Presentation on theme: "WRHA Surgical Program Delirium Guidelines"— Presentation transcript:
1 WRHA Surgical Program Delirium Guidelines Cheryl BilawkaApril 18, 2012
2 PurposeThe WRHA Surgery Program had identified that there was no formal regional guidelines in place to identify, screen or manage postoperative delirium.
3 ProcessA 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.
4 MethodologyThe 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.
5 Delirium 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)
6 Opportunity for Interventions PreoperativelyPostoperatively
7 The 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
8 Preoperative Screening The WRHA Surgery Program Preoperative Assessment Patient Questionnaire, has been revised to have delirium screening criteria embedded using flags
9 Example 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
10 Delirium 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
11 Communication 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..
14 Delirium 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
15 The 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)
16 Delirium 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
17 Delirium 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
18 Delirium 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?
19 Lanyard 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
21 Goals 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
22 Audit 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..
23 MetricsLength of stayConstant Care UseFalls Reduction
24 Future 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.
25 Delirium 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