Shared learnings and results from the Delirium Med Rec Collaborative

1. National Call
“Learning from Delirium Collaborative”
Appel National
“apprendre de la Collaboration sur le delirium”
Monday, February 25 2013
Lundi, le 25 février 2013
** All lines are muted upon entry. If you have any questions, please raise your hand or CHAT to Host **
**Toutes les lignes sont en sourdine au départ. Si vous avez des questions, s'il vous plaît levez votre main
ou clavardez pour joindre l'hôte) **

2. Your Hosts & Planning Team
Vos hôtes & l’équipe de planification et de soutien
Dr. Claudio Martin, Chair Canadian ICU Collaborative
Président, Collaboration canadienne des
soins intensifs
Bruce Harries, Collaborative Director and Moderator
Directeur de la Collaboration et Animateur
Ardis Eliason, Project Coordinator and Technical Host for today’s session
Coordonatrice de projet et hôte technique
Leanne Couves, Improvement Advisor
Conseillère en amélioration
Anne MacLaurin, Project Manager, Canadian Patient Safety Institute (CPSI)
Coordonatrice de projets, ICSP
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3. Faculty
Membres de la faculté
Chaim Bell, MD, PhD, FRCPC Denny Laporta, MD, FRCPC
Paule Bernier, Dt.P., M.Sc. Cathy Mawdsley, RN, M.Sc.
Vanda DesRoches; RN BN
Yoanna Skrobik, MD, FRCPC
Greg Duchscherer, RRT, FCSRT
Jennifer Turple, BSc Pharm, ACPR
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4. Interacting in WebEx: Today’s Tools
Interagir dans Webex : outils à utiliser
Have you used WebEx before?
Avez-vous déjà utilisé WebEx?
 YES / OUI NO / NON 
Soyez prêts à
Be prepared to use:
utiliser les outils :
- Pointer - le pointeur
- Raise hand - lever la main
- CHAT - clavardage
- Text Tool - Outil textuel pour
Type your
“writing on the slide” « écrire sur la diapo » Select message &
- Shape Tools - Outils de forme ‘send to’ click ‘send’
02/12/2013 4

5. POINTER Who’s Online? Qui est en ligne?
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6. POINTER
What professions are represented?
Quelles professions sont représentées?
Nurse/ MD Infection
infirmière ControlPCI
Administrator /Administrateur
Educator /Éducateur Senior Leader
Quality Improvement
Professional/Professionn
el en amélioarion de la
qualité
Other/
Psychiatry/ autre
Pharmacy/ psychiatrie
pharmacie
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7. Context and Results
Contexte et Résultats
Bruce Harries
Collaborative Director
Directeur de la Collaboration

8. Collaborative Aim
Buts de la collaboration
• Improve care of the • Améliorer les soins du
critically ill patient patient en phase
through critique grâce à la mise
implementation of en œuvre du dépistage
standardized screening standardisé et de
and identification of l'identification de
prevention and stratégies de prévention
management strategies et de gestion du
for delirium delirium
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9. Accreditation Canada
Standard 9.8
“The team uses a delirium • “Léquipe utilise un outil de
screening tool to assess clients dépistage pour éaluer les
for delirium. Delirium, a pts pour delirium. Le
heightened state of agitation, delirium, un état avancé
contributes to increased length d’agitation, contribue à
of stay and may cause clients augmenter la durée du
to self-extubate or remove séjour et le risque d’auto-
catheters. The team identifies extubation ou d’enlèvement
and consistently applies a des sondes. L’équipe
delirium screening tool.” identifie et applique l’outil
de dépistage de façon
constante”
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10. Collaborative Principles
Principes d’une Collaboration
• Everybody teaches, • Tout le monde enseigne,
everybody learns tout le monde apprend
• Share generously • Partagez généreusement
(transparency) (transparence)
• Volez sans honte
• Steal shamelessly
• Reconnaîssez avec grâce
• Acknowledge graciously
When we cooperate, Lorsque nous coopérons, tout
everybody wins. le monde gagne.
» W. Edwards Deming
W. Edwards Deming
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11. The Collaborative Approach
l’approche Collaborative
Action Period One Action Period Two Action Period Three
A P A P A P
S D S D S D
Planning & Learning Learning
Pre-work Session Learning Session
One Three Distribute
a) Teams Session
(A&B) (A&B) Findings
b) Topic
-Jan 18 & Two -Nov 14 & Dec
25- -May 28-29- 21-
-July-Dec-
Support
Team Calls List Serve Document Sharing Monthly Reports
Assessments Site Visits Faculty Coaching
*Based on Institute for Healthcare Improvement Breakthrough Series Collaboratives
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12. Participating Teams-Équipes particiapntes
AHS Edmonton Zone University of Alberta Hospital
Grey Nuns Hospital
AHS Edmonton Zone – Sturgeon Hospital
Misericordia Hospital
AHS - Calgary Zone
Saskatoon Health Region
Horizon Health Network
Timmins & District Hospital
AHS – Medicine Hat Hospital
Humber River Regional Hospital
Hamilton Health Sciences Centre
Thunder Bay Regional Health Science Centre
North York General Hospital
Joseph Brant Hospital
Bluewater Health
Hotel-Dieu Grace Hospital London Health Sciences Centre
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13. Delirium Measures in Indicateurs du delirium
Patient Safety Metrics sur le portail SSPSM
System (PSMS)
1. Percentage of Patients 1. % patients ayant subi un
Screened for Delirium dépistage ppour le
2. Percent of Patients delirium
Identified with Delirium 2. % pts identifiés ayant le
3. Percent Compliance with délerium
Non-Pharmalogical 3. % conformité aux
Strategies stratégies non
4. Number of Unplanned pharmacologiques
Extubations per 1,000 4. Nombre d’extubation non
Invasive Mechanical planifié pae 1000 jours de
Ventilation Days ventilation effractive
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14. Change Concepts
• Recognize/manage/mitigate • Reconnaître/gérer/diminuer
risk factors (prevention & les facteurs de risque
reduction) for every patient (prévention et réduction)
• Assess for Delirium every pour chaque patient
shift • Évaluer pour le delirium à
• Document compliance with chaque quart de travail
standardized protocol for • Documenter la conformité
management au protocole standardisé
• Support patients and pour la gestion du delirium
families • Soutenir les patients et
leurs familles
27-Feb-13 Delirium and Med Rec Collaborative 14

15. Change Concepts
• Consider others to be part • Considérer les autres
of same system comme faisint partie du
• Change work environment même système
• Standardize clinical • Changer l’environnement de
processes travail
• Manage hand-offs • Gérer les transitions
• Establish reliable processes • Établir des processus fiables
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16. 1.0 Percentage of Patients Screened for Delirium
1.0 Pourentage de pts faisant objet de dépistage
• Xxx of teams now have data for 2-3 key measures,
standardized definitions x-Canada
• Insert run chart for those measures
Source: SHN Patient Safety Metrics System
February 2012
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17. 2.0 Percentage of Patients Identified with Delirium
2.0 Pourcentage de patients identifiés avec delirium
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18. Lessons Learned on the
Collaborative Journey
Dr. Yoanna Skrobik
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19. The Agitated Patient
• Pain
• Insufficient sedation
• Delirium

20. Patient views on what is important in the
ICU
• Painlessness
• Reassurance
– Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000
– Information, orientation, cognitive abnormalities American Journal of
Critical Care. 9(3):192-8, 2000 May

21. Sedation

22. Monitoring Sedation
• The RASS and SAS scales are valid and reliable for
measuring quality and depth of sedation in adult ICU
patients .

23. Sedation
– Depth of sedation vs. clinical outcomes:
• Maintaining lighter levels of sedation in adult ICU patients is
associated improved clinical outcomes, such as a shorter duration
of mechanical ventilation and a shorter ICU length of stay.
• Maintaining lighter levels of sedation increases the physiologic
stress response, but is not associated with an increased incidence
of myocardial ischemia .
• The relationship between depth of sedation and psychological
stress in these patients is unclear .
• sedative medications titrated to maintain light (vs. deep) levels of
sedation in adult ICU patients are associated with better
outcomes .

24. Outcomes Related to Sedation
• sedation strategies using non-benzodiazepine sedatives have
better outcomes than benzodiazepine infusions in mechanically
ventilated adult ICU patients.
• analgesia should be evaluated prior to sedation in adult ICU
patients who are mechanically ventilated .

25. Delirium
Van der Mast. PhD Thesis, Delirium After Cardiac Surgery, Erasmus University, Rotterdam,
1994

26. Delirium and Outcomes
• Delirium is strongly associated with increased mortality and LOS in
adult ICU patients.
• Delirium is moderately associated with the development of post-
ICU cognitive impairment in adult ICU patients.

27. Delirium and Distress
Breitbart W et al. Psychosomatics 2002;43:183

28. Delirium Scales
ICDSC CAM-ICU
(Intensive Care Delirium Screening (Confusion Assessment Method-ICU)
Checklist)
http://www.icudelirium.co.uk/ www.icudelirium.org

29. Delirium Nomenclature Consistency is
Important
Delirium and its consequences

30. Delirium Prevention
• early mobilization of adult ICU patients reduces the incidence and
duration of delirium.
• there are no compelling data that pharmacological delirium
prevention in the ICU reduces the incidence or duration of
delirium.

31. Protocol to address patient views on what
is important in the ICU
• Painlessness
• Reassurance
– Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000
– Information, orientation, cognitive abnormalities American Journal of
Critical Care. 9(3):192-8, 2000 May

33. How can optimal patient care be
provided?
• a multidisciplinary ICU team approach, that includes
provider education, preprinted and/or computerized
sedation protocols and order forms, and a quality
rounds checklist, can be used to facilitate analgesia,
sedation and delirium management in adult ICUs.

34. Impact of Using a Validated Delirium Screening Tool, With
or Without a Pharmacist and Nurse-led Delirium Education
Program, on the Ability of Nurses to Recognize Delirium in a
Surgical-Trauma ICU
Andrew Lin, PharmD
Brittany Russell, RN, BSN, CCRN
John W. Devlin, PharmD, BCPS, FCCM, FCCP
H. James Norton, PhD
Susan Evans, MD
Gail Gesin, PharmD

35. Educational Interventions

36. Results: Subject Nurse Delirium Knowledge
Average Number of Correct Answers
Phase I
p=0.08
p=0.001
Phase II
p=0.001
Phase III
0 1 2 3 4 5 6 7 8 9 10

37. Delirium is challenging to assess in
ICU patients
Phase I
Phase II
Phase III
The ICDSC makes delirium easier to
identify in my patient(s)
0 10 20 30 40 50 60 70 80 90 100
% of Nurses that Agree (Moderately or Strongly)

38. Delirium Treatment
• There is low quality evidence that atypical antipsychotics reduce
the duration of delirium in adult ICU patients .

39. Patients with First Resolution of Delirium
Log-Rank
Proportion of Patients with Delirium
P = 0.001
Placebo
Quetiapine
Day During Study Drug Administration
Quetiapine added to as-needed haloperidol results in faster delirium resolution,
less agitation, and a greater rate of transfer to home or rehabilitation.
Devlin JW, et al. Crit Care Med. 2010;38:419-427.

40. Drug Specificity:
Comparative Receptor Binding Profiles
Quetiapine Olanzapine
D1D2 D1
D2
5HT2A
5HT1A
5HT2A
M
H1 A1
A1
A2 A2
H1
Ziprasido Risperidone Haloperidol
ne D1 D2
A1 D2
D1 A2 H1 D1
5HT1A A1 A1
5HT1A
5HT1A
5HT2A
5HT2A D2
5HT2A
Adapted from Gareri P, et al. Clin Drug Invest. 2003;23:287-322.

41. Delirium Treatment
• There is no direct evidence that treatment with haloperidol
reduces the duration of delirium in adult ICU patients .
• There is low quality evidence that atypical antipsychotics reduce
the duration of delirium in adult ICU patients .
• rivastigmine should not be given to reduce the duration of
delirium in ICU patients.
• continuous intravenous infusions of dexmedetomidine rather than
benzodiazepines should be administered for sedation of adult ICU
patients with delirium, in order to reduce the duration of delirium
in these patients.

42. My Discoveries of the Collaborative
• Awesome teams from all of Canada committed to
improving patient care
• An ongoing feedback and improvement team to help
make that happen based on the team’s goals
• Interest and consideration for expert opinions on the
relevant topics
• A sneaky feeling good will and commitment are more
important than guidelines 
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43. In summary…

44. Overall management
• Protocolized nursing assessments of pain, sedation and delirium are associated with
improved short-term and long-term outcome.
• Protocol AND non protocol-driven medication administration result in better outcomes in
the context of educated and empowered nurses, and of physician buy-in.
• These data suggests that it is individualization of care, and not protocolization of
medication, which accounts for improved outcomes.

45. Managing pain, agitation and delirium in
the critical care setting
•Manage adult patients who need sedation and analgesia according to
current standards
•Use validated scales for sedation, pain, agitation, and delirium in the
assessment and to follow the management of these critically ill patients
•Assess recent clinical findings in sedation and analgesia management
and incorporate them into the management of patients in the critical care
setting

46. Thank you

47. A Case Study: Histoire de cas:
One Le périple d’une
Collaborative équipe de la
Team’s Journey Collaboration
Hamilton Health Sciences Centre
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48. Next Steps/ prochaines étapes
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49. Next Steps/ Prochaines étapes
• Measurement Reporting • Système d’indicateurs
System in SHN’s Patient
Safety Metric System de la sécurité des
(PSMS) – Available now patients- fonctionnel
Contact Central Measurement maintenant
Team
416-946-3103 – Contactez lÉquipe responsible
metrics@saferhealthcarenow. des mesures: 416-946-3103
ca – metrics@saferhealthcarenow.ca
• Delirium Getting Started
Kit – Available in late • Trousse de départ,
Spring 2013 Delirium- disponible fin
printemps 2013
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50. Thank You
Merci
• Team Sponsors / aux Soutiens exécutifs des équipes
• Faculty 3 la Faculté
• Planning & Support Team / L’équipe de planifiation et
de soutien
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51. Funded & Supported By
Financé et appuyé par