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Delirium in ICU

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Individuals that are admitted to the Intensive Care Unit (ICU) are already critically ill, and now, according to the article by Rattray will be faced with a longer recovery time that could be weeks, months and in some cases years to return to pre-ICU health status. 25-76% of these patient suffer from muscle wasting, weakness, and fatigue from prolonged bed-rest and immobility, and the severity increases with the more critically ill the person is. She further states that these patients suffer psychological problems from their stay in ICU. Due to their perceived experience they suffer from anxiety, depression (28%), PTSD (20%), and cognitive problems including delirium (20-80%), that negatively affect their health status. The characteristics of patients most likely to suffer from delirium are those that are already cognitively impaired, respiratory disease, older age, smokers, and alcohol abuse. Additionally, the illness that this is most prevalent are sepsis, dehydration, prolonged stay in the ICU, and biochemical abnormalities. Environmental precipitants include but are not limited to physical restraints, noise, sleep deprivation, isolation, as well as benzodiazepine and opioid use. Rattray states that rehabilitation should begin while the patient is still in ICU, by daily sedation reductions and early mobilization. This would need to be done with a team of multidisciplinary care providers that begin rehabilitation as soon as the patient is admitted to ICU and continue after discharge.

According to the article Intensive care delirium: the new black by Egerod, it is unclear if ICU delirium is the result of the illness or the medications. However, she does state that these patients suffer from adverse health outcomes from prolonged delirium and stay in ICU. Egerod further promotes the use of interdisciplinary team to manage pain, sleep, circadian rhythm, lighter sedation and early ambulation. Additionally, use of family to participate in care as it gives the patient comfort and familiarity and connects them to the outside world.

Both authors promote reduced sedation, decreased use of benzodiazepines, avoiding sleep disruption and increased physical therapy and activity. Due to the high rate of patients suffering from delirium and other adverse effects from their stay in ICU that have developed standardized tests in which to assess their functioning and delirium. Further research is needed to understand these mechanisms so as to provide better treatment that will provide better health outcomes for the critically ill population.

References:
Egerod, I. (2013). Intensive care delirium: the new black. Nursing in Critical Care, 18(4), 164-165.
Rattray, J. (2014). Life after critical illness: an overview. Journal of Clinical Nursing, 3(5/6), 623-633.

…more about delirium

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The topic of delirium is nothing new to the nursing world… in fact I have had my fair share of pts suffering from delirium or new onset confusion.  Unlike dementia, delirium is typically an acuteCAM-ICU Worksheet chane that may be reversed when the underlying problem is corrected. ICU delirium is actually a new topic for me.  Still keeping with the traditional definition, this acute change in mental status seems to affect pts that are sedated in the ICU while on a ventilator.  There is more recent research available on this topic, as it is still being explored and discovered.  It appears that after sedation is stopped and the pt is able to live in reality, the delirium may be reversed, but some emotional trauma
remains.  I found a recent peer reviewed article that details the main streamed assessment tool for ICU delirium.  This tool is called CAM-ICU, or Confusion Assessment Method for the Intensive Care Unit.  This article outlines an educational plan among people who are administering the test and utilizing the tool to ensure they are recording data accurately.  It was found that after the educational plan was implemented, less “unable to assess” ratings were recored and pts were able to receive a more appropriate grade.  As with most things in the medical world, the more knowledge medical professionals have the more meaningful outcomes pts may have.  Proper education for this assessment tool is instrumental in screening pts for delirium and reversing this confusion before mental health complications occur.  A copy of the CAM-ICU Assessment Worksheet is provided for review.

Reference

SWAN, J. DECREASING INAPPROPRIATE UNABLE-TO-ASSESS RATINGS FOR THE CONFUSION ASSESSMENT METHOD FOR THE INTENSIVE CARE UNIT. American Journal of Critical Care. 23, 1, 60-69, 2014. ISSN: 1062-3264.

 

What is ICU Delirium?

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Delirium is defined in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV as a disturbance of consciousness and cognition that develops over a short period of time (hours to days) and fluctuates over time. It is a common manifestation of acute brain dysfunction in critically ill patients, and occurs in up to 80% of the sickest intensive care unit (ICU) populations. People with delirium are unable to think clearly, have decreased attention, and may have auditory and/or visual hallucinations.

Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continue to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument such as, The CAM-ICU.

The CAM-ICU is modified from the Confusion Assessment Method (CAM) and assesses four features: acute change or fluctuation in mental status from baseline, inattention, altered level of consciousness, and disorganized thinking.

Delirium in the ICU is quite common. The pathophysiology of delirium is poorly understood but it is theorized to be a neurobehavioral manifestation of neurotransmitter imbalance.

Some causes of delirium include: poor oxygen perfusion of the brain, chemical changes in the brain, medications, infections or sepsis, and alcohol withdrawal.

People who are more likely to get delirium are those who have: dementia, depression, poor eyesight and/or hearing, heart failure, infection/sepsis, or take certain high-risk medicines.

Among medical ICU patients, delirium is associated with multiple complications and adverse outcomes, including self-extubation and removal of catheters, failed extubation, prolonged hospital stay, increased health care costs, and increased mortality.

When delirium is diagnosed or suspected, the underlying causes should be sought. Components of delirium management include supportive therapy and pharmacological management. Reorientation techniques or memory cues such as a calendar, clocks, and family photos may also be helpful. The environment should be stable, quiet, and well lit. Physical restraints should be avoided. Delirious patients may pull out intravenous lines, climb out of bed, and may not be compliant. Perceptual problems lead to agitation, fear, combative behavior, and wandering. Severely delirious patients should never be left alone or unattended and may benefit from constant observation to help avoid the use of physical restraints.

ICU Delirium

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ICU Delirium: Nursing and Medical Staff Knowledge of Current Practices and Perceived Barriers
Delirium is a common problem in the ICU. It’s divided into three subtypes (hyperactive, hypoactive, and mixed delirium). It’s been known that delirium in the ICU is associated with prolonged hospital and ICU stays. It is also associated with an increased six month mortality rate. The Intensive Care Society recommends screening for delirium on a daily basis using a validated screening tool such as the CAM-ICU. Two thirds of cases could be missed if a validated screening tool isn’t used. This article is suggesting that there is a lack of knowledge on ICU delirium, the screening tools used to assess it and also that it is not screened for on a regular basis, partly due to perceived barriers to screening. A sample of 149 nurses and medical staff from three different hospitals were surveyed.
The results show that 44% of the respondents never received any training or education on ICU delirium and that 37% used a delirium screening tool. 51% said they did not use a screening tool. The rest checked off “did not know”. The majority of respondents said they knew about the CAM-ICU screening tool but did not use it on a regular basis. The second most recognized screening tool was the ICDSC (Intensive Care Delirium Screening Checklist). 52% said they screened for ICU delirium on a daily basis and 14% said they screened for it on a weekly basis and another 14% said they screened on a monthly basis. The ones that did not use a screening tool said they just observed for hallucinations, agitation, and confused patients.
Some of the respondents said they did not screen for delirium due to perceived barriers such as it was time consuming to complete, that it would take up valuable nursing and medical staff time. Some were also unconfident at detecting delirium.
This article also revealed that the nurses and medical staff had some knowledge of ICU delirium but the education they received was during school and not at bedside. They also found that the staff had a medium level of knowledge about the risk factors and complications of ICU delirium.
I agree with the article in that most of the staff at many hospitals lack education on ICU delirium. This article brings to light how serious ICU delirium is and how much training and education needs to be done. The CAM-ICU takes about 2-5 minutes and needs to be done at least on a daily basis, not weekly or monthly. The medical staff who do not use a structured validated tool to assess delirium confirms that many of the ICU delirium cases are missed or are identified as hyperactive (least common) when it should be identified as hypoactive or mixed.

Reference:

Elliott, Sara.  ICU delirium: A survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit, Intensive and Critical Care Nursing (2014) 30, 333-338.

Delirium in Hospitals Overlooked

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If you’ve ever visited a family member or friend in the hospital it is an overwhelming emotional scene with the amount of machinery, loud constant noises, code calls over the intercom, and staff going in and out of the room. Not to mention the increase concern you have for your loved one, it can make anyone one in their right mind go delirious for that brief moment. Now imagine being one of those patients, critically ill, in bed most of the day where their physical, emotional, and mental abilities that have become altered. It came to my surprise that over 7 million Americans out of about 36 million of hospital admissions have been affected by cases of delirium each year (Boodman, 2015)

Delirium is a “sudden disruption of consciousness and cognition marked by vivid hallucinations, delusions, and an inability to focus”. It occurs suddenly and typically fluctuates throughout the day. One patient mentioned his delirium being like nightmares, although he knew that he was in the hospital and was sick he could not awaken from this terrible reality even after 3 years of being discharged from the hospital (Anthony Rossum, 2014). Some patients with delirium can be agitated and combative while other are lethargic and inattentive (Boodman, S., 2015), which makes me wonder, how many patients I have worked with in the hospital, whom had these horrible experiences and were silent about it. It wasn’t until recently that delirium was recognized or understood said Dr. Wes Ely from Vanderbilt University. Nearly, two thirds of Ely’s patients from the ICU reported signs of delirium, which led to his research and developed successful protocols in improving care and decreasing delirium in over six well known hospitals. The main interventions he utilized were the following ICU measures, in acronym: “ABCDEF,” which includes: Assessing and managing pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of Sedation/Analgesia, Delirium Monitoring, Early Mobility and Family engagement which after these interventions studied over 50% of the drugs normally given for sedation were decreased or cut cold turkey, showing a 4 day decrease stay in the ICU, and decreasing mortality rate up to 15%.

If you get a chance, please watch the story of Anthony Russo delirium he explains in the video above, I am a loss of words what he experienced in the ICU. I believe it will help in opening the eyes of what can be reality for these patients we care for everyday, as well as identifying how the long term complications can even occur after their discharge home from the ICU.

The astonishing fact is researchers have estimated that about 40% of delirium cases are preventable, which surprises me that so many people are still experiencing this reality this last year 7 million cases, especially for those elderly whom are at higher risk due to their sensitivity receiving large doses of anti-anxiety drugs and narcotics.

Brain injury is preventable by lowering exposure to potent sedative meds and shortening the duration of delirium with assessment and monitoring with the ABCDEF method. Think about it, it costs more than 143 billion annually to care for such delirium patients due to their longer hospital stays and complications, more is needed to be done in these preventable cases to reach out to those whom needs us most. Educate yourself and follow such articles on assessment tools in detecting delirium in patients.

Here are some examples:

Confusion Assessment Method (CAM)

Delirium Assessment and Management

 

References:

Boodman, S. (2015). The Overlooked Danger of delirium in Hospitals. The Atlantic Article. Published by Kaiser Public Health News. Retrieved from: http://www.theatlantic.com/health/archive/2015/06/the-overlooked-danger-of-delirium-in-hospitals/394829/

Landro, L. (2011). Informed patient: changing sedation status quo in the ICU.  Health Blog, Wall Street Journal. Retrieved from http://blogs.wsj.com/health/2011/02/15/changing-the-sedation-status-quo-in-the-icu/

The Dangers of Delirium

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The dangers of delirium
Patient safety is an important part when it comes to nursing care. Nursing intervention can be done prior to help better patient outcomes. For example, patient’s that are treated in intensive care units need interventions that will provide safety before and after care. These patients are heavily sedated and on ventilators are particularly likely to become delirious; some studies place the rate as high as 85 percent. Delirium is basically inattention and confusion that represents the brain temporarily failing. A person who is delirious is unable to think clearly and can’t make sense of what is going on around him. But the condition is common among patients recovering from surgery and in those with something as easily treated as a urinary tract infection.
Regardless of its cause, delirium increases the risk of longer stays in the hospital, higher cost of care, can persist for months after discharge, more long-term cognitive impairment up to one year later and even death. Therefore it is important to provided safe care before and after treatment. Researchers estimate that about 40 percent of delirium cases are preventable. Many cases are triggered by the care patients receive like Mechanical ventilation is well known to cause ventilator associated pneumonia (VAP) and other nosocomial infections. Another example includes large doses of anti-anxiety drugs and narcotics or the environments of hospitals themselves, such as, a busy, noisy, brightly lit place where sleep is constantly disrupted and staff changes frequently. Overall there is evidence based support for getting patients off of ventilators and sedation, as quickly and safely as possible. Also, non-drug interventions, which included making sure patients’ sleep-wake cycles were preserved, that they had their eyeglasses and hearing aids and that were not dehydrated.

References
The Washington Post: Health and Science- “The perils of delirium” (2015). Retrieved on September 21, 2015 from: https://www.washingtonpost.com/national/health-science/the-perils-of-delirium/2015/06/01/0f263996-ed22-11e4-8666-a1d756d0218e_story.html

ICU Sedation Practices

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The article : Changing the Sedation Status Quo in the ICU was very interesting to me because it talks about how hospitals are adopting new policies that limit the amount of time a patient is sedated in the ICU. The new treatment methods would allow patients to be awakened from sedation to assess for pain and removing them from a ventilator as soon as possible.  A growing body of research suggests that patients who are heavily sedated in the ICU are suffering from prolonged delirium. This can have long term effects on cognitive function long after the patient leaves the hospital (Landro, 2011).

Hospitals began rethinking the standard of care in the early 1990s, when patients reported suffering from depression, stress and extreme physical limitations linked to therapy they had received in the ICU (Landro, 2011). Studies conducted by Vanderbilt University show that new monitoring techniques will shorten the duration of delirium by decreasing the amount of potent sedatives a patient receives. Research from John Hopkin’s University shows that getting patients up and moving even when still on a ventilator can also prevent the muscle weakness that results when patients lose conditioning from misuse and the body becomes frail. Hospitals now plan to use milder sedation medication and to wean patients off as soon as possible and not put them back under. This will help patients to go home sooner and avoid having to go to a rehabilitation center.

I agree with this article, I think that it is not healthy to have patients sedated for a prolonged amount of time. If there is a way to get them moving sooner I think this would be beneficial for circulation, skin care, and oxygenation. However the research presented here also shows that in addition to the physical reasons there are also psychological reasons to wean patients from section sooner rather than later. Before reading this article and watching the videos, I had no idea that patients were experiencing delirium while sedated in the ICU. Furthermore it is also very concerning to see how the delirium they experienced in the ICU can affect their lives even months to years afterward. Some patients experience PTSD or depression that interferes with their daily lives. I think that if the amount of time a patient can be sedated can be shortened, and they can be ambulated sooner this will be therapeutic for the patient and will help them to recover sooner.

I think that the next step is to implement this practice in more hospitals by training ICU doctors and nurses. Educating healthcare professionals about delirium will help patients to get the support they need sooner.

 

 

References:

Landro, L. (2011, February 15). Informed Patient: Changing the Sedation Status Quo in the ICU. Retrieved September 24, 2015, from http://blogs.wsj.com/health/2011/02/15/changing-the-sedation-status-quo-in-the-icu/

Nurses Collaborate for Ventilator Weaning

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Situation

              Patients that have serious illnesses often are admitted to the Intensive Care Unit (ICU). A majority of these patients are also on mechanical ventilation to assist with breathing after experiencing acute respiratory distress syndrome (ARDS) as a result of “either direct or indirect pulmonary injury” (Morton & Fontaine, 2013, p.233). Mechanical ventilation is used to  treat a patient that cannot breath on their own. Unfortunately, invasive artificial airways often come with their own complications and high costs.

Background

              Mechanical ventilation is well know to cause ventilator associated pneumonia (VAP) and other nosocomial infections. Studies also show that the longer the length of time on a ventilator, the higher it correlates with hospital re-admissions and a draining of ICU resources (Douglas, Daly, Brennan, Gordon & Uthis, 2011). There is evidence based support for getting patients off of ventilators and sedation, as quickly and safely as possible.

Assessment

              In the article, “Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation,” authors write about how patients are typically weaned off of the ventilator and identified a problem with the fact doctors decided subjectively to wean patients and it is not based on protocols (Grap, Strickland, Tormey, Keane, Lubin, Emerson, & … Sessler, 2003). The doctors would use different parameters and those parameters varied from each doctor and each hospital (Grap, 2003).

Resolution

               Grap et al., have focused on using a multidisciplinary approach to wean  patients off of their ventilators sooner; this approach utilizes a standardized protocol for weaning the patients (2003). The article researched the medical respiratory ICU (MRICU) protocol which is composed of several scales, guidelines, and assessment tools to help identify if the patient is ready to be weaned (Grap et al., 2003). The article showed that “[p]atients receiving mechanical ventilation have shorter hospital stays and lower costs when a weaning protocol is used” (Grap et al., 2003, p. 455). The article also supported nurses autonomy and working with the respiratory therapist to individualize the weaning process; this encouraged strong communication within the interdisciplinary team (Grap et al., 2003).

Douglas, S., Daly, B., Brennan, P., Gordon, N., & Uthis, P. (2001). Hospital

readmission among long-term ventilator patients. Chest, 120(4), 1278-1286.

Grap, M., Strickland, D., Tormey, L., Keane, K., Lubin, S., Emerson, J., & … Sessler,

C. (2003). Collaborative practice: development, implementation, and

evaluation of a weaning protocol for patients receiving mechanical

ventilation. American Journal Of Critical Care, 12(5), 454-460.

Morton, P. G., & Fontaine, D. K. (2013). Essentials of Critical Care Nursing; a

               holistic approach. Philadelphia, PA: Wolters Kluwer.

ICU Delirium

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Did you know that having an illness that requires a prolonged ICU stay, can lead to months of disability after discharge? As patients are grateful for overcoming a critical time in their lives, there is a high probability of having another difficult challenge ahead of them: not being able to function as they had been able to prior to their ICU stay. This may result from ICU delirium which affects 60% to 80% of patients that were on ventilators and 20% to 40% of patients that were not on ventilators (Brummel et al., 2014). In Nashville, Tennessee at St. Thomas Hospital, 126 ICU patients were studied between October 2003 and March 2006 and researchers found an association between the duration of ICU delirium and patients’ post ICU disability (Brummel et al., 2014). During the following year after discharge from the ICU, functional ability to perform activities of daily living (ADLs) were tested and the correlation of a longer period of ICU delirium and decreased ability to perform ADLs was found.

After watching three videos on ICU delirium and reading the article on this study, I agree with Dr. Brummel et al., that treatment of delirium is essential in attempt to prevent months of diminished motor function since performing one’s ADLs is of high importance to most individuals. This article also pointed out another interesting study that showed reduced delirium in ICU patients at risk of atrophy and weakness who received physical and occupational therapy (PT/OT) within the first couple of days while on a ventilator. It appears steps that need to be taken are assessment of ICU delirium, attempt to reduce the duration of ICU delirium, have PT/OT work with patients at risk in the ICU sooner rather than later, and continue to research ways to reduce disability post ICU discharge.

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References

Brummel N E Jackson J C Pandharipande P P Thompson J L Shintani A K Dittus R SGirard T D 2014 Delirium in the Intensive Care Unit subsequent long-term disability among survivors of mechanical ventilation.Brummel, N. E., Jackson, J. C., Pandharipande, P. P., Thompson, J. L., Shintani, A. K., Dittus, R. S.,…Girard, T. D. (2014). Delirium in the Intensive Care Unit subsequent long-term disability among survivors of mechanical ventilation. Crit Care Med, 42(2), 369-377. doi:10.1097/ccm.0b013e3182a645bd 201509211616561221419573

 

 

Delirium

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Week 4 Blog Post: Delirium (Janell Nunn)

Briefly summarize your findings. Do you agree with the article? Why or why not? What are the next steps needed? Share your “finds” from your own blog for this week.

 

This was a very short section of a larger article. It agreed with the article and videos we all read. Stating that the CAM ICU Delirium tool is extremely helpful in catching more cases of delirium. The article discussed adding this and other tools to help prevent long term effects of delirium and was concerned with having these tools added to hospital protocols, especially given the success of the trials (done in four stages at large hospitals in ICUs only).

I agree with the article, mostly due to the evidence presented in the other article we read and the videos. The next steps needed for this article are: getting the CAM ICU added into hospital protocols; putting interventions in place for those identified to have delirium based on these new protocols.

My “Finds” from the reading/videos: This is an issue of which I was entirely unaware. The testimony the patient gave on video was astounding and the quote he gave from his psychiatrist stating that it was as real to him as any Post Traumatic Stress Disorder (PTSD) sufferer from the military or police really made the issue come alive. This is what health care protocol is doing to survivors! It is made clear by the information given, that changes need to be made. Research for changes began back in the 1990s and is finally on its way into practice and needs to be taken seriously and swiftly added into daily best practice.

 

References:

Landro, L. (2011). Informed patient: changing sedation status quo in the ICU.  Health Blog, Wall Street Journal. Retrieved from http://blogs.wsj.com/health/2011/02/15/changing-the-sedation-status-quo-in-the-icu/

Nulles, S. (2008).  Improving goal-directed sedation practices and recognition of delirium in the MICU. Critical Care Nurse, 28(2), 11.