learning session 2 -...

Learning Session 2

Monday and Tuesday

May 28 – 29, 2012

Toronto, Ontario

Welcome from Safer Healthcare Now!

and Canadian Patient Safety Instituteand Canadian Patient Safety Institute

Carrie-Lynn Haines

Project Manager, CPSI

ICU COLLABORATIVE LEARNING SESSION 2

Canadian Patient Safety InstituteJune 2011

ASKLISTENTALK

SAFE CARE...

Our Strategic Priorities

� Improve the safety of patient care in Canada through learning, sharing and implementing interventions that are known to reduce avoidable harm;avoidable harm;

� Build governance capability;

� Support networks;

� Increase capacity through evidence-informed resources and tools.

5

Current Reality for the System

Clinical Support

Canadian ICU

Operations

Canadian Patient Safety Institute

SHN RNAO

Safer Healthcare Now! Structure

Partner Network

MentorNetwork

Measurement Working Group &

CMT Education & Resource Working Group

ICUCollaborative

ISMPCanada

Teams

Other Canadian Faculty

Communications Support

SHN Atlanti

cSHN Ontari

o

SHN West

Patients&

Families

SHN Quebec

RNAO

Dr. William Geerts

Sunnybrook Health Science Centre

Dr. Michael GardamUniversity Health Network

• AMI: All patients receive perfect AMI care (all 9 strategies implemented 100% of the time)

• SSI: 95% or more of all surgical patients will receive timely prophylactic antibiotics

Safer Healthcare Now! Interventions

receive timely prophylactic antibiotics

• CLI: Reduce central line infections by 50% in one year

• RRT: Decrease the rate of codes by 50% (per 1000 discharges)

• VAP: Reduce the rate of ventilator-associated pneumonias by 50% over one year

• NACS: New Approach to Controlling Superbugs

• Falls: Reduce the reduce the incidence of falls and injury from falls by 40%

• VTE: 100% of patients receive appropriate

Safer Healthcare Now! Interventions

• VTE: 100% of patients receive appropriate thromboprophylaxis

• MedRec (acute care, home care and LTC): Prevent adverse drug events by implementing medication reconciliation

• HH: Implement Strategies to improve hand hygiene

• Safer Surgery Saves Lives

Teams Continue to Enroll

National Med Rec Strategy

13

The Mainstays of SHN

� Social Movement� Evidence� People� Science of Improvement� Learning and Sharing� Learning and Sharing

– Improvement programs (Collaboratives, Action Series, workshops)– National Calls– Tools and Resources (GSK, pocket cards, videos)– Community of Practice– Staff and Faculty for coaching

15

Social Movement

� SHN started as a grassroots campaign

� Continued to evolve into the flagship program of CPSIof CPSI

� Inspires people to get involved and make a difference

16

Evidence

� All the SHN interventions are based on evidence.

� SHN works to accelerate the length of time it � SHN works to accelerate the length of time it takes to move evidence into practice

17

People

� Clinical intervention leads

� Improvement support and coaching through the SHN regional structuresthe SHN regional structures

� Clinical faculty associated with each intervention

� Healthcare teams and care providers

� Patients

18

Grounded in Science of Improvement

� Model for Improvement

� Positive Deviance

� Sustaining and spreading change� Sustaining and spreading change

� Measurement

19

Measuring for Patient Safety!

Goals of Patient Safety Metrics System

� Streamline enrollment for organizations

� Streamline data � Streamline data submission for teams

� Enhance reporting and provide real-time access to data and standardized reports

Learning and Sharing

� Communication Tools

� Communities of Practice

� National Calls� National Calls

� Improvement Programs

� Tools and Resources

Staying informed and connected

Canadian Patient Safety Institute and Safer Healthcare Now! Websites

www.patientsafetyinstitute.ca

www.saferhealthcarenow.cawww.saferhealthcarenow.ca

www.patientsafetycrosswalk.ca

www.improvingcaresearchcentre.com

Communities of Practice http://tools.patientsafetyinstitute.ca

National Webinars Free webinars for all SHN interventions

Revised Products Coming soon

� STOP Infections Now: Revised Getting Started Kit (Fall 2012)

� Medication Reconciliation LTC: Revised Getting Started Kit (June, 2012)

� VTE: Revised Getting Started Kit (May 2012)

� Falls Prevention Revised Getting Started Kit (Dec 2012)

� CLI: Revised Getting Started Kit (June 2012)

� VAP: Revised Getting Started Kit (June 2012)

Upcoming National Calls

� CLI: Release of the new CLI Guidelines

– Guest speaker: Dr. William Jarvis

– June 21st at 12 ET

� VAP: Release of the new VAP Guidelines � VAP: Release of the new VAP Guidelines

– June 26th at 12 ET

� MedRec in the Home Care Setting:Sharing Ontario’s Central Community Care and Access Centre’s Success Story

– June 5th at 12 ET

Safer Healthcare Now! Contacts

Western Canada: [email protected]

Ontario: [email protected]

Quebec: [email protected]

Atlantic Canada: [email protected] Canada: [email protected]

Safer Healthcare Now! [email protected]

ASKLISTENTALK

SAFE CARE...

Shared Vision for Collaborative

& Learning Session 2& Learning Session 2

Dr. Claudio Martin

Chair, Canadian ICU Collaborative

Patient Stories

• 45 male, transferred

from ICU to ward after

14 days management of

septic shock, ARDS

• 72 male, pneumonia,

ischemic heart disease,

difficult to wean from

ventilation

• Hydromorphone 12 mg

po given → LOC ↓

• Prior to transfer, had

been weaned to 5 mg

po q4h

• Agitated (pulled feeding

tube twice), no

attention to discussion

about weaning

attempts, poor sleep

pattern

5/28/2012 Delirium and Med Rec Collaborative 28

Collaborative Aims

By December 2012, participating teams will:

• Delirium: improve care of the critically ill patient

through implementation of standardized screening

and identification of prevention and management and identification of prevention and management

strategies for delirium

• Medication Reconciliation: Reduce adverse drug

events for critically ill patients by following a

medical reconciliation process


The Collaborative Approach

Action Period One Action Period Two

A

S

P

D

A

S

P

D

A

S

P

D

Action Period Three

Delirium and Med Rec Collaborative 30

Learning

Session

One

(A&B)-Jan 18 & 25-

Learning

Session Two-May 28-29-

Learning

Session

Three-Nov 15 & 21-

SupportTeam Calls List Serve Document Sharing Monthly Reports

Assessments Site Visits Faculty Coaching

Planning &

Pre-work

a) Teams

b) Topic

-July-Dec-

Distribute

FindingsDec

*Based on Institute for Healthcare Improvement Breakthrough Series Collaboratives

5/28/2012

Aim of Learning Session 2

By the end of this sessions, participants will:

• Assess progress in testing and implementing changes

• Share and adapt ideas for improvement

• Identify strategies for overcoming barriers• Identify strategies for overcoming barriers

• Continue to build skills and capability in

improvement work


Delirium & Medication Reconciliation

Collaborative

A National Effort!

Kelowna General Hospital

AHS Edmonton Zone University of Alberta Hospital

Grey Nuns Hospital

AHS Edmonton Zone – Sturgeon Hospital

Misericordia Hospital

AHS - Calgary Zone

Saskatoon Health Region

CHAU Hôtel-Dieu de Lévis

London Health Sciences Centre

Humber River Regional Hospital

Hamilton Health Sciences Centre

North York General Hospital

Joseph Brant Hospital

AHS – Medicine Hat Hospital

Bluewater Health

Hotel-Dieu Grace Hospital

Hôpital Cité de la Santé de Laval

Timmins & District Hospital

Thunder Bay Regional Health Science Centre

Horizon Health Network

Ongoing Expectations

• Desire to innovate

• Commitment of a team sponsor

• Full participation of a multidisciplinary team

• Development of measures • Development of measures

• Regular access to email and Internet

• Regular reporting of progress

• Willingness and commitment to implement rapid and

widespread change

Delirium and Med Rec Collaborative 335/28/2012

Planning & Support Team

Dr. Claudio Martin, Chair Canadian ICU Collaborative

Bruce Harries, Collaborative Director

Ardis Eliason, Project Coordinator

Leanne Couves, Improvement Advisor

Anne MacLaurin, Project Manager, Canadian Patient Safety

Institute (CPSI)


Faculty

Chaim Bell, MD, PhD, FRCPC

Paule Bernier, Dt.P., M.Sc.

Denny Laporta, MD, FRCPC

Cathy Mawdsley, RN, M.Sc.

Vanda DesRoches; RN BN

Greg Duchscherer, RRT, FCSRT

Yoanna Skrobik, MD, FRCPC

Jennifer Turple, BSc Pharm, ACPR


How Faculty Can Help

• Provision of evidence-based changes and guidance on application of those changes

• Provision and education on methods and tools for improvement and measurement

• Advice and feedback on your progress• Advice and feedback on your progress

• Direction and co-ordination for the initiative on a provincial basis

• Communication strategies and mechanisms to keep organizations connected throughout the Collaborative


Welcome Guests

• Carrie-Lynn Haines, Project Manager, CPSI

• Clarence Chant, PharmD, St. Michael’s Hospital

• John Devlin, PharmD, FCCM, FCCP


Collaborative Principles

• Everybody teaches, everybody learns

• Share generously (transparency)

• Steal shamelessly

• Acknowledge graciously• Acknowledge graciously

When we cooperate, everybody wins. » W. Edwards Deming


Monday Agenda

1320 Delirium Screening – Dr. Yoanna Skrobik

1400 Delirium Assessment and Management: A Confusing Journey – Cathy Mawdsley

1430 Working Groups

1500 BREAK1500 BREAK

1515 Role of Medications in ICU Delirium – Clarence Chant

1600 Experience a Collaborative in 45 Minutes – Tennis Ball Simulation Exercise

1700 Rapid Fire Presentations

1730 Storyboard & Networking Reception

1800 Close Day 1


Delirium Screening

Dr. Yoanna Skrobik

Delirium Assessment Tools in the Critical Care Setting

Yoanna Skrobik MD FRCP(c)

Measuring delirium in the criticalcare setting

� Why would you want to do it?� Does the assessment tool matter?� Impact of delirium identification on patient outcomes� Convincing your staff

Why would you want to assessdelirium?

The agitated patient� Pain� Insufficient sedation� Delirium� Delirium

Patient views on what is important in the ICU

� Painlessness� Reassurance

– Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000

– Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May

Memories and perceptions in ICU survivors: a multidimensional

questionnaireG Hernandez, R de la Fuente, C Romero, ME Naranjo, M Zanolli, N Barticevic, L Castillo, G Bugedo

Reported perceptions:

� 60% recalled paranoid delusions.� 60% recalled paranoid delusions.� Anxiety was reported by 47%� 28% expressed fear of getting permanently disabled

and 23% of death

What was it like?� One patient (deemed oriented) would recognize one nurse who

had cared for her more often. The patient experienced anxiety when that nurse would go on coffee breaks. Then, the whole room changed; the wall in front of the patient opened, the floor rose, and she could “watch the nurse having coffee on the next floor”, and therefore felt better.

� Nurses actions were often part of the unreal experiences; entering into personal space or “saying something stupid” could result in the patient trying to hit the nurse.

� Paranoia and fear of harm by staff, nurses or equipment (“angry eyes” provoked fear in one patient) and yet the presence of the nurse was simultaneously perceived as reassuring.

� Sleeplessness and tiredness were ubiquitous. Closing eyes described as problematic as visual hallucinations were more common with eyes closed.

� Bodies felt unreal, “strange and empty”.

Delirium and outcomes

� Delirium is strongly associated with increased mortality in adult ICU patients.

� Delirium is strongly associated with prolonged length of stay in adult ICU patients.

� Delirium is moderately associated with the � Delirium is moderately associated with the development of post-ICU cognitive impairment in adult ICU patients.

Delirium and Distress

Breitbart W et al. Psychosomatics 2002;43:183

So does the tool matter?

Not likely!

Delirium scales

CAM-ICU(Confusion Assessment Method-ICU)

ICDSC(Intensive Care Delirium Screening

Checklist)

http://www.icudelirium.co.uk/ www.icudelirium.org

PATIENT EVALUATION DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 Altered level of consciousness* (A-E) If A or B do not complete patient evaluation for the period Inattention Disorientation Hallucination - delusion – psychosis Psychomotor agitation or retardation Inappropriate speech or mood

Intensive Care Delirium Screening Checklist (ICDSC)

Inappropriate speech or mood Sleep/wake cycle disturbance Symptom fluctuation

TOTAL SCORE (0-8)

Bergeron, N. Dubois M.J. Skrobik, Y. Intensive Care Delirium Checklist : evaluation of a new screening tool. Intensive Care Medicine , 2001

重症监护谵妄筛查表重症监护谵妄筛查表重症监护谵妄筛查表重症监护谵妄筛查表（（（（第一版第一版第一版第一版））））

武汉市同济医院武汉市同济医院武汉市同济医院武汉市同济医院

� 4/8 or more corresponds to a delirium diagnosis

Nursing comparisons of ICDSC vs. CAM-ICU

� Zurich, Charlotte and all of Australia� Aust Crit Care 2005 Feb;18(1)

Multicentre study of delirium in ICU patients using a simple screening tool Roberts et alsimple screening tool Roberts et al

As long as you agree on whatdelirium means in your unit

Delirium and its consequences

Impact of tools on patient outcomes

Protocol to address patient views on what is important in the ICU

� Painlessness� Reassurance

– Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000

– Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May

Pre-protocol Post -protocol P

Protocol

Pre-protocol Post -protocol P

N 604 610 0.84

APACHE 17.07 18.1 0.0133

Ratio f/h 249/355 250/360 0.931

Parameter Pre-interventionPost-

intervention

Pre-post comparison P

value

…delirium incidences

Delirium 35.2% 33.8% 0.63

ICDSC=0 31.5% 41.3% 0.002

ICDSC vs . Patient Outcome

Comparison of mortality, ICU LOS and outcome accord ing to DSC score

30

40

50

60

70%

DSC 0

DSC 1-3

DSC >3

DSC=0

DSC 1-3

DSC >3

%

0

10

20

Dead (%) ICU LOS(mean)

Home Home withhelp

Convalesence Chronic care OtherLOS Days

ICU

Home+help

(%)

Convalescence

(%)

Long Term Care

(%)

Other

(%)

Home nohelp

(%)Mortality (%)

Parameter Pre-interventionPost-

intervention

Pre-post comparison P

value

…delirium incidences

Delirium 35.2% 33.8% 0.63

ICDSC=0 31.5% 41.3% 0.002

Before After

…Patient-driven analgesia, sedation and delirium Rx

Going home 45.2% 52.2% P=0.024

1 ou moins

1 ou moins

Two more things the nurse can do

So now you want to do it…

� How did we convince our staff?

The staff buy -in

� The premise was nurse empowerment� All leaders were targeted� Much feedback was provided� It is now routine care

� Protocolized nursing assessments of pain, sedation and delirium are associated with improved short-term and long-term outcome.

� adjusted protocol-driven medication administration result in better outcomes in the context of educating and empowering nurses, and of physician buy-in.

� These data suggests that individualization of care accounts for improved outcomes.� Implementation is a challenge, takes time, and is very rewarding :-)

Thank you !

Delirium Assessment and

Management: A Confusing JourneyManagement: A Confusing Journey

Cathy Mawdsley, RN MSc

Delirium Assessment and Delirium Assessment and Delirium Assessment and Delirium Assessment and

Management: A Management: A Management: A Management: A Management: A Management: A Management: A Management: A

Confusing JourneyConfusing JourneyConfusing JourneyConfusing Journey

Cathy Mawdsley, CNS MSICUCathy Mawdsley, CNS MSICUCathy Mawdsley, CNS MSICUCathy Mawdsley, CNS MSICU

University HospitalUniversity HospitalUniversity HospitalUniversity Hospital

ObjectivesObjectivesObjectivesObjectivesObjectivesObjectivesObjectivesObjectives

� Review challenges in caring for patients with delirium Review challenges in caring for patients with delirium Review challenges in caring for patients with delirium Review challenges in caring for patients with delirium in the ICUin the ICUin the ICUin the ICU

� Screening tools

� Non-pharmacologic strategies

� Pharmacological strategies

79

79

� Pharmacological strategies

� Highlight our experiences at University Hospital, Highlight our experiences at University Hospital, Highlight our experiences at University Hospital, Highlight our experiences at University Hospital, LHSCLHSCLHSCLHSC

� Not perfect

Pathophysiology of DeliriumPathophysiology of DeliriumPathophysiology of DeliriumPathophysiology of DeliriumPathophysiology of DeliriumPathophysiology of DeliriumPathophysiology of DeliriumPathophysiology of Delirium

80

81Justic, M. (2000). Does "ICU psychosis" really exis t? Critical Care Nurse, 20 (3), 28-37

Delirium SubtypesDelirium SubtypesDelirium SubtypesDelirium SubtypesDelirium SubtypesDelirium SubtypesDelirium SubtypesDelirium Subtypes

CombativeCombativeCombativeCombativeAgitatedAgitatedAgitatedAgitatedRestlessRestlessRestlessRestless

Hyperactive DeliriumHyperactive DeliriumHyperactive DeliriumHyperactive Delirium

Mixed Mixed Mixed Mixed

82

Alert & CalmAlert & CalmAlert & CalmAlert & Calm

RestlessRestlessRestlessRestless“Flat affect” “Flat affect” “Flat affect” “Flat affect” DepressionDepressionDepressionDepression

Hypoactive DeliriumHypoactive DeliriumHypoactive DeliriumHypoactive Delirium

Mixed Mixed Mixed Mixed DeliriumDeliriumDeliriumDelirium

http://www.mc.vanderbilt.edu/icudelirium/index.htmlABCDE Education Slides

Why Why Why Why Why Why Why Why should we monitor delirium?should we monitor delirium?should we monitor delirium?should we monitor delirium?should we monitor delirium?should we monitor delirium?should we monitor delirium?should we monitor delirium?

� Distressing for patients and families…and nurses!Distressing for patients and families…and nurses!Distressing for patients and families…and nurses!Distressing for patients and families…and nurses!

� Increased mortality with each day of deliriumIncreased mortality with each day of deliriumIncreased mortality with each day of deliriumIncreased mortality with each day of delirium

� ICU delirium is an independent predicator of longICU delirium is an independent predicator of longICU delirium is an independent predicator of longICU delirium is an independent predicator of long----

83

� ICU delirium is an independent predicator of longICU delirium is an independent predicator of longICU delirium is an independent predicator of longICU delirium is an independent predicator of long----term cognitive impairment up to one year after term cognitive impairment up to one year after term cognitive impairment up to one year after term cognitive impairment up to one year after critical illnesscritical illnesscritical illnesscritical illness

� What does cognitive impairment look like

� Associated with impaired activities of daily living and Associated with impaired activities of daily living and Associated with impaired activities of daily living and Associated with impaired activities of daily living and quality of life in survivors of critical illnessquality of life in survivors of critical illnessquality of life in survivors of critical illnessquality of life in survivors of critical illness

Girard, T.D. et al, Crit Care Med 2010; 38(7):1513-1 520Skrobik, Y. Crit Care Clinics 2009; 35(3): 585-591

Barriers to Delirium AssessmentBarriers to Delirium AssessmentBarriers to Delirium AssessmentBarriers to Delirium AssessmentBarriers to Delirium AssessmentBarriers to Delirium AssessmentBarriers to Delirium AssessmentBarriers to Delirium Assessment

� “at risk” “at risk” “at risk” “at risk” vsvsvsvs everyoneeveryoneeveryoneeveryone

� Tools are complex and not perfectTools are complex and not perfectTools are complex and not perfectTools are complex and not perfect

� Not 100% agreement between 2 tools� Sleep and hallucinations not captured with CAMI ICU

� SubdromalSubdromalSubdromalSubdromal and hypoactive forms are missed and hypoactive forms are missed and hypoactive forms are missed and hypoactive forms are missed –––– the easiest the easiest the easiest the easiest to nurse and “double up”to nurse and “double up”to nurse and “double up”to nurse and “double up”

84

to nurse and “double up”to nurse and “double up”to nurse and “double up”to nurse and “double up”

� Other organ failures are more importantOther organ failures are more importantOther organ failures are more importantOther organ failures are more important

� Difficult to get interdisciplinary “buyDifficult to get interdisciplinary “buyDifficult to get interdisciplinary “buyDifficult to get interdisciplinary “buy----in”in”in”in”

84

Barriers to Delirium ManagementBarriers to Delirium ManagementBarriers to Delirium ManagementBarriers to Delirium ManagementBarriers to Delirium ManagementBarriers to Delirium ManagementBarriers to Delirium ManagementBarriers to Delirium Management

� NonNonNonNon----pharmacologic strategies are not rigorously pharmacologic strategies are not rigorously pharmacologic strategies are not rigorously pharmacologic strategies are not rigorously studiedstudiedstudiedstudied

� NonNonNonNon----pharmacologic strategies are not rewarded pharmacologic strategies are not rewarded pharmacologic strategies are not rewarded pharmacologic strategies are not rewarded or valued in high tech environmentor valued in high tech environmentor valued in high tech environmentor valued in high tech environment

� Nursing workload software

85

� Nursing workload software

� Delirium days are not an outcome that is rewarded by hospital systems

� Labour intensive for ABCDELabour intensive for ABCDELabour intensive for ABCDELabour intensive for ABCDE

� RCT of drugs are limitedRCT of drugs are limitedRCT of drugs are limitedRCT of drugs are limited

� Minimal evidence for protocols

� How to evaluate treatment effect?How to evaluate treatment effect?How to evaluate treatment effect?How to evaluate treatment effect?

85

How can How can How can How can How can How can How can How can we we we we we we we we assess for delirium? assess for delirium? assess for delirium? assess for delirium? assess for delirium? assess for delirium? assess for delirium? assess for delirium?

ICDSCICDSCICDSCICDSC

� The patient does not have to The patient does not have to The patient does not have to The patient does not have to communicate communicate communicate communicate

� Suitable for the entire ICU Suitable for the entire ICU Suitable for the entire ICU Suitable for the entire ICU populationpopulationpopulationpopulation

� Accounts for the patient’s Accounts for the patient’s Accounts for the patient’s Accounts for the patient’s behaviourbehaviourbehaviourbehaviour over a period of over a period of over a period of over a period of

CAMCAMCAMCAM----ICUICUICUICU

� PPPPatients atients atients atients need to be alert need to be alert need to be alert need to be alert and able to follow and able to follow and able to follow and able to follow commands, able commands, able commands, able commands, able to to to to recognize pictures and the recognize pictures and the recognize pictures and the recognize pictures and the letter “A”letter “A”letter “A”letter “A”

86

behaviourbehaviourbehaviourbehaviour over a period of over a period of over a period of over a period of timetimetimetime

� Can track symptoms patternsCan track symptoms patternsCan track symptoms patternsCan track symptoms patterns� E.g., sleep

� Result: ≥ 4 = delirium Result: ≥ 4 = delirium Result: ≥ 4 = delirium Result: ≥ 4 = delirium � Range of delirium (1-3)

� Used with Used with Used with Used with neuroneuroneuroneuro----populationspopulationspopulationspopulations

Roberts et al, Australian Critical Care 2005; 18 (1 ): 6-16

letter “A”letter “A”letter “A”letter “A”� Pass/fail testPass/fail testPass/fail testPass/fail test� Higher specificity Higher specificity Higher specificity Higher specificity for for for for

deliriumdeliriumdeliriumdelirium� Result: yes or no answerResult: yes or no answerResult: yes or no answerResult: yes or no answer

CAMCAMCAMCAMCAMCAMCAMCAM--------ICUICUICUICUICUICUICUICU

87


88


89

ICDSCICDSCICDSCICDSCICDSCICDSCICDSCICDSC

Score ≥ 4: deliriumScore 1-3: subdromal

delirium

90

Skrobik, Y. Crit Care Clinics 2009; 35(3): 585-591

Completing the ICSDCCompleting the ICSDCCompleting the ICSDCCompleting the ICSDCCompleting the ICSDCCompleting the ICSDCCompleting the ICSDCCompleting the ICSDC

1

1

1

91

1

11

10

0

6

CAM ICU CAM ICU CAM ICU CAM ICU CAM ICU CAM ICU CAM ICU CAM ICU vsvsvsvsvsvsvsvs ICDSC ICDSC ICDSC ICDSC ICDSC ICDSC ICDSC ICDSC ((((((((PlaschkePlaschkePlaschkePlaschkePlaschkePlaschkePlaschkePlaschke, ICM, 2008), ICM, 2008), ICM, 2008), ICM, 2008), ICM, 2008), ICM, 2008), ICM, 2008), ICM, 2008)

ICDSC +ICDSC +ICDSC +ICDSC + ICDSC ICDSC ICDSC ICDSC ----

CAMCAMCAMCAM ICU ICU ICU ICU ---- 20202020 (8%)(8%)(8%)(8%) 219219219219

- 374 pairs of assessments- 174 pts -2 tools used everymorning between 8 -10am

92

CAM ICU +CAM ICU +CAM ICU +CAM ICU + 120120120120 15 (11%)15 (11%)15 (11%)15 (11%)

140140140140 234234234234

92

morning between 8 -10am-ICU RN used ICDSC- researcher used CAM ICU - only 30 min between tests- 41% delirium rate- agreement rate of 80%

CAM ICU compared with ICDSC CAM ICU compared with ICDSC CAM ICU compared with ICDSC CAM ICU compared with ICDSC CAM ICU compared with ICDSC CAM ICU compared with ICDSC CAM ICU compared with ICDSC CAM ICU compared with ICDSC ((((((((TomasiTomasiTomasiTomasiTomasiTomasiTomasiTomasi et al, 2012)et al, 2012)et al, 2012)et al, 2012)et al, 2012)et al, 2012)et al, 2012)et al, 2012)

383 pts

221 excluded

162 pts (42%)

56 < 24 ICU stay56 < 24 ICU stay56 < 24 ICU stay56 < 24 ICU stay163 had decreased 163 had decreased 163 had decreased 163 had decreased LOCLOCLOCLOC

Agreement in 147/162

93

56 (34.9%) ICDSC

positive

14 positive ICDSC with 14 positive ICDSC with 14 positive ICDSC with 14 positive ICDSC with

negative CAM ICUnegative CAM ICUnegative CAM ICUnegative CAM ICU

---- SleepSleepSleepSleep

---- disorientationdisorientationdisorientationdisorientation

53 (32.7) ICDSC

subdromal positive

43 (28.5%) CAM ICU

positive

1 positive CAM ICU 1 positive CAM ICU 1 positive CAM ICU 1 positive CAM ICU

with 1 negative ICDSCwith 1 negative ICDSCwith 1 negative ICDSCwith 1 negative ICDSC

Mortality not as bad

MISCU University HospitalMISCU University HospitalMISCU University HospitalMISCU University HospitalMISCU University HospitalMISCU University HospitalMISCU University HospitalMISCU University Hospital

� 24 bed tertiary level MSICU24 bed tertiary level MSICU24 bed tertiary level MSICU24 bed tertiary level MSICU

� Neuroscience (no multisystem trauma)

� Transplant

� Cardiac

Medical/Surgical

94

� Medical/Surgical

� 900 pts a year

� 2 attempts at systemic delirium assessment on all 2 attempts at systemic delirium assessment on all 2 attempts at systemic delirium assessment on all 2 attempts at systemic delirium assessment on all patientspatientspatientspatients

94

First Attempt (2007)First Attempt (2007)First Attempt (2007)First Attempt (2007)First Attempt (2007)First Attempt (2007)First Attempt (2007)First Attempt (2007)

� Nurses piloted the 2 screening toolsNurses piloted the 2 screening toolsNurses piloted the 2 screening toolsNurses piloted the 2 screening tools

� Chose ICDSC

� Limited MD engagement

� Time

� Lack of awareness of impact of delirium

� Not comfortable with selected tool – how to use

95

Not comfortable with selected tool – how to use

� Lessons learnedLessons learnedLessons learnedLessons learned

� Physician champions

� Needed throughput model for information from delirium assessment

� Legitimacy in rounds

� Management guideline for bedside RN and residents

� Some patients are ICDSC positive and CAM ICU negative

95

Second Attempt (2010)Second Attempt (2010)Second Attempt (2010)Second Attempt (2010)Second Attempt (2010)Second Attempt (2010)Second Attempt (2010)Second Attempt (2010)

� Implemented along with a “research program”Implemented along with a “research program”Implemented along with a “research program”Implemented along with a “research program”

� Outcome was required for another research stream

� RNs resoundingly wanted ICDSCRNs resoundingly wanted ICDSCRNs resoundingly wanted ICDSCRNs resoundingly wanted ICDSC

� ICDSC not “user friendly” for physicians as part of ICDSC not “user friendly” for physicians as part of ICDSC not “user friendly” for physicians as part of ICDSC not “user friendly” for physicians as part of their bedside assessmenttheir bedside assessmenttheir bedside assessmenttheir bedside assessment

96

their bedside assessmenttheir bedside assessmenttheir bedside assessmenttheir bedside assessment

� Consultants wanted residents to be comfortable with delirium assessment

� Residents more comfortable with CAM-ICU

� Management guideline created with ICU, Neurology Management guideline created with ICU, Neurology Management guideline created with ICU, Neurology Management guideline created with ICU, Neurology and Psychiatry physiciansand Psychiatry physiciansand Psychiatry physiciansand Psychiatry physicians

� Nursing, Pharmacy, Psychology, etc

� Outcome: 90% screenedOutcome: 90% screenedOutcome: 90% screenedOutcome: 90% screened96

Implementation at LHSCImplementation at LHSCImplementation at LHSCImplementation at LHSCImplementation at LHSCImplementation at LHSCImplementation at LHSCImplementation at LHSC

97

Delirium ManagementDelirium Management

1. Identify etiology

2. Identify risk factors

98

2. Identify risk factors� APACHE score

� HTN, alcohol, cognitive impairment

3. Consider non-pharmacologic

and pharmacologic treatment

Jacobi J, et al. Crit Care Med 2002;30:119-141

99Justic, M. (2000). Does "ICU psychosis" really exis t? Critical Care Nurse, 20 (3), 28-37

Delirium Management: Delirium Management: Delirium Management: Delirium Management: Delirium Management: Delirium Management: Delirium Management: Delirium Management:

what works?what works?what works?what works?what works?what works?what works?what works?

Non-

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Non-

pharmacologicPharmacologic

NonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologic InterventionsInterventionsInterventionsInterventionsInterventionsInterventionsInterventionsInterventions

Pain and Sedation: Pain and Sedation: Pain and Sedation: Pain and Sedation: � Monitor and manage using an objective scaleMonitor and manage using an objective scaleMonitor and manage using an objective scaleMonitor and manage using an objective scale� Link between poor pain control and delirium Link between poor pain control and delirium Link between poor pain control and delirium Link between poor pain control and delirium

Orientation:Orientation:Orientation:Orientation:� Convey the day, date, place, and reason for Convey the day, date, place, and reason for Convey the day, date, place, and reason for Convey the day, date, place, and reason for

hospitalizationhospitalizationhospitalizationhospitalization

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� Convey the day, date, place, and reason for Convey the day, date, place, and reason for Convey the day, date, place, and reason for Convey the day, date, place, and reason for hospitalizationhospitalizationhospitalizationhospitalization

� Familiar belongings in room Familiar belongings in room Familiar belongings in room Familiar belongings in room � Update whiteboards with caregiver namesUpdate whiteboards with caregiver namesUpdate whiteboards with caregiver namesUpdate whiteboards with caregiver names� Use clock and calendar in roomUse clock and calendar in roomUse clock and calendar in roomUse clock and calendar in room� Discuss current events Discuss current events Discuss current events Discuss current events � Minimize restraintsMinimize restraintsMinimize restraintsMinimize restraints� Family participation and knowledge of deliriumFamily participation and knowledge of deliriumFamily participation and knowledge of deliriumFamily participation and knowledge of delirium

NonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologicNonpharmacologic InterventionsInterventionsInterventionsInterventionsInterventionsInterventionsInterventionsInterventions

Sensory: Sensory: Sensory: Sensory:

� Hearing aids and/or eye glasses

� Ear plugs

� Music

� Familiar belongings e.g., blanket, etc

Sleep hygiene:Sleep hygiene:Sleep hygiene:Sleep hygiene:

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Sleep hygiene:Sleep hygiene:Sleep hygiene:Sleep hygiene:

� Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs)

� Normal day-night variation in illumination

� Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)

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Do earplugs help?Do earplugs help?Do earplugs help?Do earplugs help?Do earplugs help?Do earplugs help?Do earplugs help?Do earplugs help?

� Earplugs used from 2200Earplugs used from 2200Earplugs used from 2200Earplugs used from 2200----0600 hours0600 hours0600 hours0600 hours

� All patients

� NEECHAM scale used to assess delirium

� Earplug group had a lower proportion of patients Earplug group had a lower proportion of patients Earplug group had a lower proportion of patients Earplug group had a lower proportion of patients

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� Earplug group had a lower proportion of patients Earplug group had a lower proportion of patients Earplug group had a lower proportion of patients Earplug group had a lower proportion of patients with mild confusion or deliriumwith mild confusion or deliriumwith mild confusion or deliriumwith mild confusion or delirium

� EEEEffects were strongest in the first 48 hours after ffects were strongest in the first 48 hours after ffects were strongest in the first 48 hours after ffects were strongest in the first 48 hours after admissionadmissionadmissionadmission

CCM, 2012

Early Mobility (ABCDE) Early Mobility (ABCDE) Early Mobility (ABCDE) Early Mobility (ABCDE) Early Mobility (ABCDE) Early Mobility (ABCDE) Early Mobility (ABCDE) Early Mobility (ABCDE)

Awakening

BreathingEarly

Mobilty

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Choice of

Sedation

Delirium

Assessment

Mobilty

Early Exercise and Mobility Protocol

Progression

Active ROM (in bed)Active ROM (in bed)

Sit/ DangleSit/ Dangle

No Exercises, but Passive

Range of Motion

No Exercises, but Passive

Range of Motion

Pro

gre

ss a

s to

lera

ted

IC

U

Ex

erc

ise

RASS ≥ -3RASS ≥ -3RASS -5 / -4RASS -5 / -4

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Sit/ DangleSit/ Dangle

March/ WalkMarch/ Walk

TransferTransfer

Range of Motion allowed

Range of Motion allowed

Pro

gre

ss a

s to

lera

ted

IC

U D

isch

arg

e

Ex

erc

ise

scre

en

icudelirium.org

Pharmacologic InterventionsPharmacologic InterventionsPharmacologic InterventionsPharmacologic InterventionsPharmacologic InterventionsPharmacologic InterventionsPharmacologic InterventionsPharmacologic Interventions

No perfect No perfect No perfect No perfect

drug regimen!drug regimen!drug regimen!drug regimen!Haloperidol

Quetapine

108

Treatment forTreatment forTreatment forTreatment for

hypoactive patients?hypoactive patients?hypoactive patients?hypoactive patients?Risperidone

Olanzipine

AtypicalsAtypicalsAtypicalsAtypicalsAtypicalsAtypicalsAtypicalsAtypicals

RisperidoneRisperidoneRisperidoneRisperidone OlanzipineOlanzipineOlanzipineOlanzipine QuetapineQuetapineQuetapineQuetapine LoxapineLoxapineLoxapineLoxapine

DopamineDopamineDopamineDopamine +++ ++ + ++

SerotoninSerotoninSerotoninSerotonin +++ +++ + ++

AlphaAlphaAlphaAlpha----AdrenergicAdrenergicAdrenergicAdrenergic

++ + +++ +

109

AdrenergicAdrenergicAdrenergicAdrenergic

HistaminicHistaminicHistaminicHistaminicMuscarinicMuscarinicMuscarinicMuscarinic

+/- ++/++ +/+ -/-

EPSEPSEPSEPS +++ +++ + +

109Caballero, 2010

Stop and THINKStop and THINKStop and THINKStop and THINKStop and THINKStop and THINKStop and THINKStop and THINK

Do any meds need to be Do any meds need to be Do any meds need to be Do any meds need to be stoppedstoppedstoppedstopped or lowered?or lowered?or lowered?or lowered?

� Especially consider Especially consider Especially consider Especially consider sedativessedativessedativessedatives

� Is patient on minimal amount Is patient on minimal amount Is patient on minimal amount Is patient on minimal amount necessary? necessary? necessary? necessary?

Daily sedation cessation

TTTToxic Situationsoxic Situationsoxic Situationsoxic Situations• CHF, shock, dehydrationCHF, shock, dehydrationCHF, shock, dehydrationCHF, shock, dehydration• New organ failure (liver/kidney)New organ failure (liver/kidney)New organ failure (liver/kidney)New organ failure (liver/kidney)

HHHHypoxemiaypoxemiaypoxemiaypoxemia

IIIInfection/sepsis (nosocomialnfection/sepsis (nosocomialnfection/sepsis (nosocomialnfection/sepsis (nosocomial) ) ) )

IIIImmobilizationmmobilizationmmobilizationmmobilization

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� Daily sedation cessation

� Targeted sedation plan

� Assess target daily

� Do sedatives need to be Do sedatives need to be Do sedatives need to be Do sedatives need to be changed?changed?changed?changed?

� Remember Remember Remember Remember to assess for to assess for to assess for to assess for painpainpainpain!

IIIImmobilizationmmobilizationmmobilizationmmobilization

NNNNonpharmacologic onpharmacologic onpharmacologic onpharmacologic

interventionsinterventionsinterventionsinterventions• Hearing aids, glasses, reorient, Hearing aids, glasses, reorient, Hearing aids, glasses, reorient, Hearing aids, glasses, reorient,

sleep protocols, music, noise sleep protocols, music, noise sleep protocols, music, noise sleep protocols, music, noise control, ambulationcontrol, ambulationcontrol, ambulationcontrol, ambulation

KKKK+ or electrolyte problems+ or electrolyte problems+ or electrolyte problems+ or electrolyte problems

Consider antipsychotics after evaluating etiology & risk factorshttp://www.mc.vanderbilt.edu/icudelirium/terminolog y.html

Non-Pharmacological ProtocolOrientation

Provide visual and hearing aidsEncourage communication and reorient patient repetitivelyHave familiar objects from patient’s home in the roomAttempt consistency in nursing staff

EnvironmentSleep hygiene: Lights off at night, on during day.Sleep aids (extra dose of antipsychotic)?Control excess noise (staff, equipment, visitors) a t nightAmbulate or mobilize patients early and often

Clinical parametersMaintain systolic blood pressure >90 mmHg

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Attempt consistency in nursing staffAllow television during day with daily newsNon-verbal musicInvolve family in orientationEducate family about delirium

Maintain systolic blood pressure >90 mmHgMaintain oxygen saturation >90%Treat underlying metabolic derangements and infections

Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium

� Recognize /manage risk factors for every patientRecognize /manage risk factors for every patientRecognize /manage risk factors for every patientRecognize /manage risk factors for every patient

� UNIVERSAL PRECAUTIONS

� Establish reliable processesEstablish reliable processesEstablish reliable processesEstablish reliable processes

� Assess for delirium every shift

� Clarify who does “what” with information

� Integrate into existing documentation

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� Integrate into existing documentation

� Document compliance with standardized protocol for Document compliance with standardized protocol for Document compliance with standardized protocol for Document compliance with standardized protocol for management of deliriummanagement of deliriummanagement of deliriummanagement of delirium

� Support patients and families with deliriumSupport patients and families with deliriumSupport patients and families with deliriumSupport patients and families with delirium

� Reorientation

� Education of families

� Consider others to be part of the systemConsider others to be part of the systemConsider others to be part of the systemConsider others to be part of the system

� E.g., psychiatry, receiving floors116

Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium Change Concepts for Delirium ContinuedContinuedContinuedContinuedContinuedContinuedContinuedContinued

� Standardize clinical processesStandardize clinical processesStandardize clinical processesStandardize clinical processes

� Bundle elements

� ABCDE (sedation, early mobility)

� Pain and sedation assessment -

� Environmental controls

� Approach to patient

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� Approach to patient

� Medication reviews

� How to manage delirious episodes

� Manage handoffsManage handoffsManage handoffsManage handoffs

� Within the unit

� Beyond the unit

� Use family as information “brokers”

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118

118

119

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Bundle It All TogetherBundle It All TogetherBundle It All TogetherBundle It All TogetherBundle It All TogetherBundle It All TogetherBundle It All TogetherBundle It All Together

� Focus on nonFocus on nonFocus on nonFocus on non----pharmacologic strategiespharmacologic strategiespharmacologic strategiespharmacologic strategies

� 6 key items 6 key items 6 key items 6 key items –––– require conversation with bedside staff require conversation with bedside staff require conversation with bedside staff require conversation with bedside staff to determine if occurto determine if occurto determine if occurto determine if occur

1.1.1.1. Consider early mobilityConsider early mobilityConsider early mobilityConsider early mobility

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1.1.1.1. Consider early mobilityConsider early mobilityConsider early mobilityConsider early mobility

2.2.2.2. Optimize sleep Optimize sleep Optimize sleep Optimize sleep

3.3.3.3. Daily reassessment of sedation/ready to weanDaily reassessment of sedation/ready to weanDaily reassessment of sedation/ready to weanDaily reassessment of sedation/ready to wean

4.4.4.4. Involve family in management of deliriumInvolve family in management of deliriumInvolve family in management of deliriumInvolve family in management of delirium

1. Reorientation

2. Education on delirium

5.5.5.5. Provide communication adjunctsProvide communication adjunctsProvide communication adjunctsProvide communication adjuncts

6.6.6.6. Reassess restraintsReassess restraintsReassess restraintsReassess restraints120

SummarySummarySummarySummarySummarySummarySummarySummary

�Choose a tool that works forChoose a tool that works forChoose a tool that works forChoose a tool that works for

�Your stakeholders

�Your patient population

There is no perfect tool

121

�There is no perfect tool

�Integrate into existing systems Integrate into existing systems Integrate into existing systems Integrate into existing systems and processesand processesand processesand processes

�Standardize a management Standardize a management Standardize a management Standardize a management approachapproachapproachapproach

121

ANY QUESTIONS?ANY QUESTIONS?ANY QUESTIONS?ANY QUESTIONS?

122

ANY QUESTIONS?ANY QUESTIONS?ANY QUESTIONS?ANY QUESTIONS?

122

� CAMCAMCAMCAM----ICU vs. ICDSCICU vs. ICDSCICU vs. ICDSCICU vs. ICDSC� In a prospective observational study, both assessment tools (CAMIn a prospective observational study, both assessment tools (CAMIn a prospective observational study, both assessment tools (CAMIn a prospective observational study, both assessment tools (CAM----ICU and ICU and ICU and ICU and

ICDSC) were compared in aICDSC) were compared in aICDSC) were compared in aICDSC) were compared in a� medical and surgical ICU population for up to 7 days after ICU admission (10). medical and surgical ICU population for up to 7 days after ICU admission (10). medical and surgical ICU population for up to 7 days after ICU admission (10). medical and surgical ICU population for up to 7 days after ICU admission (10).

Delirium was found inDelirium was found inDelirium was found inDelirium was found in� 41% of patients as determined by a positive result from either test. Agreement 41% of patients as determined by a positive result from either test. Agreement 41% of patients as determined by a positive result from either test. Agreement 41% of patients as determined by a positive result from either test. Agreement

between tests was high,between tests was high,between tests was high,between tests was high,� with a kappa coefficient for agreement of 0.8. There was an 8% discrepancy with a kappa coefficient for agreement of 0.8. There was an 8% discrepancy with a kappa coefficient for agreement of 0.8. There was an 8% discrepancy with a kappa coefficient for agreement of 0.8. There was an 8% discrepancy

rate in deliriumrate in deliriumrate in deliriumrate in delirium----negativenegativenegativenegative

123

rate in deliriumrate in deliriumrate in deliriumrate in delirium----negativenegativenegativenegative� patients and 11% discrepancy in deliriumpatients and 11% discrepancy in deliriumpatients and 11% discrepancy in deliriumpatients and 11% discrepancy in delirium----positive patients. The study positive patients. The study positive patients. The study positive patients. The study

concluded that results of eitherconcluded that results of eitherconcluded that results of eitherconcluded that results of either� assessment method are comparable. (Class II)assessment method are comparable. (Class II)assessment method are comparable. (Class II)assessment method are comparable. (Class II)� While it may appear that the CAMWhile it may appear that the CAMWhile it may appear that the CAMWhile it may appear that the CAM----ICU had higher specificity than the ICDSC in ICU had higher specificity than the ICDSC in ICU had higher specificity than the ICDSC in ICU had higher specificity than the ICDSC in

clinical trials, the studiesclinical trials, the studiesclinical trials, the studiesclinical trials, the studies� validating CAMvalidating CAMvalidating CAMvalidating CAM----ICU excluded patients with neurological abnormalities whereas ICU excluded patients with neurological abnormalities whereas ICU excluded patients with neurological abnormalities whereas ICU excluded patients with neurological abnormalities whereas

the ICDSC trials did not.the ICDSC trials did not.the ICDSC trials did not.the ICDSC trials did not.� The CAMThe CAMThe CAMThe CAM----ICU questionnaire is more involved than that of ICDSC. Thus, based ICU questionnaire is more involved than that of ICDSC. Thus, based ICU questionnaire is more involved than that of ICDSC. Thus, based ICU questionnaire is more involved than that of ICDSC. Thus, based

on available evidence,on available evidence,on available evidence,on available evidence,� the scales have similar reliability, but the ICDSC may be a quicker and easier the scales have similar reliability, but the ICDSC may be a quicker and easier the scales have similar reliability, but the ICDSC may be a quicker and easier the scales have similar reliability, but the ICDSC may be a quicker and easier

tool to use.tool to use.tool to use.tool to use.

ICDSC ICDSC ICDSC ICDSC ICDSC ICDSC ICDSC ICDSC

1. Altered LOC1. Altered LOC1. Altered LOC1. Altered LOC1. Altered LOC1. Altered LOC1. Altered LOC1. Altered LOC

Consider the patient’s LOC over the entire Consider the patient’s LOC over the entire Consider the patient’s LOC over the entire Consider the patient’s LOC over the entire shiftshiftshiftshift

� Score 0 or 1 Score 0 or 1 Score 0 or 1 Score 0 or 1 in the in the in the in the LOC section #LOC section #LOC section #LOC section #1111

Use your sedation scale resultsUse your sedation scale resultsUse your sedation scale resultsUse your sedation scale results

124

Use your sedation scale resultsUse your sedation scale resultsUse your sedation scale resultsUse your sedation scale results

� If patient is heavily sedated/comatose, stop and record If patient is heavily sedated/comatose, stop and record If patient is heavily sedated/comatose, stop and record If patient is heavily sedated/comatose, stop and record “N/A” (patient cannot be assessed)“N/A” (patient cannot be assessed)“N/A” (patient cannot be assessed)“N/A” (patient cannot be assessed)

� If LOC is normal, score “0”If LOC is normal, score “0”If LOC is normal, score “0”If LOC is normal, score “0”

� If LOC is not normal, score “1” If LOC is not normal, score “1” If LOC is not normal, score “1” If LOC is not normal, score “1”


2. Inattention2. Inattention2. Inattention2. Inattention2. Inattention2. Inattention2. Inattention2. Inattention

� Score 1 point forScore 1 point forScore 1 point forScore 1 point for� Difficulty following conversation or instructions

OR� If easily distracted by external stimuli

OR� If difficulty shifting focus

125

� If difficulty shifting focus

� Score 0 (instead of 1) if inattention is due to recent Score 0 (instead of 1) if inattention is due to recent Score 0 (instead of 1) if inattention is due to recent Score 0 (instead of 1) if inattention is due to recent sedation or analgesiasedation or analgesiasedation or analgesiasedation or analgesia

� If undecided, does the patient follow you with their eyes?If undecided, does the patient follow you with their eyes?If undecided, does the patient follow you with their eyes?If undecided, does the patient follow you with their eyes?� Use Use Use Use SAVEAHAART from the CAMSAVEAHAART from the CAMSAVEAHAART from the CAMSAVEAHAART from the CAM----ICUICUICUICU


3. Disorientation3. Disorientation3. Disorientation3. Disorientation3. Disorientation3. Disorientation3. Disorientation3. Disorientation

� Score 1 point forScore 1 point forScore 1 point forScore 1 point for

� Significant mistake in person, place, or time

� Small errors may be understandable and should not score a point

126

� Does the patient recognize Does the patient recognize Does the patient recognize Does the patient recognize staff staff staff staff caring for him/her? caring for him/her? caring for him/her? caring for him/her?

� Recognition of family?Recognition of family?Recognition of family?Recognition of family?

� What kind of a place are you in? Provide examples What kind of a place are you in? Provide examples What kind of a place are you in? Provide examples What kind of a place are you in? Provide examples (mall, at work, hospital)(mall, at work, hospital)(mall, at work, hospital)(mall, at work, hospital)


4. Hallucinations or Delusions4. Hallucinations or Delusions4. Hallucinations or Delusions4. Hallucinations or Delusions4. Hallucinations or Delusions4. Hallucinations or Delusions4. Hallucinations or Delusions4. Hallucinations or Delusions


� Hallucination = perception of something that is not there (e.g. trying to catch something that isn’t there-with no stimulus)

OROROROR

� Delusion = false belief that is fixed/unchanging

127

� Delusion = false belief that is fixed/unchanging

� Ask the patientAsk the patientAsk the patientAsk the patient

� Are you having or have you had hallucinations?

� Are you afraid of the people or things around you? Is there a reason?

� Note: patient Note: patient Note: patient Note: patient recognition that they are having recognition that they are having recognition that they are having recognition that they are having hallucinations can be therapeutichallucinations can be therapeutichallucinations can be therapeutichallucinations can be therapeutic


5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation5. Psychomotor Agitation or Retardation

� Score 1 pointScore 1 pointScore 1 pointScore 1 point

� Hyperactivity requiring use of additional sedation or restraints to control for potential danger (such as pulling lines out, hitting staff)

� Hypoactive or clinically noticeable psychomotor slowing or retardation (delayed responses to

128

slowing or retardation (delayed responses to questions or commands)

� Score 0 (instead of 1) if patient’s Score 0 (instead of 1) if patient’s Score 0 (instead of 1) if patient’s Score 0 (instead of 1) if patient’s hypoactivityhypoactivityhypoactivityhypoactivity is due is due is due is due to recent sedation or analgesiato recent sedation or analgesiato recent sedation or analgesiato recent sedation or analgesia

� The presence of restraints does not automatically The presence of restraints does not automatically The presence of restraints does not automatically The presence of restraints does not automatically indicate hyperactivity!indicate hyperactivity!indicate hyperactivity!indicate hyperactivity!

ICDSC ChecklistICDSC ChecklistICDSC ChecklistICDSC ChecklistICDSC ChecklistICDSC ChecklistICDSC ChecklistICDSC Checklist

6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood6. Inappropriate Speech or Mood


� Inappropriate mood related to clinical events or situation

OR

� Inappropriate, disorganized or incoherent speech

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� Inappropriate, disorganized or incoherent speech

� Is the patient apathetic to current clinical situation? Is the patient apathetic to current clinical situation? Is the patient apathetic to current clinical situation? Is the patient apathetic to current clinical situation? (i.e. lack of emotion) (i.e. lack of emotion) (i.e. lack of emotion) (i.e. lack of emotion)

� Are there any gross abnormalities in speech or mood? Are there any gross abnormalities in speech or mood? Are there any gross abnormalities in speech or mood? Are there any gross abnormalities in speech or mood? � Is patient inappropriately demanding? Is patient inappropriately demanding? Is patient inappropriately demanding? Is patient inappropriately demanding? ;);););)


7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance7. Sleep/Wake Cycle Disturbance

� Score 1 point for Score 1 point for Score 1 point for Score 1 point for

� Sleeping less than 4 hours a night

OR

� Waking frequently during the night

OR

Sleeping greater than 4 hours during the day

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� Sleeping greater than 4 hours during the day

� Do not include wakefulness initiated by medical staff Do not include wakefulness initiated by medical staff Do not include wakefulness initiated by medical staff Do not include wakefulness initiated by medical staff or loud environmentor loud environmentor loud environmentor loud environment

� This emphasizes the need for improved nursing This emphasizes the need for improved nursing This emphasizes the need for improved nursing This emphasizes the need for improved nursing documentation of patient sleep while in the ICUdocumentation of patient sleep while in the ICUdocumentation of patient sleep while in the ICUdocumentation of patient sleep while in the ICU


8. Symptom Fluctuation8. Symptom Fluctuation8. Symptom Fluctuation8. Symptom Fluctuation8. Symptom Fluctuation8. Symptom Fluctuation8. Symptom Fluctuation8. Symptom Fluctuation


� Fluctuation of any of the above items (1-7) over 24 hours

� Consider fluctuation over the course of your shift Consider fluctuation over the course of your shift Consider fluctuation over the course of your shift Consider fluctuation over the course of your shift

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� Consider fluctuation over the course of your shift Consider fluctuation over the course of your shift Consider fluctuation over the course of your shift Consider fluctuation over the course of your shift

� BBBBetter to score later rather than during initial etter to score later rather than during initial etter to score later rather than during initial etter to score later rather than during initial assessmentassessmentassessmentassessment

Working Groups (Table Discussions):

Exploring Change Concepts in Detail

(Part One)(Part One)

Faculty & Facilitators

Purpose

• Summarize what has been learned during the Action

Period

• Answer questions about the Change Package

• Identify changes that are working and why• Identify changes that are working and why

• Discuss to move from single elements to multiple

elements


Change Package Worksheet

Change Concepts and Ideas Ideas Working & Why Ideas to Test

Recognize/manage/mitigate risk factors (prevention and reduction strategies) for every patient (“universal precautions”) • Identify pre-admission risk factors – hypertension, alcohol

consumption, APACHE II scores (very sick), cognitive impairment. AGE and GENDER are NOT factors for ICU patients (these are different than those admitted to the ward), use the ICU criteria not the ward criteria

• Manage sedation: daily sedation interruption + daily awakening, spontaneous breathing trials, use of sedation scales

• Manage the environment: visible daylight, discuss social supports, allow visitors, display calendar and clocks in the room, talk with the patient, observe sleep-wake cycles,

134Delirium and Med Rec Collaborative 5/28/2012

room, talk with the patient, observe sleep-wake cycles, allow familiar objects and family supports, avoid restraints

• Communicate the balance between comfort with harm reduction to all staff (e.g. more drugs may mean increased risk), empower nurses with the tools to balance these

• Target risk factors (advanced age, impaired cognition & functional status, sensory impairment, psychoactive drug/ETOH use)

• Optimize orientation and mobilization interventions (practice early mobilization), titration of analgesic, sedative and psychotropic medications, normal sleep, physiological homeostasis, appropriate communication methods

• Use general education strategies for staff on precipitating factors, impact of delirium on patient outcomes, length of stay and mortality, differentiate between pain & need for sedation

• Stop (meds) and THINK (Toxic Situations, Hypoxemia, Infection/sepsis nosocomial, immobilization, non-pharm interventions (hearing aides, glasses, reorient, sleep protocols, noise control, ambulation), K+/electrolyte problems

Logistics

• Split your team amongst Faculty tables

– Yoanna Skrobik

– Cathy Mawdsley

– Greg Duchscherer

– Claudio Martin

– Paule Bernier


Discussion Questions

• What questions do you have about the change

package? What needs clarification?

• What ideas have been tried in your centre? How did

it work? Why did it work? When did they not work? it work? Why did it work? When did they not work?

• What are some emerging issues?

136Delirium and Med Rec Collaborative 5/28/2012

Role of Medications in ICU Delirium

Clarence Chant, PharmD

St. Michael’s Hospital

Delirium in the ICU and MedicationsDelirium in the ICU and Medications

Clarence Chant , BScPhm PharmD, BCPS, FCSHP, FCCP

Clinical Pharmacy Specialist/Leader, St. Michael’s Hospital

Associate Scientist, Keenan Research Center of the Li Ka Shing Knowledge Institute

Disclaimer/Disclosure

• Hospira Dexmedetomidine Pharmacy Advisory Board 2011

• Adult ICU focus

Outline

• Background• Deliriogenic Medications• Medications and Prevention• Medications and Treatment• Medication Reconciliation and Delirium• Medication Reconciliation and Delirium

Delirium

• Disturbances of consciousness

• Inability to focus• Change in cognition• Perceptual

• Rapid onset (hours to days)

• Fluctuating course

• Perceptual Disturbances

DSM-IV

Assessment• CAM-ICU or ICU Delirium Screening Checklist (ICUDSC)• Others: Cognitive Test for delirium, NEECHAM scale, Delirium

detection score

• Similarities:– Dichotomous (not severity or impact of treatment)– Not prognostic– Does not account for underlying psychiatric illness

• Differences:– LOC assessment optional for CAM-ICU, mandatory step 1 for

ICU-DSC– Validation in patients with neurological injuries– Detection of hypoactive delirium

Intensive Care Med 2007;33: 929-940

Delirium – Outcome

Delirium = ICDSC ≥4

Coma = RASS -5

Intensive Care Med 2007; 33:66-73

Outline


Deliriogenic Medications

• Analgesics: (codeine, fentanyl, morphine, meperidine)• Antidepressants (Amitriptyline, paroxetine)• Anticonvulsant (phenytoin)• Antihistamine (chlorphenamine)• Antiemetic (prochlorperazine)• Benzodiazepine (lorazepam, midazolam)• Benzodiazepine (lorazepam, midazolam)• Cardiovascular agent (atenolol, digoxin, lidocaine,

dopamine)• Corticosteroids• Furosemide• Ranitidine

http://www.icudelirium.co.uk/deliriogenic-drugs/(accessed May 23, 2012)

Systematic Review

• Study design: of RCTs, prospective cohort and case-controlled studies– Exclude: retrospective studies, case series, case reports– Quality assessment (Newcastle-Ottawa checklist); used

for sensitivity analysis• Patient population: hospitalized or in LTC facility• Delirium diagnosis: DSM III/III-R or IV, or ICD 10 codes• Delirium diagnosis: DSM III/III-R or IV, or ICD 10 codes• Search: MEDLINE, EMBASE, PsychInfo, Allied and

Complementary medicine until October 2009• Study selection/data abstraction: NOT in duplicate

• 18767 results, 140 for detailed review, 14 met criteria/included

Age Ageing 2011;40: 23-29.

Systematic Review – ICU studies

Age Ageing 2011; 40: 23-29

Systematic Review – Medication Class

Age Ageing 2011; 40: 23-29

Benzodiazepine / Opioid

N=198 MICU or CCU patients; CAM-ICU (+)

Anesthesiology 2006; 104: 21-6

ICU (+)

Statistical modeling using amount of drug given in the past 24 hours

Variables use: age, sex, visual/hearing deficits, history of neuro disease (dementia, depression), APACHE II, sepsis, Hct, BG

Deliriogenic Medications - Summary

• Many extensive lists published• Mostly derived from case reports• Largely extrapolating from other patient population

(e.g. geriatric, orthopedic surgery)• Quality evidence lacking for most

– Multifactorial, and confounders not controlled– Multifactorial, and confounders not controlled– Benzodiazepine / opioid

• Routine universal avoidance not possible– Not appropriate in many cases (new ADR)– Systematic and individualized evaluation

Outline


Medications and Prevention

• Non-pharmacologic means-Spontaneous breathing trials-cognition/communication-mobility-bowels, feeds, fluid balances

• Appropriate sedation / analgesia management• Daily assessment of delirium• Specific preventative medications

Prevention - Haloperidol

• Hip surgery elderly (> 65) patients• Double blinded, placebo-controlled RCT• Haloperidol 1.5 mg PO daily vs Placebo

– from admission to POD #3 (max 6 days therapy)• Delirium assessed daily by Geriatric consult team

using DSM IV and CAM (not CAM ICU), and Delirium Rating Scale (for severity)Delirium Rating Scale (for severity)

• n=603 screened, 482 eligible, 430 randomized, 48 dropped out, 35 lost to follow-up

• Haloperidol reduced severity and duration, not incidence of delirium

JAGS 2005;53: 1658-1666

Prevention - Haloperidol

Haloperidol (n=212) Placebo (N=218)

Age 78 ± 6 80 ± 6

% female 81 79

APACHE II 13 ± 3 13 ± 3

Risk of delirium (moderate/high) (%)

84 / 16 83 / 16

Delirium + 32 (15.1%) 36 (16.5%)

DRS-Max score 14.4 ± 3.5 18.4 ± 4.4

Duration of delirium (days) 5.4 ± 4.9 11.9 ± 7.6

Hospital LOS 17.1 ± 11.1 22.6 ± 16.7

JAGS 2005;53: 1658-1666

Prevention - Olanzapine

• Knee/Hip replacement surgery elderly (> 65) patients

• Double blind, placebo-controlled RCT• Olanzapine 5 mg pre/post op vs Placebo• Delirium assessed daily by Geriatric consult team

using DSM IV and CAM (not CAM ICU), and Delirium Rating Scale (for severity)Delirium Rating Scale (for severity)

• N=4836 screened, 495 randomized, non-ITT: 400 analyzed

• Haloperidol reduced incidence, severity and duration, as well as delayed onset of delirium

Psychosomatics 2010;51: 409-418

ICU Prevention - Risperidone

• n=126 (>40) elective post CV surgery ICU patients• Double blinded, placebo-controlled, concealed RCT• Risperidone ODT 1 mg upon awakening X 1vs Placebo

(listerine strip)– Standardized post-op analgesia and sedation protocol

• Delirium assessed daily CAM ICU

• N=126 (no CONSORT diagram)• Risperidone prevented delirium (11 vs 32%, NNT=5)• No difference in any other outcomes• Logistic regression did not include treatment

assignment????

Anaesth Intensive Care 2007; 35: 714-9

ICU Prevention - Rivastigmine

• n=120 elderly (>65) post CV surgery ICU patients• Double blinded, placebo-controlled RCT• Rivastigmine 1.5 mg po daily for 3 days vs Placebo

– Standardized post-op analgesia and sedation protocol• Delirium assessed daily CAM ICU

• N=348 screened, 120 randomized, non-ITT n=113 analyzed

• No difference found in any of the outcomes assessed

Crit Care Med 2009; 37: 1762-8

ICU Prevention - Haloperidol

• n=457 elderly (>65) post non-CV surgery ICU patients

• Double blinded, placebo-controlled, multicenter• Haloperidol 0.5mg IV bolus then 0.1mg/h X 12 hrs

vs Placebo– Standardized post-op analgesia and sedation – Standardized post-op analgesia and sedation

using PCA, RASS, and Daily awakening• Delirium assessed daily CAM ICU

• N=1346 screened, 608 eligible, 457 randomized

Crit Care Med 2012; 40: 731-9

ICU Prevention - Haloperidol

Haloperidol (n=229) Placebo (N=228)

Age 74 ± 6 74 ± 7

% female 37 37

ASA Class II/III/IV (%) 63 / 35 / 1 59 / 39 / 2

Delirium + 35(15.3%) 53 (23.2%)

Delirium-free days 6.8 ± 0.5 6.7±0.8Delirium-free days 6.8 ± 0.5 6.7±0.8

Hospital LOS post-op 11 (10-12) 11 (10-12)

Crit Care Med 2012;40:731-9

Adjusted OR for delirium = 0.57 ; 95% CI=0.35-0.94

Medications & Prevention: Summary

• Many non-pharmacologic strategies• Intertwined with sedation/analgesia management

- Strategies for sedation/analgesia should be followed first

- Risperidone or Haloperidol (?Olanzapine) may be - Risperidone or Haloperidol (?Olanzapine) may be effective in prevention- Single study with some methodological issues- Surgical ICU patients - Risk vs benefits

Outline


Medications and Treatment

• Typicals:– Haloperidol, Loxapine ,(methotrimeperazine)

• Atypicals – Olanzapine, quietiapine, risperidone

• Antagonizes multitude of receptors in CNS– Dopamine, serotonin, histamine, alpha

adrenergic• Minimal respiratory effects• Minimal dependence/addictive potential

Antipsychotic - ADR

Haloperidol Loxapine Risperidone Olanzapine Quetiapine Z iprasidone

Sedation >2 >30 >10 >30 >30 >10

EPS >30 (?) >10 <2 <2 <2 >2

↑ QTc >2 (low) ?? <2 <2 <2 <2 (low)

↑ glucose >10 >2 >10 >30 >30 >2

Anti-Ach >2 >10 >10 >30 >30 >10

DP ++++ +++ ++++ +++ ++ ++++

H1 + +++ +++ ++++ +++ +++

α1 +++ +++ ++++ +++ ++++ +++

5HT2A +++ ++++ ++++++ ++++ +++ +++++

Clinical Handbook of Psychotropic Drugs, 18th edition

Antipsychotic - Evidence

Crit Care Med 2010; 38:428-437; Crit Care Med 2010; 38;419-427; Intensive Care Med 2004;30: 444-449; Harv Rev Psychaitry 2011;19:59–67

Which agent?

• Selection largely based on:- Urgency of control- Personal experience- Side effect profile- Patient’s previous response / regimen- Patient’s previous response / regimen- Evidence

Dexmedetomidine (Precedex)

• “new” central alpha-2 receptor agonist• Sedation / anxiolysis (analgesic) without

respiratory depression• May be associated with less delirium

- MENDS (JAMA 2007; 298: 2644-2653)- MENDS (JAMA 2007; 298: 2644-2653)

- SEDCOM (JAMA 2009;301:489-9)

- PRODEX (JAMA 2012; 307: 1151-1160)

Outline


Medication Reconciliation & Delirium

• Response to psychotropic agents largely unpredictable and individualized– Resume previous home regimen

• Both antipsychotics and other psychotropics for other indications

– Previous regimen for other neurologic disease – Previous regimen for other neurologic disease gives clues to which agent to use

• Withdraw of psychotropic medications– Benzodiazepines, opioids, SSRI

Perceptions and Realities

• 259/457 US pharmacists • Routinely discussed delirium on rounds → 50%• Routinely treated agitation with medications → 85%

– Use 2 medications → 65%• Drug of first choice:

– Haloperidol (85%), Atypicals (14%), BZD (10%), – Dexmedetomidine (0.5%)

• At least daily ECG if on Haloperidol (44%)• At least daily ECG if on Haloperidol (44%)

• Haloperidol: 42% thought there was RCT evidence, 34% thought FDA-indicated

• Quetiapine: 40% (RCT Evidence) and 8% (FDA-indicated)

Ann Pharmacother 2011; 45: 1217-29

Closing thoughts

• Delirium still a “new topic” with misconceptions– associated with poor outcomes– effects of treatment on important outcomes unknown but

routinely done– little ICU data ; extensive extrapolation from outpatient

psychiatric data • Haloperidol EPS and Route

• Closely linked to sedation/analgesia• Closely linked to sedation/analgesia• Maybe (likely) preventable• Medication reconciliation definite role (may reduce use of

treatment agent)• Multi-factorial in nature and supports standardization via

institution protocols/guidelines

Collaborative Simulation:

The Tennis Ball ExerciseThe Tennis Ball Exercise

Bruce Harries

Collaborative Director

Simple Rules

• Patient flows through the process from Tallest to

Shortest provider

• Patient must touch every step (provider) in the

processprocess

• Process begins with “GO”

• Process ends when shortest successfully receives

patient and yells “DONE”

• If anyone “drops the ball” (error), apologize to

patient and start over


Measurement

• Appoint a measurement person

• Develop operational definitions:

– Record time as “Seconds between GO and DONE”

– Record errors as “Number of Drops”– Record errors as “Number of Drops”

– Record provider satisfaction as “% of Thumbs Up”


Team Action

• At “Go” run current process

• Record your baseline data


We Need to Improve

(Better Performance Exists)(Better Performance Exists)

Join the Collaborative

(There is a Solution)

Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?


Act Plan

Study DoSource: Associates in Process Improvement

5/28/2012

Improvement Charter

• What are we trying to accomplish (aim)?

– To reduce amount of time tennis ball (patient) spends in the system with minimal errors.

• How will we know that a change is an improvement (measures)?(measures)?

– Reduce total time

– Provider satisfaction

– # of Errors

• What changes can we make that will lead to improvement?

– See change package


Simple Measurement

• Plot data on an annotated run chart

Time Errors Satisfaction


Day Day Day

5/28/2012

Change Concepts

“What the Experts Know”

• Do tasks in parallel

• Reorder steps

• Move steps closer together

• Remove bottlenecks and constraints• Remove bottlenecks and constraints

• Minimize handoffs

• Combine steps

• Work with suppliers


Plan 1st PDSA Cycle

Plan:•State objectives.

•Make predictions

•Make conditions

explicit.

•Develop plan (5 W’s,

How)

Act:•Adopt, adapt or

abandon based on

what was learned.

•Build knowledge

into next PDSA Cycle


Do:•Carry out the test.

•Document problems,

surprises, and

observations.

•Begin analysis.

Study:•Complete analysis, synthesis

•Compare data to predictions.

•Record under what

conditions results could

be different.

•Summarize what

was learned.

5/28/2012

Tennis Ball Simulation Aim & Goal: To reduce time tennis ball (i.e. patient) spends in the system by 50% while reducing errors and increasing staff satisfaction. Measures: Baseline Goal Total Time _____ seconds between GO and DONE 50% reduction Errors _____ drops 0 drops Provider Satisfaction _____ % thumbs up 100% thumbs up Change Concepts: Do tasks in parallel Reorder steps Move steps closer together

Remove bottlenecks and constraints Minimize handoffs

Combine steps Work with suppliers

PDSA CYCLE #

PLAN What change is being tested?

What is prediction & theory?

DO Test prediction

Collect data

Record observations

STUDY Plot & interpret data

Was prediction correct?

What did you learn?

ACT What action will you take (adopt, adapt, abandon)?

Example

Plan: have a coordinator Prediction: reduce time and errors Theory: Centralizing control to sequence the activities will improve flow

18 seconds (up from 10 seconds) with 2 drops 20% satisfied Mass confusion!

Prediction incorrect – increased time and errors Coordinator adds complexity and resources

Abandon Try another change concept

1 Plan:

Delirium and Med Rec Collaborative 182 Page 1 Improvement Associates Ltd.

Prediction:

Theory:

2 Plan:

Prediction:

Theory:

3 Plan:

Prediction:

Theory:

5/28/2012

Team Action

• At “Go” run test cycles

• Plot your data on your run chart

• Complete Monthly Report


1st Collaborative Call

• Learn from other teams with similar problems

• What is working for other teams?

• How have they adapted the change ideas

successfully?successfully?

• Pick a common change idea and each try different

ways to adapt it


Team Action

• At “Go” run test cycles

• Complete monthly report


Action Period Activities

• Continue to test

• Record data, observations and learning

• Learn from each other by participating on conference

calls, online community and list serve discussionscalls, online community and list serve discussions

• Submit monthly report– Changes tested

– Results achieved

– Accomplishments

– One to share, one to ask


Tennis Ball Game

• What did you observe?

• What surprised you?


Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?


Act Plan

Study DoSource: Associates in Process Improvement

Lessons Learned

• Concept of PDSA cycle(s)

• Appropriate scale of PDSA cycles

– Small test of change?

– Quick test of change?– Quick test of change?

• It’s about rate of learning, not speed of the PDSA

cycle

• Use of PDSA in collaborative environment

• Common knowledge → practice


Lessons Learned (continued)

• Importance of measurement

• Data for learning, not research

• Multiple measures may be important

• Teamwork issues• Teamwork issues

• Power of collaboration

• Significance of a failed test


This Collaborative

• What are the important activities for your team?

• How will your team make sure they happen?


Change and Improvement

• Every system is perfectly designed to produce the

results it gets. Performance is not simply a matter of

effort; it is a matter of design. – Donald Berwick, MD, Institute for Healthcare Improvement

• All improvements require change but not all changes • All improvements require change but not all changes

are improvements.– Associates in Process Improvement


Overview of Collaborative Progress,

Results and OpportunitiesResults and Opportunities

Bruce Harries

Collaborative Director

Collaborative Progress

• What progress has your team made?


A Sample of Results – Outcome Measures

Incidence of Delerium

40%

Pts. Unable toAssess

Cam Positive

0.15

0.2

0.25

% DELIRIOUS


0%

20%

14-Feb-12 28-Feb-12 13-Mar-12

Cam Positive

Source: Saskatoon Health Region

0

0.05

0.1

0 2 4 6

% DELIRIOUS

Source: Hotel Dieu

A Sample of Results – Outcome Measures (continued)


Source: Medicine Hat

Process Measures

20

40

60

80

100% compliance with ICDSC completion each shift

3

4

5

6

7

8

9

Number Scored ≥ 4

≥ 4


0

Source: Edmonton Zone - UAH

0

1

2

3

19-Dec-11 19-Jan-12 19-Feb-12 19-Mar-12 19-Apr-12

Collaborative Self – Assessments


Action Period Activities

Teams are :

• Getting organized and re-organized – 13 of 18 teams posted

Improvement Charters to the CoP

• Trying and testing ideas – PDSA Cycles posted to the CoP

• Gathering, using and reporting data, locally or to PSMS

• Starting to show positive results for one or more goals

• Sharing documents and questions through Team Calls, CoP and list

serve


Some Ideas Being Tried

Risk

Factors

Assess

(CAM-ICU)

Assess

(ICSDC)

Protocol

Mgmt

Support

Pts & Fam

Same

system

Change

Work EnvStdize

Mge

Handoffs

Reliable

Processes

Education/

Training

1 ��

2 ��

3 ��

4 ��

5

6

7 ��

Change Concepts - Med RecChange Concepts - Delirium Change Concepts - General


7 ��

8

9 ��

10 ��

11 ��

12

13

14 ��

15 ��

16 ��

17 ��

18

19

20

Collaborative Activities


Staying Connected

30

40

50

Number of Posts to CoP


0

10

20

30

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Mar

-13

# of

Pos

ts

Month

Real-Time Assessment

0 Non-Starter

Team formed. Aim determined. Team attended Learning Session 1.

1 Activity but No Testing

Team engaged in data collection and developing changes. No tests of change or evidence of

testing within last month.

2 Modest Improvement

Testing has begun. There is anecdotal evidence of improvement.

3 Improvement

Implementation has begun. Improvements have reached 50% of at least one goal.

4 Significant Improvement

100% of at least one goal is reached.

5 Outstanding Sustainable Results

Targets exceeded. Changes spread to larger system.


Challenges & Opportunities

• What challenges has your team faced?


Challenges & Opportunities

• Connect the aims from the charter to the measures and begin getting data

• Decide what questions need to be answered and use these as the basis for each PDSAthese as the basis for each PDSA

• Engage staff and others by having them develop and test ideas

• Start testing now!


Rapid Fire Presentations

Selected Teams

Order

Delirium:

• Saskatoon

• Grey Nuns Community Hospital

• University of Alberta Hospital• University of Alberta Hospital

Med Rec

• Thunder Bay Regional Health Sciences Centre


Storyboards & Networking

ReceptionReception

All Teams, Faculty and Guests

Questions to Run On

• What are 1 or 2 ideas that stood out for you?

Examples you could use and adapt?

• What continues to be challenging?

• Find an example of where data supported the team • Find an example of where data supported the team

learning….

• One person stay at storyboard, rotate


Day 2 Reminders

• Breakfast is at 7:00 am

• Session starts at 8:00


Funded & Supported By

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