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Delirium in ICU
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
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 acute
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?
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.
Pacemakers & Cellphones: Keep Your Distance
It seems like everyone and their brother has a smart phone of some sort these days or at least is exposed to someone who has one. And for patients with pacemakers, this could be a dangerous combination. I look at the medical news on my favorite science-oriented website regularly and a new study from the European Society of Cardiology found that those who have pacemakers should keep their distance from cell phones to avoid unwanted painful shocks or frightening pauses in the function of their device. The study was presented in June to the joint meeting of the European Heart Rhythm Association and the European Society of Cardiology by one of the main authors, Dr. Carsten Lennerz, a cardiology resident in Germany.
Although it does not happen all the time, pacemakers can sometimes mistakenly pick up electromagnetic interference from smartphones and treat them like a cardiac signal, which can cause them to stop working for a brief period of time, according to Lennerz. He recommends that patients should hold their phone on the ear opposite to their pacemaker when talking and not place the phone in a pocket directly above the pacemaker just to be safe.
The authors added that another area of concern for patients with pacemakers is when they are under high voltage power lines. Although is ok for them to walk under power lines, the authors recommend that they do not spend extra time under the power lines, as high electric fields can also tamper with the pacemaker’s normal functioning.
I found it interesting and worrisome that the authors noted that pacemakers themselves do not come with any warnings about these possible problems. My uncle has a pacemaker that has saved his life and next time I see him walking around with his cell phone in his pocket as he often does, I will be sure to warn him about the possible dangers of doing so. In this smartphone inundated world, I wonder how many people with pacemakers have been affected by this problem. This would be an interesting and timely topic to pursue in further research studies.
I would also like to know how long medical experts have known about the interference cell phones and power lines play in the role of the pacemaker. It seems like something that every patient should be warned about but this is the first I have ever heard of the topic. I plan to do more research on this issue since I have a vested interest in it with my uncle’s health at stake.
Here is the link to the article:
http://www.sciencedaily.com/releases/2015/06/150622071207.htm
ICU Delirium
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
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
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
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/
