WRHA Surgical Program Delirium Guidelines Cheryl Bilawka April 18, 2012

Purpose The WRHA Surgery Program had identified that there was no formal regional guidelines in place to identify, screen or manage postoperative delirium.

Process A working group was created with members representing all the acute care sites chaired by Wendy Rudnick, WRHA Surgery Program Director. The objective of this group was to develop a standardized approach to delirium care for surgical patients in the WRHA.

Methodology The group complied existing tools and protocols from all the acute care sites and with the assistance of the experts in delirium and surgical management, the WRHA Delirium Implementation Tools will be rolled out across the region May 14, 2012.

Delirium Tools Delirium Brochure for patients and their families WRHA Surgery Program PREoperative Assessment Questionnaire Delirium Clinical Practice Guidelines Delirium Decision Tree Lanyard Cards Audit tool for evaluation Evidence Informed Practice Tool (coming soon)

Opportunity for Interventions Preoperatively Postoperatively

The Surgical Patient Preoperatively If patient assessed as at risk for delirium, slating department to be notified. Slating to identify patient at risk for delirium on the OR slate. All patients will be screened for delirium in PAC If patient at risk and patient is seen, PAC will give patient or family a Delirium brochure

Preoperative Screening The WRHA Surgery Program Preoperative Assessment Patient Questionnaire, has been revised to have delirium screening criteria embedded using flags

Example from the PREoperative Assessment Patient Questionnaire The last time that you were hospitalized, did you experience confusion, hallucination or behaviour that was unusual for you?........ No Yes

Delirium Elderly At-Risk (DEAR) Tool For patients greater than 65 years of age, flag at risk for delirium if: □ greater than 80 years of age □ benzodiazepines and/or alcohol greater than 3 x/week □ glasses and/or hearing aides □ Mini Mental Status Exam less than 24 or previous delirium □ assistance with any activities of daily living Delirium Risk Flags: _____________/5 Delirium Risk if greater than 2 flags. Implement facility protocol. □ N/A patient less than 65 years of age

Communication of Delirium Risk Each hospital will develop a process so that the delirium risk will be identified on the OR slate. Inpatient postoperative units will have access to the delirium risk information. .

Delirium Brochure . DELIRIUM A Medical Emergency

Delirium Decision Tree

Delirium Decision Tree WHAT ARE THE RISK FACTORS? Severe Illness Sensory Impairment (hearing/vision) Age (age 65 years and over) Cognitive Impairment (dementia) Dehydration Multiple Medications (Sedatives/Hypnotics/Narcotics/Anticholinergics/ Psychotropics) ETOH/Substance abuse Previous Delirium Infection RECOVERY FROM SURGERY Impairment of Activities of Daily Living (bathing/dressing/toileting/grooming/feeding) Pain

The Surgical Patient Postoperatively Administer CAM within the 1st 8 hours of admission. Positive CAM Assess using CAM Q shift and prn Negative CAM Assess Q 24 hours and prn (with any cognitive and/or functional changes)

Delirium Decision Tree Search for reversible causes and treat: ,/ CXR ,/ EKG ,/ CBC ,/ Electrolytes ,/ BUN/CR ,/ TSH/B12 ,/ Urinalysis ,/ Medication Review Nurses Assess: ,/ Vital Signs/02 sat ,/ Assess/treat pain / Fluid balance ,/ Blood Sugar ,/ Elimination

Delirium Decision Tree INTERVENTIONS Environmental • Clocks/Calendars Cognitive • Frequent orientation Communication • Simple short sentences Safety • Fall prevention/Safe environment Psychological • Don't dispute delusions; reassurance Pharmacology Avoid Polypharmacy Avoid Benzodiazepines For agitated delirium please consider an antipsychotic Function • Balance, rest, activity

Delirium Decision Tree CONFUSION ASSESSMENT METHOD (CAM) Need presence of (1) & (2) and either (3) or (4) 1. Abrupt change? 2. Inattention, can't focus? 3. Disorganized thinking? Incoherent, rambling, illogical? 4. Altered level of consciousness? (Hyper-alert to stupor?) Trigger Questions 1. Acute changes in behavior? 2. Changes in function? 3. Changes in cognition? MMSE 4. Changes in medications? 5. Physiologically stable?

Lanyard Card of CAM CONFUSION ASSESSMENT METHOD (CAM) Answer these four questions: 1) Was the onset acute and does behaviour fluctuate? AND 2) Is there evidence of inattention? (difficulty focusing attention, shifting and keeping track) AND EITHER 3) Is there evidence of disorganized thinking? (Incoherent, rambling, illogical flow of ideas) OR 4) Is there evidence of disorganized thinking? (i.e. any state other than alert) (Alterations include hyperalert, lethargic, stuporous and comatose) FEATURES 1 AND 2, AND EITHER 3 OR 4 ARE REQUIRED FOR A DIAGNOSIS OF DELIRIUM

Delirium Clinical Practice Guideline

Goals of Implementation Awareness of postoperative delirium Screen for delirium and communicate risk Routine utilization of the CAM as the standard method for detecting delirium Use of the CAM tool when communicating with other Health Care Professionals Proactive interventions

Audit Tool Screened for delirium in PAC Delirium Risk on Slate CAM done within 8 hours postop If CAM positive, are interventions and plan documented in IPN Physician notified If CAM positive, is CAM reassessed 8 hours later If CAM is negative, is CAM reassessed q 24 hours. .

Metrics Length of stay Constant Care Use Falls Reduction

Future Opportunity? Pose the question: “What if the patient is flagged as high risk for delirium, yet does not actually go on to experience a delirium?” Examination looking for evidence of proactive care planning Early Mobilization Adequate Pain Management .

Delirium Working Group Members and Contributors Wendy Rudnick Karen Murphy Michele Lepp Lisa Anthony Graciana Mederios Ann Reichert Cheryl Bilawka Christine Johnson Leslie Dryburgh Rayan Horswill-Tees Valerie Hiebert Vera Duncan Karen Gutknecht Carol Knudson Bruce Anderson Claire Dionne The PAC Working Group