Hamilton General Hospital Hamilton, Ontario Delirium Collaborative in ICU-West (Cardiovascular Surgical ICU)

Background ICU-West: 15 bed unit focusing on postoperative care of Cardiovascular Surgical patients Summer of 2009: CAM-ICU introduced to unit Education sessions targeted all staff General delirium information, prevention/treatment strategies, proper administration of CAM-ICU January, 2012: CAM-ICU compliance low (60-70%) Frustration from front-line staff regarding perception of increased workload, validation of CAM results from physicians, lack of consistent treatment plan

Aim Continue to improve prevention, early recognition and effective management of ICU delirium in cardiac postoperative patients Reduce incidence of delirium in ICU-West by 50% through early prevention and strategic management by February 1, 2013 100% compliance with CAM-ICU Improve discussion of delirium during daily bedside rounds Increase accuracy of collecting, reviewing patient medical history Improve environmental factors that may contribute to delirium Improve awareness of pre-op substance use & anticipating / preventing withdrawal Increase participation of families in prevention, treatment of delirium

Team Members Alison Fox-Robichaud, MD (Site Lead) Dale Bialas, RN (ICU Educator) Sonya Lugowy, PharmD (ICU Pharmacist) Courtney Mitchell, RN (Staff Nurse) Leslie St Jacques, PA (Staff Physician Assistant) Yuliya Tomilovska, RN (Staff Nurse) Yvette Young, RN (Patient Safety Specialist)

PSDA Cycle 1 PLAN: Audit CAM-ICU completion for single patient over the course of the patient’s stay in ICU. Discuss CAM-ICU results and any necessary interventions on rounds DO: CAM completed on 2/6 day shifts, 1/6 night shifts STUDY: There appeared to be confusion around proper administration of CAM-ICU which decreased enthusiasm for using the tool. ACT: Increased discussion around the value of delirium assessment

PSDA Cycle 2 PLAN: Improve awareness of delirium & management strategies among team DO: Trial use of worksheet tracking interventions to decrease length of time spent in delirium. For any patient who may be CAM +VE Leave worksheet at bedside for nurse to complete Document CAM-ICU results, all interventions attempted STUDY: 88 patients monitored, 10 were CAM +. Nurses felt that worksheet was onerous to complete , significantly added to their workload. ACT: Switched to a single sheet to follow changes over time. 21-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Bedside worksheet PDSA 2

Meanwhile…. There was an ongoing review bedside to bedside looking at CAM compliance in anticipation of increasing the documentation by nursing to accreditation standards. As separate audit was performed outside of the team that looked at compliance in all 3 of our ICUs at our site. HOW DID WE COMPARE?

ALL 3 UNITS AUDIT

PDSA CYCLE 3a PLAN: Consistent attention to management of CAM +ve patient will increase compliance with CAM-ICU, as nurses will see the score as a useful intervention DO: Utilize one worksheet per patient to track CAM results & interventions; tracking done daily by PA or pharmacist until patient scored CAM –ve. Consistently discuss CAM results & interventions on rounds; follow up on planned interventions. STUDY: Compliance still low but staff now prepared to discuss delirium management plan on rounds. Nursing more comfortable discussing delirium. ACT: Abandon the tracking chart. Continue discussion on rounds. Need more education… 21-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

PDSA CYCLE 3b PLAN: Survey the nursing staff about their reluctance around the use of the CAM-ICU as a tool for delirium screening. DO: Copies of survey given at bedside and results compiled by PA and an elective clinical clerk. STUDY: see next slide… ACT: We need to go back and do additional education that emphasizes the patient perspective. 21-Nov-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

SURVEY AND RESULTS

Then We Had A Big Interruption And we switched our perioperative sedative from midazolam to propofol

Documentation Post eCare Implementation Compliance for completion on a recent audit of 75 pts over a 2 week period (May 1-15th) was 63%. 12 of 75 (16%) patients had at least one positive CAM.

LESSONS LEARNED Need followup for “buy in”. Nursing had some misconceptions about the use of the CAM-ICU in the intubated patients Physicians are an important part of understanding and treating delirium. A consistent approach is needed.

NEXT STEPS Education is planned for next 2 weeks. Slides prepared. We have a delirium order set in development that should improve consistency of care. We need to get back to the greater than 90% compliance with CAM documentation that we had just prior to eCare implementation.