The Webinar will begin at 2:00 PM PDT.

Michele Balas, PhD, RN, CRNP, CCRN
University of Nebraska Medical Center

Michele C. Balas PhD, RN, APRN-NP, CCRN
Assistant Professor
University of Nebraska Medical Center, College of Nursing mbalas@unmc.edu

University of Nebraska Medical Center
OBJECTIVES
• Describe the importance of delirium monitoring in the
ICU setting
• Define the 4 delirium features assessed by the CAM-
ICU
• Demonstrate performance of CAM-ICU administration
• Provide case studies of delirium assessment using the
CAM-ICU
• Discuss strategies for successful CAM-ICU implementation

University of Nebraska Medical Center
ICU DELIRIUM
WHY SHOULD WE CARE?
1.70-87% Mechanically ventilated ICU patients
2.50-80% Surgical/Trauma/Burn ICU
3.20-50% Non mechanically ventilated ICU
• Independent predictor of higher ICU, hospital, & longterm mortality rates
• 3 fold ↑ risk at 6 months
•Each day delirious ↑ 10% mortality!!!!!!

University of Nebraska Medical Center
ICU DELIRIUM
WHY SHOULD WE CARE?
•Outcomes
• ICU & hospital LOS
• Poor functional recovery
• New institutionalization
• Multiple complications
• Long-term cognitive impairment
• Cost
•
(38-152 BILLION $$ annually!!!!)

University of Nebraska Medical Center
ICU DELIRIUM
WHY SHOULD WE CARE?
• PTSD
• Depression
• Anxiety
• Sleep disorders
• Need for caregiver assistance

THE PROBLEM………..
• Recognition
•Weinert et al. (2007) CCM
•85% of 18,050 evaluations had sedation (N=274)
•1 in 3 unarousable (32%)
•1 in 5 no spontaneous motor activity
(21%)
•Only 2.6% of providers thought patients were “oversedated”!!!!!!

University of Nebraska Medical Center
WHAT IS DELIRIUM?-DSM IV DEFINITION
• Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention
• A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia
• The disturbance develops over a short period of time (usually hours to days) & tends to fluctuate during the course of the day
• There is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition

University of Nebraska Medical Center
WHAT IS THE CAM-ICU
• Bedside assessment tool intended for use by nonpsychiatrists (i.e. ICU RNs, MDs, RTs, PT/OT)
• Adapted from original CAM, for use in critically-ill, nonvocal (i.e. mechanically ventilated) patients
• Delirium defined in terms of 4 diagnostic features
1.
Feature 1-Acute onset or Fluctuating Course
2.
Feature 2-Inattention
3.
Feature 3-Altered level of consciousness
4.
Feature 4-Disorganized thinking
• Delirium is present when patient displays features 1
AND 2 and either 3 OR 4

University of Nebraska Medical Center
TRUST ME
CAM-ICU QUICK & EASY
LESS THEN 90 SECONDS TO ADMINISTER

University of Nebraska Medical Center
STEP 1
ADMINISTER RASS
•Determine if you can even administer the CAM-ICU
•Consciousness=arousal level
+ content
•“Are the lights on?”
•Use valid & reliable sedation/arousal tool (i.e. the
RASS)

University of Nebraska Medical Center

University of Nebraska Medical Center
STEP 2
ADMINISTER CAM-ICU
• To every patient except if they are comatose (i.e.
RASS -4 or -5)
• You do NOT have to assess all 4 features (only those needed to determine if they are delirious)
• Delirium= Feature 1 AND Feature 2 AND either
Feature 3 OR 4
• Good news-you have already assessed for
Feature 3

What is the CAM-ICU?

University of Nebraska Medical Center
FEATURE 1
MUST HAVE!!!!!
• Has the patient had an acute change from mental status baseline?
OR
• Has the patient’s mental status fluctuated during the past 24 hours?
__________________________________________
• If both of these questions are answered NO,
STOP you are done. The patient is NOT delirious!

University of Nebraska Medical Center
FEATURE 1
MUST HAVE!!!!!
FAQs
• How do you determine mental status baseline?
• Do you always use same baseline?
• How do you handle a permanent change of baseline during hospitalization?
• Does it still count as fluctuation if patient is receiving sedatives?

University of Nebraska Medical Center
FEATURE 2
MUST HAVE!!!!!
• Inattention
• “Squeeze my hand when I say the letter A”
1. SAVEAHAART
• Errors=No squeeze with “A” & squeeze on letter other than “A”
• Feature 2 is present if the patient has >2 errors
• If inattention is NOT present, STOP you are done. The patient is NOT delirious!

University of Nebraska Medical Center
FEATURE 2
MUST HAVE!!!!!
•Alternate Inattention
Assessment-
• Use of Pictures
• Step 1-5 pictures
•
Step 2-10 pictures
• Scoring

University of Nebraska Medical Center
FEATURE 2
MUST HAVE!!!!!
FAQs
• If the patient is RASS -3 or very lethargic, is the CAM-
ICU unable to assess? Is the patient delirious?
• Do I have to do both the letters & pictures on every patient?
• How do I get the pictures?
• Are there other letter sequences I could use to assess
Feature 2?

University of Nebraska Medical Center
FEATURE 3
MUST HAVE EITHER THIS FEATURE
OR FEATURE 4
• Altered Level of Consciousness
• Assess with RASS
• Feature is PRESENT when patient scores anything other than a RASS of O (i.e. alert)
• If Features 1, 2 & 3 are deemed present,
STOP you are done, the patient is delirious
(CAM-ICU positive)

University of Nebraska Medical Center
FEATURE 3
MUST HAVE EITHER THIS FEATURE OF
FEATURE 4
FAQs
• Is feature 3 positive in coma?
• What is the difference between Feature 3 and
Feature 1?
• What if we use a different sedation assessment scale?

University of Nebraska Medical Center
FEATURE 4
MUST HAVE EITHER THIS FEATURE OF
FEATURE 3
• Disorganized thinking
• 2 steps
• Step 1-Questions
• Will a stone float on water?
• Are there fish in the sea?
• Does 1 pound weigh more than 2 pounds?
• Can you use a hammer to pound a nail?

University of Nebraska Medical Center
FEATURE 4
MUST HAVE EITHER THIS FEATURE OF
FEATURE 3
• Step 2-Command
1.
“Hold up this many fingers” (Hold up 2 fingers)
2.
“Now do the same thing with the other hand” (Do not demonstrate)
3.
OR“Add one more finger” (If patient is uanble to move both arms)
• Feature 4 is present if there is >1 error for the combined
Questions & Command
• If Features 1, 2 & 4 are deemed present, STOP you are done, the patient is delirious (CAM-ICU positive)

University of Nebraska Medical Center
FEATURE 4
FAQs
• How frequently do you have to assess for this
Feature?
• If the patient answers the 4 questions correctly, do you still assess the command?
• Is there an alternate set of questions?

University of Nebraska Medical Center
CASE STUDY #1
Mrs G. is a 65 y/o admitted for acute respiratory failure. She lives independently in her own home, is active in her church, and still drives herself everywhere. You walk into the room and she looks at you immediately. She appears anxious as she is being ventilated with BIPAP. Her arms are restrained and she is pulling at them to get her BIPAP mask off. Her lowest RASS in the previous 24 hours was –2, and highest RASS was +2. She scored 5 on the Letters of Feature 2. She answers 2 questions correctly and follows the commands of Feature 4.

University of Nebraska Medical Center
CASE STUDY #4
You enter the room of a 78 y/o cardiac patient you have been seeing over several days. She lives at home and cares for her husband. She has been RASS -1 to 0 and CAM-ICU negative for the past 48 hours. She is RASS 0 this morning and greets you by saying “How do you think I look?” You exchange pleasantries about how she is doing today. She answers 2 questions correctly, follows commands but gets 6 letters and 5 pictures correct.

University of Nebraska Medical Center
CASE STUDY #2
Your 80 y/o patient was successfully weaned from the ventilator and extubated at 0800 after abdominal surgery. He is alert and calm since all sedation and analgesia had been stopped earlier in the morning. Yesterday evening and last night he had periods of agitation with a documented RASS of
-1 to +3. He lives with family due to physical limitations with mobility but is still cognitively intact. He correctly answers all the questions and is able to identify the number of fingers the interviewer holds up and follows the command. He squeezes correctly on all the letters.

University of Nebraska Medical Center
CASE STUDY #3
You enter the room of a 65 y/o patient you enrolled 2 days ago after she had emergency abdominal surgery. She is still on the ventilator, her eyes are closed, she does not open her eyes to verbal stimuli but does respond to physical stimuli. She was on paralytics and has been off them for 24 hours. She is still receiving sedatives. She has been RASS -
5 to -2 over the past 24 hours. She is unable to follow any commands. Prior to surgery she had just retired from her teaching job.

University of Nebraska Medical Center
ISSUES IN IMPEMENTATION
FAQs
• Can I use the CAM-ICU outside the ICU?
• Can I use the CAM-ICU in my Neuro unit or with patients with TBI?
• Can I perform a CAM-ICU on a patient with known dementia?
• Can I use the CAM-ICU in patients having
ETOH withdrawal?

University of Nebraska Medical Center
ISSUES IN IMPEMENTATION
FAQs
• How do I perform the CAM-ICU with non-
English speaking patients?
• How do you identify delirium in the depressed patient?
• When should pharmacologic treatment for delirium be discontinued?
• Is it necessary to assess for all 4 features of delirium on every patient?

University of Nebraska Medical Center
ISSUES IN IMPEMENTATION
FAQs
• How frequently should I administer the CAM-ICU?
• My patient is CAM-ICU negative, but is still acting delirious. What does this mean?
• Do I need to do all 4 Features in order?
• How should I document the CAM-ICU?
• Should I do the CAM-ICU before or after an SAT?
• How do I know if my staff is performing the CAM-
ICU correctly?

University of Nebraska Medical Center
RESOURCES
• All information contained in this presentation was retrieved from the website: www.icudelirium.org
1. CAM-ICU training manual
2. Case studies
3. Spot check forms
4. Example documentation forms
5. CAM-ICU/RASS pocket cards available upon request
• Coming soon“ICUsurvivors.com”
• Supported by grant funds through the RWJF INQRI program