1. WRHA Surgical Program Delirium Guidelines
Cheryl Bilawka
April 18, 2012

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

3. 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.

4. 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.

5. 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)

6. Opportunity for Interventions
Preoperatively
Postoperatively

7. 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

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

9. 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

10. 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

11. 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. .

12. Delirium Brochure .
DELIRIUM
A Medical Emergency

13. Delirium Decision Tree

14. 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

15. 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)

16. 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

17. 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

18. 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?

19. 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

20. Delirium Clinical Practice Guideline

21. 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

22. 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. .

23. Metrics
Length of stay
Constant Care Use
Falls Reduction

24. 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 .

25. 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