General Systems ICU & Burns Edmonton, Alberta Delirium Collaborative

Delirium Collaborative Who Are We? Occupancy 92%; Mean Length of stay 5.0 days; Mean age 57 years; Mortality per admissions 16%; Mean APACHE II  20.4; Delirium Incidence ICDSC (≥4) 41% Early Mobilization (EM) protocol brought delirium to the forefront Participating in the first Delirium Action Series 2010/2011 Utilizing current research & best practice AHS provincially selected ICDSC tool for Delirium assessment We have a high incidence of delirium in our unit due to the acuity & types of patients we deal with More detailed time line for presentation

Aim– Improvement Charter Improve understanding & impact of delirium regarding quality of life post hospital, demographics, mortality & morbidity. Goals/Objectives—Decrease Delirium by: Revising Standards for Patient Care Revising Early Mobilization Protocol Ongoing education - Unit Orientation, OPACCA©, annual recertification’s Pharmacological & Non-pharmacological treatments EM protocol adapted from Salt Lake Protocol Examples of phamacologic tx: Quetiapine, Haloperidol & Olanzapine per MD order set.---ID pt psych history Examples of non pharm tx: Orient and reorient patient at least once every shift • Have day, date, and time visible to the patient • Ensure proper day / night cycling; if possible have patient facing window • Ensure that patient has restful sleep - Minimize noise during sleep times (22:00 to 06:00) - Minimize nursing and medical interventions (22:00 to 06:00) - Provide ear plugs - Single private rooms - Relaxation techniques, i.e. music • Promote mobilization • Daily SBTs to assess for possible extubation • Minimize sedation; try to avoid use of continuous infusions, if possible—sedation vacation • Correct any metabolic disturbances • Treat for substance withdrawal, including smoking • Treat any underlying infections • Cognitive stimulation – talk to the patient, have the patient involved in their own car Hearing aids and glasses should be placed on patients who are awake • Involve family and anyone familiar to the patient in their care Cognitive stimulation Orientation/ reorientation Bringing in hearing aids and glasses, if needed Bringing in objects from home that are familiar to patient—see “All About Me”

Team Members Registered Nurses Physicians Respiratory Therapists Pharmacists Occupational Therapists Physiotherapists Dieticians

Biomedical Technologist Spiritual Care Critical Care Research Group Team Members Social Workers Nursing Attendants Unit Clerks Biomedical Technologist Spiritual Care Critical Care Research Group Quality Improvement Families/Support persons 29-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Results Nursing education—using ICDSC, Initial blitz with nursing ed re: ICDSC—paper version Change to computer charting March rise—first order set and another nursing blitz Drop—dr compliance therefore RN not doing ICDSC Dip—delay with order set Another blitz in nursing ed with order set delivery Dip—dr not follow through with order set Two initiatives getting off the ground We started this initiative Sept 2011 so by looking at this graph we think we are doing an excellent job—overall compliance is 80%

Results Note the number of pt with a score of >4 Drop in early May coincides with increased use of Seroquel

Delirium and Med Rec Collaborative Results 29-Dec-18 Delirium and Med Rec Collaborative

ICDSC initially on paper as education tool, then computer charting Changes Tested ICDSC initially on paper as education tool, then computer charting Include in Handover, shift report, bedside report/rounds Educating leaders– Team leaders, Unit Managers, Charge Nurses. Five revisions to Delirium order sets-ongoing Two drug choices Paper tool initially used to educate as it had objective tools to assist with assessment. Implemented in computer charting incorporated care beacons as reminder to complete ICDSC tool q12. Reporting tools again a good reminder and opportunity for discussion—implemented Aug 2011 Drug choices– 2 scheduled, one prn

Lessons Learned Lack of knowledge regarding delirium within the multidisciplinary critical care team. Feedback from Psychiatrist to start with higher dose of Quetiapine. ICU patients too sedated—returned to lower dose Starting with paper version of ICDSC to educate as computer charting limit subject matter We have Physician, nursing & PT champions

Shift report trigger reminder to facilitate RN assignments Lessons Learned Shift report trigger reminder to facilitate RN assignments More leader/champions educated- increased support of new initiative One champion dedicated to education is crucial Public relations very important focus One person dedicated is crucial from moving from information to application to integration of practice PR—sharing what we have done to date with other CNE’s, UM across the province, facilitated by the Webinar 29-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM

Continue education on non-pharmacological treatments Cognitive games Next Steps Continue education on non-pharmacological treatments Cognitive games Increase Occupational Therapist and Physiotherapist coverage Increase Physician compliance Family education/pamphlet Public relations, networking, sharing Cognitive games—applying for nursing research grant

Next Steps Latest Delirium Order Set All About Me Nursing History—Patients family to fill out upon admission to hospital All About Me– gives direction to bedside staff regarding what pt likes and does not like. Reference tool to identify e.g. TV stations, music, name preference. Focus on all about the pt as a person. STORY BOARD Per the template distributed there where also designated plots on the table in front of the board. I propose the following laid out in front of the board on the table numbered left to right 1-5. 1. Folder on PDSA & Improvement charter 2. Copy of Early Mobilization Protocol 3. Nursing Standards in GSICU 4. Draft of GSICU Pamphlet 5. example of Delirium Order Set

Acknowledging Zone Involvement University of Alberta Hospitals Stollery Children's Hospital Grey Nun’s Community Hospital Misericordia General Hospital Royal Alexandra Hospital Sturgeon Community Hospital 29-Dec-18 Delirium and Med Rec Collaborative Collaboration sur le delirium et le BCM