Problem

Clinical practice guidelines recommend intensive care unit (ICU) patients be assessed for delirium at least once per shift.1 An initial audit determined that delirium assessments for ICU patients were only being performed 31% of the time at an urban tertiary care hospital in Illinois, USA. In addition, variability existed in the assessment, documentation and interventions for ICU patients with delirium. Timely recognition and management is essential to reduce the incidence, severity and duration of delirium. To help improve patient outcomes, The Society of Critical Care Medicine initiated an ICU Liberation Campaign to implement the ABCDEF bundle, a standardised plan that targets delirium as a key quality metric.2

Background

Delirium, an acute state of confusion that includes symptoms of alternating mental status, inattention, disorganised thinking and/or altered consciousness, can occur in up to 80% of mechanically ventilated critically ill adult patients and up to 50% of critically ill adult patients not requiring mechanical ventilation in the ICU.3–5 Classified based on the patient’s psychomotor behaviour, symptoms of delirium can be hyperactive characterised by restlessness, agitation and delusions or hypoactive characterised by lethargy and slow response time. A combination of hyperactive and hypoactive symptoms is described as mixed delirium.6 Identification of hypoactive delirium, which comprises around 44% of delirium cases, can be difficult because patients may appear calm and relaxed.7

Delirium is associated with increased hospital and ICU stay.4 5 Ely et al, reported that ICU patients with delirium spend an average 10 days longer in the hospital than ICU patients without delirium.4 Delirium is also associated with a higher incidence of cognitive impairment at hospital discharge and higher hospital and ICU mortality.4 5 8 9 The cost of care for an ICU patient with delirium is significantly higher than an ICU patient without an episode of delirium.10 It is estimated that total healthcare costs for delirium range up to $152 billion per year in the USA.11

The duration of delirium is independently associated with long-term cognitive impairment, one aspect of post intensive care syndrome commonly experienced by critical illness survivors.12 However, management of delirium risk factors can reduce the frequency and duration of delirium.13 The Society of Critical Care Medicine’s ABCDEF bundle was developed to reduce delirium, improve pain management and encourage early mobility, and for use of appropriate medication and family involvement to reduce long-term consequences for adult ICU patients. Component D of the ABCDEF bundle focuses on assessing, preventing and managing delirium and promotes use of the Confusion Assessment Method for the ICU (CAM-ICU) tool to monitor delirium through evaluation of mental status, inattention, altered consciousness and disorganised thinking.1 The CAM-ICU tool was developed and validated in non-verbal mechanically ventilated ICU patients but does not determine type or severity of delirium.3

The CAM-ICU tool can be challenging to implement because training is required to ensure that providers are familiar with all components of the tool and are able to interpret findings before applying the tool in clinical practice. Although the sensitivity of the CAM-ICU tool in identifying delirium has been reported at 81%, education and guidance are needed to achieve this level of sensitivity. Devlin et al reported that the per cent of ICU nurses able to effectively evaluate delirium increased significantly after implementation of delirium assessment training and scripted case scenarios.14 Once staff are trained on the CAM-ICU tool, an additional challenge is ensuring that screening is performed regularly and consistently. Education and training by itself does not ensure sustainability and demands process and culture changes.

It is widely accepted that prevention is key in delirium management. At this time, treatment options are limited once a patient becomes delirious. Non-pharmacological interventions are reported to decrease the duration of delirium; however, there is not enough evidence to support pharmacological interventions, further highlighting the importance of delirium prevention and early identification.1 13 15

Baseline measurement

Delirium screening was measured in ventilated and non-ventilated ICU patients 18 years and older at an urban tertiary care hospital. Patients with traumatic brain injury, severe intellectual disability, patients receiving comfort care only and patients with a Richmond Agitation Sedation Scale score of −4 or −5 with or without sedation were excluded from the study. Documentation of delirium screening was tracked by the Electronic Health Record. Documentation by nursing staff was measured per 12 hour shift and documentation of physician communication of delirium status during rounding was measured per 24 hours. Results are displayed as a percentage with the numerator representing the number of patients with documentation at least once per 12 hour shift and the denominator representing all patients included in the audit.

In August 2015, an initial audit revealed that delirium screening using the CAM-ICU assessment tool was performed by nursing staff at least once in a 12 hour shift in 31% (5/16) of patients. Based on initial audit data, delirium was under-recognised and undercoded. Further investigation revealed that staff were more familiar with hyperactive delirium but were not formally trained to recognise hypoactive delirium or use the CAM-ICU assessment tool. A standardised approach was needed to improve delirium recognition, documentation and timely management of care.

Design

This project was reviewed by the local institutional review board. It was determined that this project was not research involving human subjects. Lean Six Sigma methodology determined potential causes for ICU patients with undocumented and unidentified delirium. Solutions were chosen based on input from front-line providers and members of a delirium committee. Effort to implement the solutions and potential impact were considered. A standardised delirium screening tool and critical care progress note were developed in addition to education and training. Interventions were implemented between January 2016 and December 2016. Change in process was targeted to maintain sustainability. Two-proportion tests were used to determine differences in the per cent of patients with delirium screening documentation and 30-day mortality rates. Mann-Whitney U test was used to determine differences in ICU length of stay and χ² analysis was used to determine differences in severity of illness, determined by All Patient Refined Diagnosis Related Groups. A p value of <0.05 was considered significant.

Strategy

Lessons and limitations

Although the interventions were successful in increasing delirium documentation, nurses may be over documenting on some patients. For example, CAM-ICU assessment was documented on one patient seven times within a 24-hour period. Additionally, documentation on patients that are admitted during early morning hours could be missed if a shift change occurs before the full documentation process is completed. A limitation of the study was that it was performed at a single institution and results cannot be generalised. In addition, documentation results are displayed per patient rather than continuously for every 12-hour period. We learnt that significant challenges to process change can be identified through communication with stakeholders. Finally, we believe involvement in quality improvement projects should be incorporated into residency training and required for administrative staff. Overall, multidisciplinary collaboration can result in significant positive outcomes.