1. Hotel-Dieu Grace Hospital
Delirium
Identify
Treat
Prevent

2. Background Inner-city Hospital in Windsor, Ontario
20 bed Neurosurgical/Medical/Trauma ICU
Team consists of Intensivist, RN clinical educators, NP, Staff RN’s, and Pharmacist
Goal: improve the management of delirium through education, early identification, prevention, and optimal treatment.

3. Team Members Dr. Natalie Malus, MD FRCPC, Medical Director ICU
Sue Elliott, RN, BScN, CNCC(C) ICU PPL
Anne Marie Marsigliese, RN, BScN, MScN, NP
Chim Seng, RN
Dianna Thorn, RN
Marc Conte, RN
Frank Foote, B.Sc., Pharm. D.

4. Aim Implement & reinforce routine screening Educate staff
identification
prevention
treatment
Determine baseline incidence at 3 months
Determine incidence at 12 months
Goal 10-15% reduction

5. Improvement Charter Measures Current screening rate
Screening rate at 2 months
Incidence at 3 months
Incidence at 12 months
Rate of unintended extubation
Benzodiazepine use
Ventilator days
Current Performance
74% (initial rate)
60-80% for 1st 6 months
14%, then variable(higher)
Unknown check in January 2013
4 in 2011
Reduced
8.7/day (2011)
Goals
100%
Baseline for comparison
10-15% reduction
25% reduction
5% reduction
4-Dec-18
Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

6. Delirium Initiative Timeline
2007 ICDSC built into our 24hr flow sheet
Feb - Survey/brainstorming re: barriers to consistent completion of Q-shift delirium screening
Feb - Nursing worksheet updated to encourage delirium discussion at rounds
March/April - Delirium presentation made at yearly requalification for all ICU RN’s
April - Delirium PowerPoint slides posted on education board and scroll monitor
June – information pamphlet developed
August – 95% screening rate achieved
Visiting hours project underway by UBC
Development started for mobility protocol, Delirium PPO, ETOH withdrawal PPO
September – Dexmedetomidine added to formulary
4-Dec-18
Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

7. Changes Tested
Delirium education will improve compliance with ICDSC screening tool and preventative measures
Wrong - Screening rate is variable and has not improved
When ICU Physician requests delirium score at rounds completion rate of Q-shift ICDSC improved (94% vs. 71/81/69%)

8. Changes Tested
Delirium education will promote the use of consistent treatment modalities
Educating the Nursing staff has not influenced prescribing practices
We should re-test this following physician continuing education
Expectation that delirium PPO will help promote consistent treatment practices

9. Lessons Learned
Education on delirium has been ineffective in improving compliance with screening
Future nursing education needs to focus on clinical significance of delirium
We need to empower RNs to gain buy-in, initiate preventative strategies, be proactive in identification of delirium

10. Lessons Learned Barriers to consistent screening include:
Perception of low clinical significance among RNs
Perception that our large Neurosurgical population cannot be reliably assessed for delirium
If the information goes unused, why collect it?
It would have been more effective to have a standardized treatment algorithm in place earlier in the process
4-Dec-18
Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

11. Next Steps Continue to monitor for screening compliance
Continue to monitor delirium rates
Ongoing education
Focus on preventative strategies
Implement Delirium PPO
Implement ETOH withdrawal PPO
Investigating flow sheet modification to improve trending of delirium treatment

12. Next Steps Reevaluate our pain control and sedation practices
Use of narcotic infusions
Use of Midazolam infusions
Use of Propofol
Dexmedetomidine for sedation where appropriate
Ultimate goal:
Develop a ‘Delirium Bundle’ integrating Sedation, Spontaneous Breathing, and Mobility strategies
4-Dec-18
Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM