1. General Systems ICU & Burns
Edmonton, Alberta
Delirium Collaborative

2. Background GSICU & Burns
ICU- Mean Length of stay 5.0 days; Mean age 57 years; Mortality per admissions 16%; Mean APACHE II  20.4
Burns – Mean Length of stay 6.0 days; Mean age 47 years; Mortality per admission 1%
Delirium incidence approximately 30%-40%
Recognized need to better identify and intervene
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

3. Aim
Improve care of the critically ill patients at risk for delirium through the implementation of standardized screening and identification of prevention and management strategies in GSICU and Burns unit.
Goals/Objectives—Decrease Delirium by:
Develop and deliver education and support for staff regarding delirium awareness, prevention, and management within 12 months.
Implement processes to screen 100% of all ICU patients for delirium within 6 months or less.
Identify and Implement standardized delirium prevention interventions in all ICU patients within 12 months or less.
Implement standardized interventions for the management of delirium within
12 months or less.
Implement strategies to support families of patients with delirium within 18
months or less
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”

4. Team Members Registered Nurses Physicians Respiratory Therapists
Pharmacists
Occupational Therapists
Physiotherapists
Dieticians
Social Workers
Nursing Attendants
Unit Clerks
Biomedical Technologist
Spiritual Care
Critical Care Research Group
Quality Improvement
Families/Support persons

5. Results - GSICU

6. Results - GSICU

7. Delirium and Med Rec Collaborative
Results - Burns
9-Nov-18
Delirium and Med Rec Collaborative

8. Delirium and Med Rec Collaborative
Results- Burns
9-Nov-18
Delirium and Med Rec Collaborative

9. Changes Tested ICDSC tool tested using paper & electronic versions
Delirium score added to physician report at rounds
Delirium score added to charge nurse report at shift report
Delirium standardized order protocol
About Me patient information by family

10. Delirium and Med Rec Collaborative
ICDSC
9-Nov-18
Delirium and Med Rec Collaborative

11. Delirium and Med Rec Collaborative
Protocol
9-Nov-18
Delirium and Med Rec Collaborative

12. Lessons Learned Change is hard Peer pressure works
Things will seem worse for a while before they look better
Dedicated individual to teach assessment is best
Mobilizing effective intervention
Nurses can interpret avoiding sedation to mean avoiding analgesic

13. Next Steps
Build on interest – encourage focused sleep and noise interventions by night staff
Focused education on pain interventions
Create capacity in bedside staff to be experts
Reassess routines, especially night routines
Family education and information