Delirium Effects Linger for Critical Care Patients; Nurses Key to Treatment

ICU patients often experience similar lingering emotional and psychological effects of delirium, according to a new study published in the November issue of the American Journal of Critical Care.

The research team interviewed 10 adult patients who had been diagnosed with delirium while in the ICU after they were no longer delirious. The overarching themes in patients’ reports were:

• Lack of recall about their experience, often accompanied by feelings of guilt and shame about their behavior while delirious; 
• Feeling disconnected while delirious and unable to communicate or move, leading to frustration and fear;
• Vivid hallucinations, disorganized thinking and periods of disorientation; and
• Believing they or their family were in danger while they were delirious. 

The study also looks at the importance of critical care nurses in early recognition and treatment of patients with delirium, and how that can positively influence patient outcomes. Nurses also help patients and families deal with the aftermath of delirium in the ICU, particularly the psychological effects, according to the researchers.

This work mirrors that of INQRI grantees Michele Balas and William Burke who conducted research on patients on ventilators in ICUs, who are typically at high risk for delirium and weakness. Their research focused on preventing complications in ventilated patients through use of the "Awakening and Breathing Coordination, Delirium assessment and management and Early Exercise and progressive mobility (ABCDE)" bundle.

Balas and Burke led a team to implement, analyze and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults.  Their "Implementing the ABCDE Bundle at the Bedside" was selected as the American Association of Critical-Care Nurses' first PEARL (Practice, Evidence, Application, Resources and Leadership) web-based tool.

Click here to learn more about the Balas-Burke project "Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults."

Dedicated “Sleep Time” in ICUs May Prevent Delirium, Shorten Hospital Stays

Patients who had a four-and-a-half hour window of uninterrupted sleep experienced less delirium and shorter hospitalizations during a protocol study conducted at a Philadelphia-area hospital intensive care unit (ICU).

An interprofessional team, including a nurse, pharmacist, dietitian, and respiratory therapist, developed the protocol. The team was led by Critical Care Director Dominic Valentino at Mercy Fitzgerald Hospital, the Philadelphia Inquirer reports. 

During the study, ICU room lights were turned off and loud talking was prohibited from midnight until 4:30am to protect patients' sleep. During those hours, nurses monitored patients remotely and all routine bloodwork, medications, and exams were halted, unless a patient's medical condition required immediate intervention.

One hundred twenty-five patients were put on the protocol during January and February of 2013. Patients who had uninterrupted nightly sleep for more than half of their time in the ICU shortened their stays there by approximately four-and-a-half days. Researchers also found that these patients averaged two days of delirium, compared with three–and-a-half days for patients who got uninterrupted nightly sleep for less than half of their stays.

The successful protocol has now been adopted at other Mercy Health System hospitals in West Philadelphia, East Norriton, and Northeast Philadelphia. Hospitals are particularly open to it because it is effective and there is no cost to implementing the protocol, Valentino told the Inquirer.

A recent study funded by INQRI and published in Critical Care Medicine found that implementing a set of practices to encourage patients’ mobility and reduce sedation effectively reduces delirium and the need for a ventilator, and increases patients’ mobility during hospitalization. This, in turn, decreases weakness.

The INQRI study tested the effectiveness and safety of implementing a bundled set of evidence-based practices into everyday practice in the ICU. It is called the ABCDE bundle, for Awakening and Breathing Coordination, Delirium monitoring and management, and Early mobility.

The research team, led by Michele Balas and William Burke, examined the results of having a nurse-led interdisciplinary team use the bundle with roughly 150 patients in five adult ICUs, one step-down unit, and an oncology/special care unit in a medical center; researchers compared their outcomes with those of a similar group of patients in the same setting prior to implementation of the bundle.

“Bundle” of Practices Reduces Risks of Delirium and Immobility, INQRI Study Shows

Patients in hospital intensive care units (ICUs) are often put on ventilators, sedated, and/or immobilized for part of their stays. Unfortunately, all of these procedures can also put them at risk for delirium, which can be debilitating and have long-term negative effects. A new study funded by INQRI and published in Critical Care Medicine, finds that implementing a set of practices to encourage patients’ mobility and reduce sedation effectively reduces delirium and the need for a ventilator, and increases patients’ mobility during hospitalization, which decreases weakness.

The study tested the effectiveness and safety of implementing a bundled set of evidence-based practices into everyday practice in the ICU. It is called the ABCDE bundle, for Awakening and Breathing Coordination, Delirium monitoring and management, and Early mobility.

The research team, led by Michele Balas and William Burke, examined the results of having a nurse-led interdisciplinary team use the bundle with roughly 150 patients in five adult ICUs, one step-down unit, and an oncology/special care unit in a medical center and compared their outcomes with those of a similar group of patients in the same setting prior to implementation of the bundle.

Patients in the study who were managed with the ABCDE bundle spent more days breathing without a ventilator (a median of 24 days compared with a median of 21 days). Fewer of those patients experienced delirium, compared with the other group (48.7% compared with 62.3%), and delirium duration was reduced by one day. Patients treated with the bundle had twice the odds of getting out of bed at least once during their hospital stays, and lower hospital mortality (11.3% compared with 19.9%).

ABCDE is a bundle of interventions tested in clinical trials that have been adapted for everyday use in the ICU. The bundle is founded on three primary principles: improving communication among members of the ICU team; standardizing care processes; and breaking the cycle of oversedation and prolonged attachment to a ventilator that can lead to delirium and weakness.

Diagnosing and Adequately Treating Delirium Vital for Patient Recovery

As many as two out of every three patients in hospital settings with delirium may not be recognized as such by health care professionals. This is due in part to of a lack of validated tools for properly managing delirious patients and because some practitioners may not recognize the condition, according to an article in MedPage Today.

A major barrier to assessing delirium in emergency departments (ED) is the lack of a rapid assessment tool specifically designed for such a fast-paced environment. Relying on past experience and the patients’ behavior is not enough.  In fact, using clinical gestalt to diagnose delirium can result in providers missing up to 83 percent of cases, particularly in patients where the symptoms are more subtle.

The impact on the patient of a missed diagnosis can be dire. Generally, patients with delirium should receive adequate oxygenation, hydration, nutrients, pain treatment if necessary, and judicious drug intervention if needed. They should not be restrained, and should be kept awake and alert, according to experts quoted in the article.

Jin Han, MD, MSc, of the Vanderbilt University School of Medicine in Nashville, Tenn, and colleagues developed a two-step, validated diagnostic of delirium for ED patients age 65 and older: the Brief Confusion Assessment Method and Delirium Triage Screen. The screens have 82 percent sensitivity and 95.8 percent specificity when used together, Han wrote in an article published in the Annals of Emergency Medicine. Delirium assessment tools currently available often take as much as five minutes to complete, while Han’s Brief Confusion Assessment method takes only one minute, an important time difference in the ED.

However, Han noted that there is still much work to be done in screening methodology. "I don't think there is a one-size-fits-all approach to delirium screening," he said. "Different clinical environments will have different expertise, time constraints, and goals for the patients."

An INQRI-funded study led by Michele Balas and William Burke, explored the high risk for delirium and weakness for patients on ventilators in hospital intensive care units (ICU). The study found that a bundle of practices, employed by a nurse-led interprofessional team of health care providers, could help ICU patients avoid delirium and weakness. The study was published in Critical Care Nurse.

Researchers examined a “bundle” of evidence-based practices called the Awakening, and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility bundle (ABCDE bundle), which uses the best available evidence on delirium, immobility, sedation and analgesia, and ventilator management in the ICU. The bundle is founded on three primary principles: improving communication among members of the ICU team; standardizing care processes; and breaking the cycle of over-sedation and prolonged attachment to a ventilator that can lead to delirium and weakness.

New Study Provides More Evidence of the Need to Prevent Delirium in ICU Patients

A study published in the New England Journal of Medicine shows that patients who suffer from delirium while they are in intensive care units (ICU) have a higher risk of delirium when they are discharged. The study also found that putting patients in drug-induced comas can lengthen the duration of delirium.

According to the study's authors, researchers at Vanderbilt University, hospitals need to do more to keep ICU patients alert, including getting them up out of bed, even if they are on ventilators.

An INQRI-funded study conducted by Michele Balas and William Burke revealed that using a bundle of evidence-based practices helped ICU patients avoid delirium. The ABCDE bundle (Awakening, and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility bundle) was developed by a research team at Vanderbilt University and includes nurse-implemented, protocol-directed sedation; daily interruption of a patient’s infusion of sedatives until the patient can follow simple commands or becomes agitated (spontaneous awakening trials); periodically taking a patient off a ventilator to breathe on his or her own (spontaneous breathing trials); screening patients for delirium using either the Confusion Assessment Method-ICU or the Care Delirium Screening Checklist; and introducing physical and occupational therapy as soon as possible.

Wes Ely, who was a leader of that research team,also was the senior author of the new study in the New England Journal of Medicine.

The study was reported in several media outlets, including CBS News and in USA Today.

American Association of Critical Care Nurses to Host Webinar on Assessing and Managing Delirium - Sept. 19

The next presentation in the American Association of Critical Care Nurses' (AACN) Critical Care Webinar Series will focus on delirium in acute and critical care settings.

The webinar, Delirium Challenge: Assessing and Managing in Acute/Critical Care, will be held at 10am Pacific Daylight Time on Thursday, September 19.  The presenter is Leanne Boehm, RN, MSN, ACNS-BC. She is a research nurse in Vanderbilt University's Intensive Care Unit Delirium and Cognitive Impairment Study Group. And was part of an  INQRI-funded research project addressing the problem of critically ill patients on ventilators developing led by Michele Balas and William Burke. The team tested a bundle of practices aimed at reducing delirium among patients in Intensive Care Units (ICUs). The study revealed that a nurse-led interprofessional team employing the bundle could help patients int eh ICU avoid delirium and weakness so that they healed sooner and were healthier after leaving the hospital.

 Registration for the webinar is free.  To register, click here.

Upcoming AACN Webinar on Managing Delirium

The American Association of Critical-Care Nurses (AACN) is continuing its webinar series devoted to understanding and implementing updated clinical practice guidelines for pain, agitation and delirium with a session on Thursday, September 19, 10 a.m. PDT, presented by Leanne Boehm, RN, MSN, ACNS-BC.

Registration is now open for the webinar, "Delirium Challenge: Assessing and Managing in Acute/Critical Care."

This work mirrors that of INQRI grantees Michele Balas and William Burke who conducted a project which focuses on preventing complications in mechanically ventilated patients through use of the "Awakening and Breathing Coordination, Delirium assessment and management and Early Exercise and progressive mobility (ABCDE)" bundle.  Balas and Burke led a team to implement, analyze and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults.  In fact, their "Implementing the ABCDE Bundle at the Bedside" was selected as the American Association of Critical-Care Nurses' first PEARL (Practice, Evidence, Application, Resources and Leadership) web-based tool.

Click here to learn more about the Balas-Burke project "Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults."

Still Time - Register Now!

There is still time to register for the next webinar in our series which will be held this Thursday from 3p - 4pm ET.

Please join us to hear from INQRI project investigators Michele Balas and William Burke who will present their project, "Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults."

Fully two-thirds of intensive care unit patients develop delirium, which is associated with longer stays, billions of dollars in costs globally, and three-fold excess mortality at six months. Over one-half of intensive care unit survivors suffer a functionally debilitating dementia-like illness, which appears related to delirium duration. The main goal of this project was to implement, analyze and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults. The study focused on applying a program of delirium screening, prevention and treatment developed at Vanderbilt University, and was selected as the American Association of Critical-Care Nurses' first PEARL (Practice, Evidence, Application, Resources and Leadership) web-based tool.

REGISTER for this webinar. 

Webinar: Implementation of a Nurse-Led Plan to Manage Delirium

Please join us for the next webinar in our series focused on implementation and dissemination of evidence-based practices. INQRI project investigators Michele Balas and William Burke will present their project, "Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults" on February 28, 2013 from 3:00pm-4:00pmET.

Fully two-thirds of intensive care unit patients develop delirium, which is associated with longer stays, billions of dollars in costs globally, and three-fold excess mortality at six months. Over one-half of intensive care unit survivors suffer a functionally debilitating dementia-like illness, which appears related to delirium duration. The main goal of this project was to implement, analyze and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults. The study focused on applying a program of delirium screening, prevention and treatment developed at Vanderbilt University, and was selected as the American Association of Critical-Care Nurses' first PEARL (Practice, Evidence, Application, Resources and Leadership) web-based tool.

Please join us to learn more.

February 28, 2013
3:00pm-4:00pmET
REGISTER for this webinar. 

This session is part of a series featuring all of INQRI's grantee teams focused on translating research into practice. Save the Dates for these upcoming sessions: 

• Implementation of a Risk Specific Fall Prevention Bundle to Reduce Falls in Hospitals - 3/12/13 at 4pm ET - Register. 
• Translation of a Transitional Care Nursing Intervention for People with Serious Mental Illness - 3/27/13 at 12pm ET - Register. 

Click here to view the first session in this series, "Nurse-Led Intervention to Improve Screening and Treatment for Substance Abuse." 

Click here to view the second session in this series, "Dissemination and Implementation of Evidence-Based Methods to Measure and Improve Pain Outcomes." 

Click here to view the third session in this series, "Creation of a Nurse Manager Development Program to Increase Patient Safety."

INQRI Project Announced as First AACN PEARL

Congratulations to the INQRI researchers at the University of Nebraska Medical Center whose project on implementing the ABCDE bundle at the bedside was selected as the American Association of Critical-Care Nurses' first PEARL (Practice, Evidence, Application, Resources and Leadership) web-based tool.

This project focuses on preventing complications in mechanically ventilated patients through use of the "Awakening and Breathing Coordination, Delirium assessment and management and Early Exercise and progressive mobility (ABCDE)" bundle.

For more information on the PEARL program, please click here.

For more information on the INQRI project, please click here.

Upcoming IHI Seminar: Rethinking Critical Care: Reducing Patient Harm from Sedation, Immobility, and Delirium

On May 15th and 16th, the Institute for Healthcare Improvement will be hosting a symposium in San Diego, CA addressing critical care and cutting edge ICU practices aimed at improving care for elderly patients. The symposium will specifically focus on innovative ways for health care practitioners to monitor patient sedation, immobility, and delirium. Since these areas of care are strong predictors of length of stay, increased morbidity and mortality, long-term cognitive impairment, and high cost of care, this symposium offers a great way for health care practitioners to expand their skill-set and improve the quality of care they deliver.

Click here to read more about this upcoming symposium.

Hospital Delirium, Another Hospital Hazard for the Elderly

Yesterday, Susan Seliger wrote about her personal and family's experience with hospital delirium. Hospital delirium, a brain dysfunction characterized by sudden confusion and inattention, is not very well known yet very common in elderly patients who are admitted to a hospital. Each year 20% of all elderly patients in hospitals develop delirium and this serious illness is still not being identified or treated as effectively as it can be. The article, which appeared in the New York Times' New Old Age blog section, is not only related to the work of INQRI grantee, Dr. Michele Balas, but also included a quote from her regarding this serious topic.

Click here to read the full article.

New Videos Support Education Regarding Delirium

Fully two-thirds of intensive care unit patients develop delirium, which is associated with longer stays, billions of dollars in costs globally, and 3-fold excess mortality at 6 months. Over one-half of ICU survivors suffer a functionally debilitating dementia-like illness, which appears related to delirium duration. The main goal of INQRI's project entitled "Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults" is to implement, analyze, and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults. The study will focus on applying a program of delirium screening, prevention, and treatment developed at Vanderbilt University that is known as the Awakening-Breathing Coordination, Delirium Monitoring/Management & Early Mobility (ABCDE) program.

Click here to view videos which are being used as part of this project. They are included in an interprofessional, on-line, continuing educational program that describes the specific components of the ABCDE bundle. The bundle merges the best available evidence related to immobility, delirium, analgesia/sedation, and ventilator management in the ICU and tailors the pharmacologic and nonpharmacologic interventions used in prior clinical trials into a program that can be adopted into practice in less "research focused" ICUs.

This interdisciplinary team is led by Michele Balas, Ph.D. and William Burke, M.D at the University of Nebraska.