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

2. 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

3. 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”

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

5. 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

6. 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%

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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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