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 introduced to the unit Education sessions were held to educate about delirium, prevention/treatment strategies, and proper administration of CAM January 2012-compliance in ICU of completing CAM low (60-70%), along with frustration of front line staff of tools effectiveness, physicians validation and consistent treatment plans

Background March 2012, after staff education ICU compliance had improved significantly April 2012, e-Care (electronic charting) introduced and again we saw a decline in compliance April 2012, also this month we switched from versed to propofol for sedation for our patients post op 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Aim Continue to improve prevention, early recognition and effective management of ICU delirium in cardiac post operative patients Reduce incidence of delirium in ICU West by 50% by February 1, 2013 by Getting 100% compliance of CAM completion Improve discussion of delirium on rounds Increase accuracy of collecting, and reviewing patients medical history

AIM Improve environmental factors that contribute to delirium Improve awareness of pre-op substance abuse and anticipating/preventing withdrawl Increase participation of families in prevention and treatment of delirium 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

AIM Increase early mobilization of patients in the ICU west Increase staff “buy in” for the importance of delirium prevention 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Team Members Alison Fox-Robichaud, MD (Site Lead) Dale Bialas, RN (ICU Educator) Sue Di Sabatino, RN (ICU Educator) Sonya Lugowy, PharmD (ICU Pharmacist) Leslie St. Jacques, PA (Staff Physician Assistant) Yvette Young, RN (Patient Safety Specialist)

Team Members Christie Rutland, RRT (Staff Respiratory Therapist) Elise Loreto, PT (Staff Physiotherapist) Annie Newman, PT (Staff Physiotherapist) Courtney Mitchell, RN (Staff Nurse) Cathy MacPherson, RN (Staff Nurse) Lesley Hooper, RN (Staff Nurse) 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Compliance-full audit 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Compliance-spot audits Introduction of computerized charting and switch to propofol from versed post op 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Incidence of Delirium 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Results for documented activity

Breakdown of activity in Percentage 5-Dec-18 Delirium and Med Rec Collaborative

Percentage of patients with baths completed between 12am-6am 5-Dec-18 Delirium and Med Rec Collaborative

Breakdown of types of baths (between 12am-6am) 5-Dec-18 Delirium and Med Rec Collaborative

Types of baths over time (Completed between 12am-6am) 5-Dec-18 Delirium and Med Rec Collaborative

Incidence vs Compliance 5-Dec-18 Delirium and Med Rec Collaborative

Changes Tested Introduced a heart shaped display and using purple hearts on days with low percentage of patients with delirium, there was some back lash over the use of purple and it was decided to change to gold for 0% delirium, silver for less than 10% delirium, bronze for less than 20% and recently red for over 20%

Changes Tested Implemented non pharmalogical techniques to reduce delirium in patients in the ICU. (radios, eye masks, and ear plugs) It is too early to tell just what impact that has had on delirium reduction and prevention 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Lessons Learned We learned to not audit the first shift that someone comes from the operating room, as our CAM assessment is not designed for an ICU and doesn’t capture patients that are sedated properly. Choosing purple as the colour for our hearts used to represent our percentage of delirium daily caused some backlash from front line staff, and in turn less “buy in” to the importance.

Lessons Learned Increased visibility of audit results and graphs increased front line staff talking about delirium The need for a red heart to symbolize a day with greater than 20% delirium to go with our gold, silver and bronze Early mobilization needed to be focused on and the mentality of staff also needed to change 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Lessons Learned We learned that despite trying to change peoples thoughts around delirium and its prevention, that the practice of bedside nurses had not changed as much as we had hoped for. An example is that patients were still being bathed between 12am and 6am 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Next Steps Retreat planned November 19, 2012 for all sites within HHS on delirium, so that we can share information Working on a bedside checklist for delirium, to be piloted on one patient to see if daily all our techniques for prevention and reduction are being utilized Pilot order set for Delirium management in ICU

Next Steps Working to get a proper CAM assessment tool added to our electronic documentation, as the current one being used is not the CAM-ICU, and therefore does not properly capture our patient population 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

What is ahead at HHS? Retreat planned November 19, 2012 for all sites within HHS on delirium, so that we can share information Working on a bedside checklist for delirium, to be piloted on one patient to see if daily all our techniques for prevention and reduction are being utilized Pilot order set for Delirium management in ICU Working to get a proper CAM assessment tool added to our electronic documentation, as the current one being used is not the CAM-ICU, and therefore does not properly capture our patient population 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Things we learned along the way: We learned to not audit the first shift that someone comes from the operating room, as our CAM assessment is not designed for an ICU and doesn’t capture patients that are sedated properly. Choosing purple as the colour for our hearts used to represent our percentage of delirium daily caused some backlash from front line staff, and in turn less “by in” to the importance. Increased visibility of audit results and graphs increased front line staff talking about delirium The need for a red heart to symbolize a day with greater than 20% delirium to go with our gold, silver and bronze Early mobilization needed to be focused on, as well as a shift in the mentality of staff around early mobilization We learned that despite trying to change peoples thoughts around delirium and its prevention, that the practice of bedside nurses had not changed as much as we had hoped for. An example is that patients were still being bathed between 12am and 6am 5-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Incidence and Compliance Intro of e-Care and propofol for post op sedation 5-Dec-18 Delirium and Med Rec Collaborative