This document discusses strategies to prevent and manage delirium in critically ill patients. It outlines the ABCDEF bundle which includes assessing, preventing, and managing pain, both spontaneous awakening and breathing trials, minimizing sedation, assessing and preventing delirium, early mobility and exercise, and engaging family members. Screening for delirium using the CAM-ICU tool and implementing non-pharmacological interventions can reduce length of hospital stay, duration of mechanical ventilation, and mortality. Widespread use of protocols and bundles that incorporate these strategies may help address the high cost and poor outcomes associated with delirium.

1. Delirium: A culture of change
By: Charmaine Berggreen, RN, MSN, CCRN
May 2015

2. Institute for Healthcare Improvement’s
Rethinking Critical Care (IHI-RCC)
The IHI-RCC was established to reduce harm of
critically ill patients by:
 decreasing sedation
 increasing monitoring & management of delirium
 increasing patient mobility
Bassett et al., 2015
Joint Commission Journal on Quality & Patient Safety

3. What is Delirium?
• Inattention and confusion that
represents the brain temporarily failing
• A person who is unable to think clearly
and can’t make sense of what is going
on around him
www.icudelirium.org

4. Impact of Delirium
The incidence of delirium:
 11-42% in general medicine patients; 87% in critically ill
 Ventilated patients have twice the risk of delirium (50-80%)
Delirium results in an increase in:
• LOS: 15-days
• Healthcare Cost: $4 -$16 billion annually
• Mortality: 19% increase in 6 month mortality
(Rivosetti et al, 2015)

5. Delirium in Older Adults
• Occurs in 5-50% of older patients postop
• More than 1/3 of all inpatient surgeries in U.S.
are performed on patients 65 or older
• Annual U.S. cost estimated at $150 billion
• Preventable in up to 40% of patients
(American Geriatric Society Expert Panel published in
Journal of American College Surgeons, 2014)

6. T Toxic situations: CHF, Shock, Meds (opiates)
H Hypoxemia (think Haldol)
I Infection/sepsis
I Immobilization or pain
N Non-pharmacological interventions
K K+ and other lytes, metabolic problems
THIINK!
Risk Factors for Delirium

7. Don’t forget about Dr. DRE
Diseases: Sepsis, COPD, CHF
Removal of Drugs: SATs & stop benzodiazepines &
narcotics
Environment: Immobilization, sleep & day/night,
hearing aids, classes, noise

8. Delirium Awareness
• A pre survey on nurses’ knowledge about delirium
• Nurses completed a computer learning module on:
• Definition of delirium
• Causes of delirium
• CAM-ICU screening tool
• Non-pharmacological interventions
• Pharmacological interventions
• A post survey on nurses’ knowledge about delirium

10. How do we screen for delirium?
• Confusion Assessment Method (CAM-ICU)
• A tool to assess critical care patients for
delirium

11. CAM-ICU
1. Acute onset or fluctuating mental status (yes/no)
AND
2. Inattention - cardinal sign (SAVEAHAART)
AND Either
3. Altered level of consciousness (RASS other than “0”)
OR
4. Disorganized Thinking (4 yes/no questions)
Positive for 1 and 2 AND either 3 or 4 = DELIRIUM

12. CAM-ICU WORKSHEET

13. Protocols used to treat delirium?
• Protocols to include
• early mobilization
• education of nurses
• cognitive stimulation with orientation
• non-pharmacological interventions
(Rivosecchi et al., 2015)
• Nurse driven protocols increase ambulation
of ICU patients from 6.2% to 20.2%
(Roberts, et al 2014)

14. Pain, Agitation, & Delirium (PAD)
Guidelines
SCCM established PAD Guidelines in 2013 and
Assess patients every shift and prn for:
 Pain - opiates
 Agitation - sedatives
 Delirium - antipsychotics

16. Pain Agitation Delirium Protocol
1. Analgesia Pain Scale __________________ (Target 1 to 3 or CPOT 0 to 3)
2. Sedation RASS __________________ (Target 0 to -3)
3. Delirium CAM-ICU Yes / No (Target No)
**Antipsychotics as ordered:
Haldol (Haloperidol) 5-10mg every 6 hrs
Seroquel (Quetiapine) 50 mg every day &
titrate
Is there agitation?
RASS
+4 to+2
RASS
+1
Agitation No agitation
NoYes
Treat with analgesia
Consider Mechanical Ventilator
setting change
Is the patient in Pain?
Mechanical Ventilator dissynchrony?
Consider Differential Dx
(e.g. sepsis, CHF, Metabolic disturbances, Hypoxia, Medications)
Start Non-pharmacological Interventions,
Alert PharmD & Physician
Ensure adequate pain control.
**Consider antipsychotics**
**Consider antipsychotics**
Give adequate sedative for safety,
then minimize
Reassess every shift and
monitor for Pain & Anxiety
Delirium
“A Great Cost to The Patient”
Positive Delirium
No Delirium
CAM-ICU
Every Shift & PRN
Assure adequate pain
control

17. Non-pharmacological Interventions
Orientation
Provide visual and hearing aids
Encourage communication; reorient patient repetitively
Provide familiar objects from patient’s home in the room
Attempt consistency in nursing staff.
Provide television during day with daily new
Non-verbal music
Environment
Sleep “Quiet Time” Protocol
Lights on during day, off at night
Control noise (staff, equipment, visitors) at night
Ambulate or mobilize patient early
Clinical parameters
Maintain SBP > 90 mm Hg
Maintain O2 Sats> 90%
Treat underlying metabolic imbalances and infections

18. Evidence-based ICU bundle
Awake Breathing Coordination,
Delirium and Exercise
ABCDE
(Bassett et al., 2015)

19. Spontaneous Awakening Trial (SAT)
Kress et al., 2000
Outcome of SAT:
• Daily interruption of sedation on
Mechanical Ventilator (MV)
• MV duration decreased by 2 days
• ICU LOS decreased by 3.5 days

20. Sedation Vacation
 Stop sedatives every 12 hours and prn (except for Precedex)
 Allow patient to awaken gently & become oriented to surroundings
 Assess respiratory parameters & neurological function
 Sedation drip restarted at half the lowest dose if tolerated
Less use of sedatives decreases ventilator time,
ICU length of stay & mortality
(Bassett et al., 2015)

21. Awake and Breathing Controlled Trial
(ABC Trial) Girard et al., 2001
• Combined Spontaneous Breathing Trial (SBT)
with daily Spontaneous Awakening Trial (SAT)
• SAT + SBT yielded
– Extubated 3 days earlier
– Both ICU and Hospital LOS reduced by 4 day
– Absolute mortality reduction of 14% at one year

22. Vanderbilt UMC Studies
(www.icudelirium.org)
Ely EW, JAMA 2001;286:2703-10
Ely EW, JAMA 2004;291:1753-62

24. New ABCDEF Bundle
Assess, Prevent & Manage Pain
Both SAT and SBT
Choice of Sedation
Delirium: Assess, Prevent & Manage
Early Mobility and Exercise
Family Engagement & Empowerment

25. Daily Work Flow
• Perform CAM on patients every shift
• Document CAM score in EMR
• Initiate non-pharmacological
interventions if patient CAM +
• CAM score is on trauma patient list
• Discuss in multidisciplinary rounds

26. Analysis of Delirium Data
• ABCDE forms collected in ICU & CVICU Jan–May 2014
• N = 850 patients (774 Non trauma: 78 Trauma)
• Total mean age = 56
• 107 (12.6%) of all patients were CAM positive
resulting in:
• H-LOS 11.77 + 12.14 days
• ICU-LOS 7.97 + 8.59 days
• Vent days 4.53 + 8.19 days

27. Analysis of Delirium Data
• Effect of CAM positive results on LOS for all patients:
• CAM positive stay 5 days longer than CAM negative
• Non trauma patients stay 3 days longer than trauma
• Trauma patients who are CAM positive:
• 11.8% of patients were G60
• H-LOS 4.44 days longer
• LOS-ICU 0.6 days longer
• Vent days 0.6 days longer

28. Future of Delirium
Create strategies to overcome the barriers:
– Champions to reduce resistance to change
– Enhance resources / equipment to mobilize patients
– Improve knowledge: educate to change perceptions &
clarify processes - “How can we?” versus “We can’t.”
– Daily rounding to sustain improvements
– Reduce sedation use
– Delirium screening as part of daily work flow

29. Preventing delirium is the key!
Use the CAM-ICU to screen for delirium in all
patients, especially G60 population:
If CAM positive:
1. Identify etiology & risk factors
2. Control pain & agitation
3. Consider non-pharmacological interventions
Stop & Thiink before you medicate!

30. Delirium Prevention can reduce:
 Length of stay
 Ventilator days
 Mortality
 Cognitive or functional impairment
 Healthcare costs

31. References
• Balas, M.; Olsen, K.; Gannon, D.; Sisson, J.; Sullivan, J.; Stothert, J.; Jawa, R.; Vasilevskis, E.; Burke, W.; Ely, W. Safety and Efficacy of the ABCDE
Bundle in Critically-Ill Patients receiving Mechanical Ventilation. Crit Care Med 2012: 40(12S): 1-328.
• Balas, MC, et al, Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Crit Care Nurse, 2012; 32(2): 35-38, 40-47.
• Balas, MC, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility
bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines.
Crit Care Med. 2013: 41(9 supp l 1): S116-127.
• Balas M.C., Vasilevskis E.E., Olsen K.M., Schmidt K.K., Shostrom V., Cohen M.Z., Peitz G., Gannon D.E., Sisson J., Sullivan J., Stothert J.C., Lazure J,
Nuss S. L., Jawe R.S., Freihaut, Ely E.W.. Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring /
Management, and Early Exercise / Mobilization Bundle. Critical Care Medicine Journal, May 2014, vol 42, N°5.
• Barr, J. et. al. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit.
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• Bassett, R. et al (Feb 2015). Rethinking Critical Care: Decreasing sedation, increasing delirium monitoring, and increasing patient mobility. The
Joint Commission Journal on Quality and Patient Safety, 41 (2), 62-74.
• Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients
in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet. 2008;371:126-134.
• Kress JP, et al. Daily ineruption of sedation infusions in the critically ill pateints undergoing mechanical ventilation. N Engl J Med2000;
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• Rivosecchi, R.M. et al (2015). non-pharmacologicalal Interventions to Prevent Delirium: An evidence-Based Systemic Review, Crit Care Nurse,
35 (1), 39-49.
• Roberts, M., Johnson, L.A. & Lalonde, T.L. (2014). Early Mobility in the Intensive Care Unit: Standard equipment vs a mobility platform, AJCC,
23(6), 451-457.
• Society of Critical Care Medicine. www.sccm.org.
• Timothy D .G., John P.K., Barry D.F., Jason W .T., William D.S., Brenda T.P., Darren .T., Jan G.D., Anne S.P., Paul .K., James C.J., Angelo .C.,
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• www.icudelirium.org
• www.aacn.org, AACN Practice Alerts, accessed 5/2015