A Pilot Study to Evaluate the Feasibility and Effectiveness of a Multi-Component Intervention for Prevention of Delirium in Critically Ill Adults Jan Foster, PhD, APRN, CNS, CCRN This study was funded by Sigma Theta Tau International Honor Society for Nurses, Beta Beta Chapter

What is Delirium?

Hyperdynamic Subtype AgitationCombativeHyperactive Pure hyperdynamic is rare (5-30%)

Hypodynamic Subtype Decreased mental activity – Unaware of the environment – Lethargic – Apathetic – Inattention Decreased speech Staring Decreased physical activity Psychomotor retardation

Mixed Subtype Agitated & combative one moment Somnolent and hypoactive at other times Most cases are mixed (45%) Waxing and Waning

Risk Factors Delirium EnvironmentalIatrogenic Patient Characteristics

Summary of Risk Factors for Delirium Host factors Advanced age (> 65 years) Male gender Comorbidities Severity of illness Cognitive impairment prior to critical illness Pain Medication/drug/alcohol withdrawal Critical illness factors Hypoxemia Hypotension Low hematocrit Sepsis Inflammation/infection

Summary of Risk Factors for Delirium (cont) Iatrogenic Sedatives and analgesics Anticholinergics Mechanical ventilation Sleep disruption Restraints Environmental Day/night non- distinction Noise Excessive meaningless/deficient meaningful stimulation

Purpose of the Study The purpose of this pilot study was to establish the proportion of delirium in the MICU and evaluate the feasibility of a multi-component intervention aimed at preventing delirium in critically ill adults

5 Part Intervention Daily sedation cessation Sleep/wake cycle Patient mobility Meaningful sensory stimulation Preferred music listening

Setting Community hospital, MICU Delirium Team – Led by 2 CNSs – 6 frontline clinicians – MD on planning committee

Methods Prospective, descriptive, cohort design Baseline data collection took place for 1-month Education and implementation of the CAM-ICU to assess for delirium followed The intervention was implemented and post- intervention data collection took place for 2 months

Daily sedation cessation Stopped the infusions of sedatives and opiates everyday at 0730, which has been current practice in the ICU

Sleep/wake cycle Designated sleep period was hours Environmental modification to facilitate sleep consisted of – dimming the overhead lights – closing the blinds – minimizing ambient noise to < 85 d – noise reduction: limiting vocal sound, television, nursing procedures, x-rays, venipunctures, arterial sticks – cluster activities as much as possible (families, too) – Quiet Sign placed in the patient’s room, with space provided to document each patient interruption

Quiet Time 10pm-4am Time lights off _____ Time lights on _____ Check box for each patient interruption:   Place patient label on back Time lights off _____ Time lights on _____ Check box for each patient interruption:   Place patient label on back Quiet Time 10pm-4am

Patient mobility 4 level mobility protocol was to be used (Morris, et al, 2008) Designed for the critically ill population and the levels determined by patient acuity PCAs, families, RNs, PT – PT only with provider orders

Meaningful sensory stimulation Visible clocks, calendars (white board) Opening/closing blinds during day & night Patients use their vision and hearing aids – Families encouraged to provide the items A decibel meter was used to measure the noise level (noise = meaningless stimulation)

Preferred music listening Preferred music offered to each patient Managed by patient when able, by family and/or nurse when patient’s level of consciousness, sedation level, other condition rendered the patient unable to press buttons or make selection When neither patient nor family was able or available to make a selection, music was deferred (patient preference unknown) Music played from 1800 to 2000 OK to play at other times EXCEPT NOT during sleep time ( )

Participants Inclusion criteria – >18 years – Hemodynamically stable – Hearing able Exclusion criteria – Hemodynamically unstable – Hearing deficit – Neurological deficits that precluded responsiveness or physical movement

Results Pre-intervention 216 Assessments Missing data for delirium status was 52/216 = 24.07% How many of those with missing data were positive????

Results Baseline Of the remaining 164 assessments – Positive for delirium 46/164 (28%) – Negative for delirium 98/164 (60%) – Unable to assess 20/164 (12%)

Results Post-intervention 32 patients consented and enrolled – 17 female, 15 male – Caucasian 30; 1 African American; 1 Hispanic Missing data 8/92=8.69% – Less missing data than pre-intervention

Results Post-Intervention Positive delirium 26 of 84 assessments (31%) Negative 57/84 (68%) Unable to assess 1/84 (1%)

Results – Sedation Cessation 10 patients mechanically ventilated 38 ventilator days (42%) 16/38 episodes of sedation cessation (42%)

Results - Sleep Mean sleep hours was 7.75 hours with a mean of 5 interruptions nightly

Results – Noise Mean noise level was 45 decibels Well below OSHA recommendations < 85

Results - Mobility Best mobility for the majority of patient observations was bed rest with passive motion only 30 = Level I 28 = Level II

Results – Sensory Aids 12 patients known to wear corrective lenses Missing Data Wearing Not Wearing

Results – Music Listening 11 patients favored music playing

Summary Results Patients with mechanical ventilation were 17% more likely (OR.17, 95% CI , p.027) to have delirium Patients receiving beta blockers were 7.2 times more likely (OR 7.2, CI , p.028) to have delirium

Results - Feasibility Barriers : sleep promotion & mobility protocol adherence; lack of support from other disciplines; patient/family consent; documentation Facilitators : ease in environmental noise modification; family support of sleep

Discussion and Conclusions Barriers & promoters to implementation of the intervention AND in data collection process Mechanical ventilation & beta blockers increased relative risk for delirium Sleep, noise, use of sensory aids, music had no impact on delirium Effects of mobility on delirium prevention is unknown

Discussion and Conclusions People Refinement of a multidisciplinary protocol Process A structured mobility program Research Larger sample size Determine effectiveness of mobility in delirium prevention Especially in mechanically ventilated patients receiving BBs