Presentation on theme: "WRHA Surgical Program Delirium Guidelines"— Presentation transcript:
1WRHA Surgical Program Delirium Guidelines Cheryl BilawkaApril 18, 2012
2PurposeThe WRHA Surgery Program had identified that there was no formal regional guidelines in place to identify, screen or manage postoperative delirium.
3ProcessA working group was created with members representing all the acute care sites chaired by Wendy Rudnick, WRHA Surgery Program Director.The objective of this group was to develop a standardized approach to delirium care for surgical patients in the WRHA.
4MethodologyThe group complied existing tools and protocols from all the acute care sites and with the assistance of the experts in delirium and surgical management, the WRHA Delirium Implementation Tools will be rolled out across the region May 14, 2012.
5Delirium Tools Delirium Brochure for patients and their families WRHA Surgery Program PREoperative Assessment QuestionnaireDelirium Clinical Practice GuidelinesDelirium Decision TreeLanyard CardsAudit tool for evaluationEvidence Informed Practice Tool (coming soon)
6Opportunity for Interventions PreoperativelyPostoperatively
7The Surgical Patient Preoperatively If patient assessed as at risk for delirium, slating department to be notified.Slating to identify patient at risk for delirium on the OR slate.All patients will be screened for delirium in PACIf patient at risk and patient is seen,PAC will give patient or family aDelirium brochure
8Preoperative Screening The WRHA Surgery Program Preoperative Assessment Patient Questionnaire, has been revised to have delirium screening criteria embedded using flags
9Example from the PREoperative Assessment Patient Questionnaire The last time that you were hospitalized, did you experience confusion, hallucination or behaviour that was unusual for you? No Yes
10Delirium Elderly At-Risk (DEAR) Tool For patients greater than 65 years of age, flag at risk for delirium if:□ greater than 80 years of age□ benzodiazepines and/or alcohol greater than 3 x/week□ glasses and/or hearing aides□ Mini Mental Status Exam less than 24 or previous delirium□ assistance with any activities of daily livingDelirium Risk Flags:_____________/5Delirium Risk if greater than 2 flags. Implement facility protocol.□ N/A patient less than 65 years of age
11Communication of Delirium Risk Each hospital will develop a process so that the delirium risk will be identified on the OR slate.Inpatient postoperative units will have access to the delirium risk information..
14Delirium Decision Tree WHAT ARE THE RISK FACTORS?Severe IllnessSensory Impairment (hearing/vision)Age (age 65 years and over)Cognitive Impairment (dementia)DehydrationMultiple Medications (Sedatives/Hypnotics/Narcotics/Anticholinergics/ Psychotropics)ETOH/Substance abusePrevious DeliriumInfectionRECOVERY FROM SURGERYImpairment of Activities of Daily Living (bathing/dressing/toileting/grooming/feeding)Pain
15The Surgical Patient Postoperatively Administer CAM within the 1st 8 hours of admission.Positive CAMAssess using CAMQ shift and prnNegative CAMAssess Q 24 hours and prn(with any cognitive and/orfunctional changes)
16Delirium Decision Tree Search for reversible causes and treat:,/ CXR,/ EKG,/ CBC,/ Electrolytes,/ BUN/CR,/ TSH/B12,/ Urinalysis,/ Medication ReviewNurses Assess:,/ Vital Signs/02 sat,/ Assess/treat pain/ Fluid balance,/ Blood Sugar,/ Elimination
17Delirium Decision Tree INTERVENTIONSEnvironmental• Clocks/CalendarsCognitive• Frequent orientationCommunication• Simple short sentencesSafety• Fall prevention/Safe environmentPsychological• Don't dispute delusions; reassurancePharmacologyAvoid PolypharmacyAvoid BenzodiazepinesFor agitated delirium please consider an antipsychoticFunction• Balance, rest, activity
18Delirium Decision Tree CONFUSION ASSESSMENTMETHOD (CAM)Need presence of (1) & (2) and either (3) or (4)1. Abrupt change?2. Inattention, can't focus?3. Disorganized thinking?Incoherent, rambling, illogical?4. Altered level of consciousness?(Hyper-alert to stupor?)Trigger Questions1. Acute changes in behavior?2. Changes in function?3. Changes in cognition? MMSE4. Changes in medications?5. Physiologically stable?
19Lanyard Card of CAM CONFUSION ASSESSMENT METHOD (CAM) Answer these four questions:1) Was the onset acute and does behaviour fluctuate?AND2) Is there evidence of inattention?(difficulty focusing attention, shifting and keeping track)AND EITHER3) Is there evidence of disorganized thinking? (Incoherent, rambling, illogical flow of ideas)OR4) Is there evidence of disorganized thinking?(i.e. any state other than alert) (Alterations include hyperalert, lethargic, stuporous and comatose)FEATURES 1 AND 2, AND EITHER 3 OR 4 ARE REQUIRED FOR A DIAGNOSIS OF DELIRIUM
21Goals of Implementation Awareness of postoperative deliriumScreen for delirium and communicate riskRoutine utilization of the CAM as the standard method for detecting deliriumUse of the CAM tool when communicating with other Health Care ProfessionalsProactive interventions
22Audit Tool Screened for delirium in PAC Delirium Risk on Slate CAM done within 8 hours postopIf CAM positive, are interventions and plan documented in IPNPhysician notifiedIf CAM positive, is CAM reassessed 8 hours laterIf CAM is negative, is CAM reassessed q 24 hours..
23MetricsLength of stayConstant Care UseFalls Reduction
24Future Opportunity? Pose the question: “What if the patient is flagged as high risk for delirium, yet does not actually go on to experience a delirium?”Examination looking for evidence of proactive care planningEarly MobilizationAdequate Pain Management.
25Delirium Working Group Members and Contributors Wendy RudnickKaren MurphyMichele LeppLisa AnthonyGraciana MederiosAnn ReichertCheryl BilawkaChristine JohnsonLeslie DryburghRayan Horswill-TeesValerie HiebertVera DuncanKaren GutknechtCarol KnudsonBruce AndersonClaire DionneThe PAC Working Group