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Hospital Acquired Delirium and Weakness:
Our Journey at The Nebraska Medical Center
Rose Buckingham MSN
Kelly Goetschkes MSN
Objectives
• Describe what delirium is and common
risk factors
• Identify common symptoms, and implications
of delirium for the hospitalized adult
• Summarize TNMC ICU Outcomes Study results
and what we learned going forward
• Describe the Interdisciplinary Delirium Plan for
the Prevention, Early Identification, &
Treatment of delirium at TNMC
THE PATIENT STORY OF
NANCY ANDREWS
Google: Nancy Andrews delirium
Delirium Causes
Cognitive Impairment
in both older and younger patients
•
Pandharipande PP, N Engl J Med. 2013. Long-term cognitive impairment after critical illness. 369(14):1306-16.
Delirium: A Never Event?
Maybe not yet……BUT
Blankenship, C. (2008). Non-payment of never events: Implications for practice. American Health Lawyers Association,
11(2)
WHAT IS DELIRIUM?
(Acute Confusional State)
Definition:
• acute decline in attention and cognition
Characteristics:
•
•
•
•
common problem
serious complications
often unrecognized
may be preventable
Delirium Hypotheses
Reasoning proposed to explain physical
effects manifested in the patient.
Maldonado, J.R., (2008).
Neurotransmitter
Hypothesis
Cell Signaling Hypothesis
Neuronal Aging
Inflammatory Hypothesis
Physiological Stress
Decreased cholinergic function with excess release of
dopamine, norepinephrine, and glutamate. Decreased or
increased levels of serotonergic (fluctuating levels
correspond to the different symptoms seen in the clinical
presentation hypo- hyper- or mixed active presentation )
Fundamental process of disruption to intra-neuronal signal
transduction which greatly disturb neurotransmitter
synthesis and release.
Proposes that elderly patients are at increased risk of
developing delirium due to age related cerebral changes in
stress-regulating neurotransmitter and intracellular signal
transduction systems.
Increased cerebral secretions of cytokines as a result of
widespread physical stresses lead to development of
delirium by their effect on multiple neurotransmitter
systems.
Trauma, severe illness, and surgery lead to modifications to
blood brain barrier permeability.
“Delirium” is rarely called by name!
– Altered mental
status
– Dementia
– Confusion
– ICU Psychosis
– Sundowners
– Acute Confusional
State
Symptoms you see with Delirium
• Thinking is slow and
muddled
• Hallucinations/delusion
30%
• Sleep/wake reversal
• Mood swings
• Psychomotor
disturbances: 2 forms
– Hyperactive – agitation or
picking behaviors
– Hypoactive - lethargy or
sleepy
Inouye,SK NEJM 2006
Hyperactive
1.4%
Mixed
31.1%
Hypoactive
67.6% of all
delirium
Bellelli, G., Speciale, S., Barisione, E., &
Trabucchi, M., (2007)
Patients with Delirium have…
Longer Length of Stay 21 vs. 9 days
Discharge to a SNF 47% vs. 18%
at 6 months
43% vs. 8%
at 15 months
33% vs. 11%
Develop Dementia
at 48 months
63% vs. 8%
American Delirium Website, 2013
A Growing Problem
2015 = 40.2 M
2050 = 88.5 M
U.S. Department of Health and Human Services
(2013)
Seniors currently
make up 49% of
all hospital
inpatient days in
the U.S.
Fearing, M.A. & Inouye, S.K., (2009). Delirium. Focus,
7(1), 229-241.
U.S. Delirium Costs: $143-$152B/Yr
• $16,303 to $64,421 additional
per delirious patient.
• U.S. cost-of-care directly
attributed to delirium ranges
from $143 to $152 billion
•
Leslie, D.L. & Inouye, S.K. (2011). The importance of delirium: economic and societal
costs. J am Geriatr Soc, 59(Suppl 2), S241-S243.
Delirium Cost is about 2.5X’s Higher than
Non-delirious Counterparts
Estimated to occur in > 2.3M inpatients/year = 17.5M inpatient days
Cardiac Surgery Study:
•
Additional cost post-op delirium was $6,150/pt
(Ebert, 2001)
Step-down Critical Care Unit:
•
14% developed delirium & stayed 9.2 days longer
•
Costing $28,000/case = $5,880,000/year
(Maldonado, Dhami, 2003)
Cardiac Surgery Prevention Study:
•
Non-delirious $6,763 and Delirious $12,965
(Maldonadom Wysong, 2003)
ICU Patients:
•
Costs were 31% higher: $41,836 vs. $27,106
(Milbrandt, 2004)
Hospitalized Elderly Patients:
•
Cost from $16,303 to $64,421 per patient
(Leslie, 2008)
( Rizzo,2001)
)
IMPACT OF DELIRIUM
Extends Beyond the Hospital
Post-hospital costs
(>$100 B/yr)
• Institutionalization
• Rehabilitation
• Home care
• Caregiver burden
Ref: Leslie DL et al. Gerontologist 2005: 45 (Spec Iss II): 299.
5 patients become delirious
in US Hospitals every minute
Delirium Rates
Hospital:
• Prevalence (on admission)
• Incidence (hospital-acquired)
• Postoperative:
• Intensive care unit:
10-40%
15-60%
15-53%
70-87%
U.S. Dept HHS, AoA Report, Profile of Older Americans, 2011
Medical Populations
Prevalence of
Delirium (%)
Medical Populations
Prevalence of
Delirium (%)
General Medical
9-24
Hospitalization Admission
15 -23
HIV/AIDS
30-40
In nursing homes
15-60
Medical ICU
60-80
Frail elderly patient
60
Post-stroke
13-48
Elective hip or knee
replacement
25
Post-operative Delirium
10-74
Bilateral knee replacement 41
General Surgical Units
7-52
Femoral neck fracture
repair
65
Spine surgery
12.5
General Oncology
25-40
Post-CABG
25-32
Palliative Care Units
26-44
Post-Cardiotomy
50-67
Bone Marrow Transplant
73
Abdominal Aneurysm
repair
33
Advanced Cancer
Up to 85
Out-patient minor
(cataract) surgery
4.4
Psychiatric patients
14.6
Maldonado, Critical Care Clinic, 2008; 24:657-722
Patient Vulnerability + Severity of
Precipitating Risk Factor is WHY One
Patient Develops Delirium, while a
Similar Patient Does Not.
Up to 40% of Hospital-Acquired
DELIRIUM is PREVENTABLE
• Common problem
• Often unrecognized
• Typically of
multifactorial
etiology
• Serious
complications
• Often preventable
(40-50% cases)
DELIRIUM IS OFTEN CONFUSED
WITH DEMENTIA
Delirium is NOT Dementia
Feature
Delirium
Dementia
Onset
Acute
Gradual, usually insidious, but depends
on cause
Course
Short, diurnal symptom fluctuations;
worse at night and on awakening
Long; No diurnal effects, progressive,
but relatively stable over time
Progression
Abrupt
Slow, but even
Duration
Hours to days; Up to 6 months
Months to years
Awareness
Reduced
Clear
Alertness
Fluctuates ; lethargic or hyper vigilant
Generally normal
Attention
Impaired; fluctuates
Generally normal
Orientation
Fluctuates in severity; generally
impaired
May be impaired
Memory
Recent and immediate impaired
Recent and remote impaired
Thinking
Disorganized, distorted, fragmented,
slow or accelerated, incoherent
Difficulty with abstraction, makes poor
judgments, word finding difficulty
Perception
Distorted; Illusions, delusions, &
Misperceptions often absent
hallucinations; difficulty distinguishing
between reality and misperceptions
fluctuations
RELATIONSHIP OF DELIRIUM TO
DEMENTIA
Two Sides of the Coin
Delirious patients 8X’s risk to get
dementia.
(Davis,2012)
>50% dementia patients develop
delirium & have a 25%
increased risk of dying within
30 days.
(Fick, 2013).
Probability of transitioning to
delirium increases
dramatically (by 2%) for each
year of life after 65 years.
(Pandharipande, 2006)
The Duration of delirium is an
independent predictor of long-term
cognitive impairment.
(Girard et al., CCM 2010)
Patient Factors
Predisposing Disease
Older age
Alcohol/drug use
Functional dependence
Male gender
Living alone
Depression
Dehydration
Vision/Hearing impaired
Cardiac disease
Cognitive impairment
Hx Delirium or dementia
Pulmonary disease
Pain poorly controlled
Liver/Renal disease
HIV
Environment
Admission via ED or
through transfer
Isolation/No visitors
No clock
No daylight
Noise
Use of physical restraints
Tethers
Sleep deprivation
Inouye SK, et al. JAMA .1996;275:852.
Skrobik Y. Crit Care Clin. 2009;25(3):585-591.
Less
Modifiable
Acute Illness
DELIRIUM
More
Modifiable
Length of stay
Fever/Infection/Sepsis
Cardiac/Hip surgery
Medicine service
Malnutrition
Hypotension
Metabolic disorders
Tubes/catheters/tethers
Medications:
- Anticholinergics
- Corticosteroids
- Benzodiazepines
Van Rompaey B, et al. Crit Care 2009;13:R77.
Devlin J, et al. ICM, 2007; 33:929-940.
I’ve seen a dying eye
Run round and round a room
In search of something, as it seemed,
Then cloudier become;
And then, obscure with fog,
And then be soldered down,
Without disclosing what it be,
‘Twere blessed to have seen.
Emily Dickinson
DELIRIUM IS OFTEN UNRECOGNIZED
NURSES’ RECOGNIZE DELIRIUM
ONLY 31% of the time
Inouye SK, Arch Intern Med. 2001;161:24672473
Brief-Confusion Assessment Method (B-CAM) &
Confusion Assessment Method (CAM-ICU)
SIMPLIFIED DIAGNOSTIC CRITERIA
4 features assessed by B-CAM:
(1) inattention
(2) acute onset or fluctuating course
(3) altered level of consciousness
(4) disorganized thinking
-- The diagnosis of delirium requires the
presence of criteria: (1), (2) and (3) or (4)
RASS Description
+4 Overtly combative, violent,
immediate danger to staff
+3 Very agitated, pulls or
removes tube(s) or catheter(s);
aggressive
+2 Agitated, frequent nonpurposeful movement
+1 Restless, anxious but
movements not aggressive
vigorous
0 Alert and calm
-1 Drowsy, not fully alert, but
has sustained awakening
(>10 seconds)
-2 Light sedation, briefly
awakens with eye contact to voice
(<10 seconds)
-3 Moderate sedation,
movement or eye opening to
voice
(but no eye contact)
(Han et al., 2013)
What to THINK if + for delirium
Toxic Situations
 CHF, shock, dehydration
 Deliriogenic meds (tight titration, sedative choice)
 New organ failure, e.g., liver, kidney
Hypoxemia; also, consider giving Haloperidol or
other antipsychotics
Infection/sepsis (nosocomial), Immobilization
Nonpharmacological interventions
 Hearing aids, glasses, reorient, sleep protocols, music, noise control,
ambulation
K+ or Electrolyte problems
DELIRIUM IN THE ICU
ABCDE Bundle Outcomes Study at TNMC
Outcomes/benefits identified in patients with bundle
use in TNMC ICU’s:
• Patients spent 3 more days ventilator free
• 15% fewer ICU patients experienced delirium
(incident delirium)
• 17% reduction in ICU days spent delirious
(prevalent delirium)
• Odds ratio showed risk of developing delirium
reduced by almost half
• 18% more patients mobilized
• 2.1 times increased odds of being mobilized
• 8.6% reduction in the hospital mortality rate
From this study we learned that
•
•
•
•
Need to further lighten sedation
Choice of sedation
Provider use of order set
Nursing education closer to implementation &
targeted
• Need for tighter pain assessment
• Importance of Early Mobility
Awakening
ICU
Spontaneous Awakening Trial
Non-ICU
A- Awakening
Medications:
– Pharmacy consult medication review
– Poly-pharmacy taking 5 or more
medications or 3 new started in 1 day
– Review high-risk medications.
Sleep Hygiene:
– Promote and try non-pharmacological
options first.
– Progressive mobility. Avoid bed rest
orders unless medically necessary.
– We want our patients oriented to
day/night sleep patterns and tired at night.
– Promote private room with a view to the
outside, lighting appropriate to time of day
– Enforce quiet hours and nursing unit noise
reduction.
American Association of Critical Care Nurses, Delirium Assessment and Management.
2014. Retrieved from: http://www.aacn.org/wd/practice/content practicealerts/deliri
um practice-alert.pcms?menu=practice
Breathing
ICU
Spontaneous Breathing Trial
Non-ICU
B-Breathing
• Hypoxia or risk of pulmonary
complications:
– Monitor and optimize oxygen
saturation levels
– Cough and deep breathe;
promote use of incentive
spirometer
– Provide more frequent oral
care pre-op/immobile patients
to decrease the risk of hospital
acquired pneumonia.
– Speech Consult for patient
aspiration concerns
American Association of Critical Care Nurses, Delirium Assessment and
Management. 2014. Retrieved from: http://www.aacn.org/wd/
practice /content practicealerts/deliri um practice-alert.pcms?menu
=practice
Coordination/Communication
AND/OR Choice of Sedation
ICU
• Coordination,
Communication and Choice
of Sedation
Non-ICU
C-Coordination and Communication:
– Communicate/intervene with
ABCDE care plan interventions for
patients at high risk for hospital
acquired complications including
delirium, falls, skin breakdown,
dehydration, weakness,
pneumonia, and DVT’s.
– Communicate to involve/inform
significant others.
– Offer patient educational and
safety hand-outs and videos.
– Encourage family/caregiver
involvement and visitation.
American Association of Critical Care Nurses, Delirium Assessment and
Management. 2014. Retrieved from: http://www.aacn.org/wd/ practice
/content practicealerts/deliri um practice-alert.pcms?menu =practice
Delirium Prevention, Screening, and
Management
ICU
Non-ICU
• CAM-ICU
• Educate family to report
cognitive changes & provide
educational handouts
D-Delirium Prevention and
Management
–
–
–
–
Determine your patient’s baseline
cognitive status.
Prevention is basic good nursing care
tailored to meet each individual patient’s
needs.
Delirium is multi-factorial, balanced and
governed by exposure to noxious stimuli
and each individual’s unique ability and
reserve to cope with it.
Assess both non-modifiable and
modifiable risk factors and consider these
along with precipitating factors that may
cause delirium that are part of the hospital
experience when you tailor the ABCDE
interdisciplinary care plan.
American Association of Critical Care Nurses, Delirium Assessment and
Management. 2014. Retrieved from: http://www.aacn.org/wd/ practice
/content practicealerts/deliri um practice-alert.pcms?menu =practice
Early Mobility
ICU
• Progressive mobilization of
critically ill patients as early
as possible
Non-ICU
E-Early Mobility:
–
–
–
–
–
–
–
Progressive mobilization plan on day one
to preserve, maintain, and enhance the
patient’s functional ability.
Up in the chair X3 meals. Ambulation tid is
a nursing unit expectation.
Confused patient use video monitoring
and bed/chair alarm
Mobilize your patient as soon as possible
after surgery.
Schedule toileting with hourly rounds. Use
bathroom or BSC rather than bedpan.
Keep the commode beside the bed.
Stay with delirious patients they will not
always follow commands to use the call
light.
Assess pain level and administer analgesics
to allow for progressive activity. Provide
mobility aids as needed.
American Association of Critical Care Nurses, Delirium Assessment and
Management. 2014. Retrieved from: http://www.aacn.org/wd/ practice
/content practicealerts/deliri um practice-alert.pcms?menu =practice
ICU delirium and early mobility
• “Kim”- 25 yo SAH from OSH arrived
intubated with some complications.
• Intubated several days
• Q 1 hour neuro checks and strict
bed rest for 35 days.
It can be done!
Morris PE, Goad A, Thompson C, et al: Early
intensive care unit mobility therapy in the
treatment of acute respiratory failure. Crit
Care Med 2008; 36:2238–2243
Schweickert WD, Pohlman MC, Pohlman AS,
et al: Early physical and occupational therapy
in mechanically ventilated, critically ill patient
A randomised controlled trial. Lancet
2009; 373:1874–1882
Early Mobility and the Hemorrhagic
Stroke Patient
Discharge Disposition for Hemorrhagic Stroke Patients
Pre-Implementation
of the PUMP-PLUS
N = 46
Post-Implementation
of the PUMP-PLUS
N = 28
% of patients
Skilled Nursing
Facility [SNF]
6
% of patients
13.04%
SNF
2
7.14%
Long-Term Acute Care
[LTAC]
3
6.52%
LTAC
1
3.57%
Inpatient
Rehabilitation
[REHAB]
20
43.48%
REHAB
13
46.43%
HOME
17
36.96%
HOME
12
42.85%
Comparison of Discharge Disposition
chi square
Discharge Disposition
Pre
Post
X
df
p
Home
17
(18.03)
12
(10.97)
0.2543
1
0.6141
Other
29
(27.97)
16
(17.03)
Comparison of Mean LOS
two tailed t
Pump-Plus Protocol
n
M
SD
t
df
p
46
20.3
15.51
0.582
72
0.562
28
18.4
10.33
Pre-Implementation
Post-Implementation
Early Mobility and the SAH Patient
The Comprehensive Delirium Initiative is:
An Always Event
Our goal at TNMC is the prevention, early
identification, and reversal of hospital acquired
delirium.
• Laying a foundation for partnering with patients and
their families
• Leading to actions for an optimal patient experience
and improved outcomes
• A unifying force demonstrating an ongoing
commitment to person- and family-centered care
Hayward M, Endo J, Rutherford P. A Focus on "Always Events." Healthcare
Executive. 2014 Jan/Feb;29(1):78-81.
The Plan for TNMC
• Risk Prediction tool on admission – coming
• Delirium Brief-CAM Screen by nursing once a
shift for early identification
• New Delirium MD Order Set
• Extended ABCDE Bundle to the Non-ICU
nursing units for both prevention and
treatment interventions
• Only treatment for delirium is to identify the
causative agent and reverse it
Balas,M (2013). J Gerontol Nurs 39(8): 39-51.
Create an Action Plan
List 1 thing on your
evaluation sheet
that increases the
risk of delirium
where you work
THAT COULD
REALISTICALLY BE
CHANGED RIGHT
NOW
Create a Wish List
List at least 1 thing on your evaluation sheet that
you would like to make available to your patients
to reduce delirium where you work.
Conclusions
• Delirium is a significant problem for hospitalized
patients and a predictor of many negative clinical
outcomes.
• Reliable and easy tools are available for identification
of delirium in patients in the ICU and Non-ICU nursing
units.
• Processes of care are available to minimize incidence of
modifiable risk factors.
• Extended ABCDE Bundle can be incorporated into
current practices with minimal additional resources.
• Some operational culture change is involved
The End... Questions?
It is not enough for a great nation to merely
have added new years to life
Our objective must also be to add new life to
those years
- John F. Kennedy
References
American Association of Critical Care Nurses (2014). Delirium Assesment and Monitoring. Retrieved from:
http://www.aacn.org/wd/practice/content/practicealerts/delirium-practicealert.pcms?menu=practice
American Delirium Society Webite. Retrieved June 1, 2013 http://www.americandeliriumsociety.org/
Balas M, Buckingham R, Braley T, Saldi S, Vasilevskis EE. (2013). Extending the ABCDE Bundle to the post-intensive care unit
setting. J Gerontol Nurs. 39(8):39-51. doi: 10.3928/00989134-2013053006.
Balas, M.C., Vasilevskis, E.E., Olsen, K.M., Schmidt, K.K., Shostrom, M.S., Cohen, M.Z., Peitz, G.,
Gannon, D.E., Sisson, J.,
Sullivan, J., Stothert, J.C., Lazure, J., Nuss, S.L., Jawa, R.S., Freihaut, F., Ely, E.W., & Burke, W.J. (2014). Effectiveness and
safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
Crit CareMed Jan 3. [Epub ahead of print]
Bellelli G, Speciale S, Barisione E, Trabucchi M. (2007). Delirium subtypes and 1-year mortality amongelderly patients discharged
from a post-acute rehabilitation center J Gerontol A Biol Sci Med Sci 62 (10): 1182-1183
Blankenship, C. (2008). Non-payment of never events: Implications for practice. American Health Lawyers Association, 11(2): 1-5.
Davis, D.H.J, Terrera, G.M., Keage, H., Rahkonen, T., Oinas, M., Matthews, F.E., Cunningham, C., Polvikoski, T., Sulkava, R.,
MacLullich, A.M., & Brayne C. (2012). Delirium is a strong risk factor for dementia in the oldest-old: a population based
cohort study. Brain.135(Pt9):2809-16. doi: 10.1093/brain/aws190.
Devlin, J.W., Fong, J.J., Fraser, G.L., (2007). Tools for diagnosing delirium in the critically ill. Intensive Care Med 33:929–940.
Ebert, A.D., Walzer, T.A., Huth, C., & Herrmann, M. (2001). Early neurobehavioral disorders after cardiac surgery: A
comparativeanalysis of coronary artery bypass graft surgery and valve replacement. Journal of Cardiothoracic and
VascularAnesthesia (15)1: 15-19.
Fearing, M.A. & Inouye, S.K., (2009). Delirium. Focus, 7(1), 229-241.
Fick, D.M., DiMeglio, B., McDowell, J.A., & Mathis-Halpin, J. (2013). Do you know your patient? Knowing individuals with
dementia combined with evidence-based care promotes function and satisfaction in hospitalized older adults. Journal of
Gerontological Nursing 39(9):2–4. doi:10.3928/00989134-20130809-89.
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R.S., Bernard, G.R., Ely, E.W. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of
criticalillness. Crit Care Med. 38(7):1513-20. doi: 10.1097/CCM.0b013e3181e47be1.
Inouye, S.K., (2006). Delirium in older persons. N Engl J Med 354: 1157-65.
Inouye S.K., Foreman, M.D., Mion, L.C., Katz, K.H., & Cooney, L.M. (2001). Nurses' recognition of delirium and its
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Han, J.H., Wilson, A., Vasilevskis, E.E., Shintani, A., Schnelle, J.F., Dittus, R.S., Graves, A.J., Storrow, A.B., Shuster, J., & Ely,
E.W., (2013). Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage
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delirium in the elderly population. Arch Intern Med, 168(1):27-32
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References
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incidence of ICU delirium in postcardiotomy patients. J Psychosom Research, 55, 150, 2003.
Marcantonio, E.R. (2012). Postoperative delirium: a 76-year-old woman with delirium after surgery. JAMA. 308(1), 73-81.
Milbrandt, E.B., Deppen, S., Harrison, P.L., Shintani, A.K., Speroff, T., Stiles, R.A.,Truman, B., Bernard, G.R., Dittus, R.S., &
Ely, E.W. (2004). Costs associated with delirium in mechanically ventilated patients. Crit card Med (32)4: 955-962.
Morris P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., et al. (2008). Early intensive care unit mobility
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373, 874–1882.
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for delirium in intensive care patients: a prospective cohort study. Crit Care 13:R77
PRECIPITATING FACTORS OR INSULTS
Drugs
Sedative hypnotics
Narcotics
Anticholinergic drugs
Polypharmacy
Alcohol or drug withdrawal
Primary neurological diseases
Stroke, particularly nondominant
hemispheric
Intracranial bleed
Meningitis/encephalitis
Environmental
Intensive care unit admission
Physical restraint use
Bladder catheter use
High number of procedures
Pain
Emotional stress
Prolonged sleep deprivation
Inouye SK. NEJM 2006;354:1157-65
Inter-current illnesses
Infections
Iatrogenic complications
Severe acute illness
Hypoxia
Shock
Fever/hypothermia
Anemia
Dehydration
Poor nutritional status
Low serum albumin
Metabolic derangements (e.g., electrolytes,
glucose, acid-base)
Surgery
Orthopedic surgery
Cardiac surgery
Duration of cardiopulmonary bypass
Non-cardiac surgery
54
PREDISPOSING OR VULNERABILITY FACTORS
Demographics
Older age
Male gender
Cognitive status
Dementia
Cognitive impairment
History of delirium
Depression
Functional status
Functional dependence
Immobility
Poor activity level
History of falls
Sensory impairment
Vision impairment
Hearing impairment
Inouye SK. NEJM 2006;354:1157-65
Decreased Intake
Dehydration
Malnutrition
Drugs
Multiple psychoactive drugs
High number of drugs
Alcohol abuse
Medical Comorbidity
High severity of illness
High level of comorbidity
Chronic renal or hepatic disease
Previous stroke
Neurologic disease
Metabolic derangements
Fracture or trauma
Terminal illness
HIV infection