Department of Critical Care Medicine Calgary Delirium Assessment and Treatment

Background Calgary DCCM comprised of 4 adult critical care sites Mix of medical, surgical, neurological, and cardiovascular surgery patients Disciplines involved: Intensivists, RNs, RTs, Pharmacists, Nurse Educators, Physiotherapists The literature has demonstrated that delirium is a strong predictor for patient morbidity and mortality We currently do not have a standardized assessment tool or treatment algorithm in place for recognition and management of delirium

Aim Determine baseline incidence/prevalence of delirium with in 3-6 months. Implement processes to screen 100% of all ICU patients for delirium within 12 months. Develop education and support for staff regarding delirium awareness, prevention, and management within 12 months. Implement standardized delirium prevention interventions in all ICU patients within 12 months. Implement standardized interventions for the management of delirium within 12 months. Implement strategies to support families of patients with delirium within 18 months

Team Members Intensivists/Nurse Practitioner Dr. Terry Hulme, Dr. Sid Viner, Nicki Johal Nursing Management Rebecca Eldridge RNs/Educators Melissa Redlich, Joan Harris, Joanne Xu, Deborah Banack, Heather Sartison, Laura Sullivan RTs Suzanne Boyd Pharmacists Barry Kushner, Diana Callfas PT/OT Megan Hudson 16-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Changes Tested Implemented the RASS scale in 4 adult ICUs as replacement for RIKER in anticipation of using CAM-ICU for delirium assessment. Trialed use of CAM-ICU in 2 adult ICUs Trialed use of ICDSC in 2 adult ICUs ICU Physiotherapist developed an Intensive Care Patient Mobility protocol. PDSA trials regarding new mobility protocol completed in 1 adult ICU.

Changes Tested continued… Trialed ICDSC with head injury patients at 1 adult ICU. ICU Pharmacist and 2 ICU Intensivists reviewing and revising Sedation protocol to include in our delirium management protocol. ICU OT , 2 ICU RNs and CNE working on the non-pharmacological algorithm for delirium management protocol. 16-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Results RASS successfully implemented at all 4 adult ICUs. Incorporated into the provincial electronic critical care documentation system. CAM-ICU trial results demonstrated strong interrater reliability and ease of use for novice practitioners. ICDSC trial demonstrated difficulties with how to measure some of the indicators, how to reliably interpret and assess indicators. ICDSC trial demonstrated difficulties with education regarding how to correctly use the tool. Required extensive educational component.

Results continues.. PDSA trials of mobility protocol provided in-depth feedback for ICU PT. PDSA trial of using ICDSC with head injury patients resulted in further questions of reliability with this patient population and how to apply this assessment tool with this population. Current sedation guidelines and protocols will require minor revisions to accommodate delirium management recommendations. Non-pharmacological processes require a visible, defined area/ focus in the ICU unit.

Lessons Learned Strong educational component will be required to address diverse learning needs associated with utilization of the ICDSC. Current sedation practices will change and education will need to occur to address changes. ICU staff are looking forward to more structure and education around delirium assessment and management. Early mobilization process has been initially well accepted by bedside staff. 16-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Lessons Learned continued… Some hesitation regarding mobilization of “drowsy” patients with mobilization protocol. Delirium Management Protocol will require comprehensive education and engagement of whole interdisciplinary team. 16-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Next Steps To test our newly developed sedation guidelines and delirium treatment algorithm PDSA cycles for the ICDSC Start with Delirium Collaborative participants Then to roll out to core group of bedside practitioners Audit of ICDSC accuracy and completeness Comparison of delirium incidence before and after the implementation of standardized assessment and treatment tools