Medicine Hat Regional Hospital ICU Delirium Collaborative

Background 10 bed critical care unit in Medicine Hat Regional Hospital Supports a catchment population of 110,000 people, SE AB & SW Saskatchewan Team comprised of Registered Nurses (16.19fte’s), supported by Internal Medicine Specialists & an interdisciplinary team of HCP AHS/MHRH has adopted the use of the intensive care delirium screening tool (ICDSC) MHRH ICU introduced the ICDSC screening tool & trained staff July 2011 on the application of the ICDSC The practice/process has not been consistently followed since being introduced

Background Rationale for non-adherence to delirium screening Staff state if the patient is not presenting with S&S of delirium or changes to behaviour they simply forget to administer the delirium screening tool lack of education, timing bad for rollout (summer), prompt/flag not on care plan or admission assessment, screening tool instructions & scoring located on the back of the graphic record.

Aim Problem Statement Goal Statement AIM Current screening practices/process for delirium detection, prevention & management not consistently being adhered to in MHRH ICU Goal Statement AHS expectation is that within 6months 100% of patients admitted to ICU be screened, using the ICDSC tool & standard care guidelines be implemented, to detect, prevent & manage Delirium AIM To improve the care of critically ill patients at risk for delirium through the implementation of standards for screening and identification of preventative and management strategies. Objectives To determine the baseline incidence/prevalence of delirium within 3-6 months Implement a process to screen 100% of ICU patients within 6 months Develop education resources and support for staff to assist with screening, prevention and management of delirium in the ICU within next 6 months Implement standardized prevention interventions within the next 12 months Implement standardized management interventions within next 12 months Implement strategies to support families within the next 18 months

Team Members Team Lead/Sponsor, Brenda Ashman Director Critical Care and Medicine ICU Manager, Rickie Pomreinke Clinical Quality Improvement Consultant, Jill Forsyth Transformational Team Leads Environmental Lead, Melissa Hill RN Mobility Lead, Stephen Yuen Team Lead Physical Therapy Sedation/Vacation Lead, Catherine Johansen Manager Respiratory Therapy Pharmacist Joyce Nishi Occupational Therapy Shayne Clinical Educator Jamie Fauth Psychiatrist Dr. Patel Social Worker Dan Stevens (to be invited to participate)

Results

Results

ICDSC audit

Changes Tested Education of all ICU staff, excluding physicians, including allied health “All about me” posters utilized & posted Initiation of interdisciplinary daily Rapid Rounds Establishment of day & night routines Documentation of # of hours of sleep Delirium awareness posters in each room Patient brochure provided to patient/family Vented patient PROM & mobilization plan documented

Lessons Learned Keys to success Interdisciplinary transformational team, including frontline-care providers Support/feedback from ICU Collaborative, networking, CoP Lessons Learned Small steps/tests, one at a time, prioritize areas to improve Communication Key! Develop a formal plan, Make it visible At onset establish responsibility, accountability for progression/completion of project

Lessons Learned Once again summer months created delay in roll-out Changes to ICU Manger, Clinical Educator & Respiratory Therapist Manager hampered momentum, buy-in, sustainability Education alone does not change practice Front-line staff engagement in all stages of improvement initiative imperative for adoption of changes to practice. Change management plan required

Next Steps Continue chart audits for compliance with ICDSC Perform root cause analysis for non-compliance to assessing & documenting ICDSC score per shift on every patient Engage staff in brainstorming sol’ns for maintaining compliance with environmental, mobility, ICDSC assessment for Delirium. Develop PDSA’s to test sol’ns Engage ICU physicians in supporting/developing plan for awake & breathing trials, (sedation vacations) Monitor incidence/prevalence of delirium diagnosis in ICU Assess effectiveness of Rapid Rounds Establish accountability for monitoring & sustaining improvements