Joseph Brant Memorial Hospital
(JBMH)
Delirium in Critical Care
Background
• JBMH chose to participate in the ICU Collaborative in
January 2012 with the intent of learning best practices to
provide quality care when screening, assessing and
treating the critical care patient for delirium. Prior to this
JBMH did not have these processes in place for the
critical care patient
• Involvement of the inter-professional critical care
team members was deemed necessary to identify
these processes to achieve best patient outcomes
and to sustain validated delirium prevention
practices
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Aim
• Develop education for ICU staff regarding delirium
definition, prevention and management within 12 months
• Implement a delirium screening process for all ICU
patients within 6 months
• Tabulate incidence of delirium within 6-8 months
• Implement standardized delirium prevention
interventions for all ICU patients within 12 months
• Implement standardized interventions for the
management of patients identified with delirium within 12
months
• Implement strategies to include families of patients with
delirium within 12-18 months
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Team Members
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Intensivist: Dr Stephanie Robbins
ICU Manger: Geoff Flannagan
JBMH Sponsor: Jill Randall Director Critical Care
Critical Care Educator: Jackie Adcock
RNs: Sandra Pagani, Ashley Robertson, Kristy Stouck
Pharmacist: Poobalan Nayiager
RT: Laurie Taplin
PT: Katie Williams
SLP: Kalen Paulson
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Results
Screening for Delirium
Education was provided about the definition
of delirium and the use of the Intensive Care Delirium
Screening Checklist (ICDSC) tool
Intensive Care Delirium Screening Compliance Rate
JBMH ICU 2012
100%
The ICDSC is to be completed
each shift and prn for all ICU patients
The goal is for 100% of ICU patients to be screened
for delirium. The audit reveals an average of 80%
Increased frequency of audits is required to validate
findings
% Compliance
Chart audits to determine whether ICDSC tools
were completed once a month over 4 months
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
9-Jul
Strategies to improve consistency of completion
of ICDSC on all ICU patients need to be explored
% Compliance
9-Aug
9-Sep
9-Oct
Months
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Results
Positive Delirium Scores
Positive delirium scores are determined by an
ICDSC score of 4 or more
Charts were audited to discover how many
patients had a positive ICDSC score
The audit reveals an average of just over 2
patients (out of 14) over the 4 months scoring
positive for delirium
As the audits were only performed once a month
over 4 months a true picture for incidence of
delirium likely was not realized
Number of Patients with Positve ICDSC Score
Positive ICDCS Score JBMH ICU 2012
4.5
4
3.5
3
2.5
Positive
Score
2
1.5
1
0.5
0
9-Jul
Availability of resources to provide more
consistent auditing has been a challenge
We will continue to consider ways of procuring
valid and consistent data collection and
measurement
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9-Aug
9-Sep
9-Oct
Changes to be Tested
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Delirium education has been provided to all ICU team members
Delirium posters are displayed throughout the ICU that define delirium, speak to
causes and the ABCDE bundle
ICDSC and RASS score templates are laminated on all ICU RN desks outside patient
rooms
RNs are to document the RASS and ICDSC on all ICU patient flow sheets each shift
The daily goal sheet used at rounds each day was revised to include RASS and
ICDSC scores
At daily patient rounds since May 2012 ICU patients are identified as being positive or
negative for delirium via the ICDSC tool
The team at rounds reviews the medications of the patient that is positive for delirium
with a view of eliminating deliriogenic medications such as benzodiazepines and
considers adding Seroquel or Haloperidol as appropriate
Other interventions to reduce delirium discussed at rounds are SBTs and mobilization
goals for the day
New ventilator orders have daily wake and wean interventions and eliminated
Midazolam infusion
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Lessons Learned
• We need the participation of the whole Critical Care Team to
promote consistency and sustainability of delirium strategies
• Some ICU staff do not complete the RASS and ICDSC scores each
shift on their patients which prohibits identifying and treating those
with delirium
• Increased frequency of audits is required to validate findings
• Availability of resources to provide more consistent auditing has
been a challenge
• It is difficult to mobilize our patients consistently as our PT
availability is only 5 hrs Mon-Tues-Thurs-Fri
• It can be difficult to keep momentum for delirium with other
competing projects
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Next Steps
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We need to continue be more compliant with completing ICDSC on all ICU
patients
Audits for completion of ICDSC and incidence of delirium need to continue
Delirium status for all ICU patients must be discussed at daily rounds
Non-pharmacological delirium prevention interventions to be added to the
ICU admission orders
Patient orders set for delirium in critical care need to be explored
A mobilization protocol for ICU patients needs to be developed with
Intensivist, Educator, RN, RT and PT as leads
We need to create noise reduction awareness posters in the ICU for staff,
patients and families
We have a highly visible board in the ICU that provides education on
delirium and we will add data on delirium audits (ICDSC compliance and
incidence of delirium)
Continue to learn strategies for delirium prevention and treatment in critical
care
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