1. Iatrogenic Delirium Driver Diagram AIMPrimary Drivers Secondary Drivers Change Ideas Reduction incidence of Iatrogenic Delirium Early Identification & Monitoring of Delirium Identify pts. at risk Implement delirium assessment tool Think Delirium – Screen on admission and on transfer within hospital to identify delirium Adapt/adopt a risk-assessment tool assess pt. at least daily & prn for changes in pt. behavior Assess ALL patients in ICU at least twice daily and Pre/post Spontaneous Awakening Trail & prn for changes in pt. behavior Use experts to spot check delirium screening to assess performance reliability & identify learning opportunities Use nurse champion to communicate reasons for & importance of this initiative Include RASS/delirium screening in multi-disciplinary rounds & hand-off communication Document assessment in a highly visible location Optimize Medications Use a goal-oriented sedation protocol designed to reduce sedation Assess agents that may be causing or exacerbating delirium Use valid & reliable pain-monitoring tools then treat pain first prior to sedation Administer sedation as ordered using a target according to a scale i.e. RASS or SAS Reduce or remove sedation when possible Use physician champion to communicate reasons for & importance of reducing sedation/other meds contributing to delirium Implement pharmacist review of medication list to help identify meds which might be removed/decreased Avoid using benzodiazepines especially for high risk pts. Implement an alert for when benzodiazepine order is entered

2. Iatrogenic Delirium Driver Diagram AIMPrimary Drivers Secondary Drivers Change Ideas Reduction incidence of Iatrogenic Delirium Delirium Management & Prevention Reorientation Cognitive stimulation Early ambulation Limit devices Nutrition & hydration Sleep promotion Immediate management of delirium (2 hours of diagnosis) Implement delirium care bundle Familiarize pt. with surroundings & date/time Encourage use of pt.’s eye glasses/hearing aids Incorporate reorientation into pt. care activities Use care boards, large clock, & calendar to aid reorientation Develop progressive early ambulation programs Involve respiratory therapists, physical therapists, nursing assistants, etc. to mobilize pts. as appropriate Assess need for urinary and central line catheters daily Reassess need for restraints Correct dehydration & electrolyte imbalance quickly Provide feeding assistance if necessary Adopt a “sleep protocol” to cluster pt. care activities, minimize unnecessary noise/light/stimulation reducing sleep disruption Enhance skin and fall prevention measures Patient & Family Engagement Family involvement Create a culture that supports family/caregiver involvement in care and reorientation Encourage Family/friends to furnish some familiar objects to help reorient pt. & more secure Promote family/caregiver feedback to improve care Ensure patient requirements are accurately reflected in care plan Family/caregiver education includes delirium risk factors, how to recognize delirium & their role in prevention of delirium