orders • Patient orders set for delirium in critical care need to be explored • A mobilization protocol for ICU patients needs to be developed with Intensivist, Educator, RN, RT and PT as leads • We need to create noise reduction awareness posters in the ICU for staff, patients and families • We have a highly visible board in the ICU that provides education on delirium and we will add data on delirium audits (ICDSC compliance and incidence of delirium) • Continue to learn strategies for delirium prevention and treatment in critical care