Don`t Get Delirious Take Sleep Serious Reducing Delirium in the ICU

Don’t Get Delirious: Take Sleep Serious
Reducing Delirium in the ICU
Deb Baker, RN, BSN, CCRN
Kim Connly, RN, BSN, CCRN
Cathie Manning, RN, BS, CCRN
Linda Pellegrino, RN, BSN, CCRN
Coaches: Paula Lusardi, RN, PhD, CNS
Susan Scott, RN, MSN, CCRN
 Level 1 Trauma Center in Western Massachusetts
 716-bed Academic Medical Center
 16-bed MICU/16-bed SICU
 Magnet Designated® Hospital for Nursing Excellence
 Beacon Award for Excellence
Purpose and Goals
To decrease delirium by:
The Nurse’s Pledge:
CAM-ICU
THE ABCDE BUNDLE
TREAT PAIN
THINK SMART. REDUCE DELIRIUM
RASS EVERY 4
HOURS
Promote Sleep
THINK
T Toxins
H Hypoxia
I Immobility,Infection
N Nonpharmacologic
K K -electrolytes
EARLY AMBULATION
 Promoting sleep
 Increasing collaboration
Sleep 1-4AM
Nap 2PM-4PM
NO
BENZO’S
Lights OFF
Reduce Noise
Cluster care
Change
electrodes @ 10PM
IMPROVE COLLABORATION: Discuss SLEEP,
RASS GOALS & CAM-ICU on rounds and in report
ICU
ROCKS
Delirium = Acute Brain Dysfunction
 Delirium is an acute change in consciousness that is
accompanied by inattention and either a change in
cognition or perceptual disturbance.1
 60%-80% of patients who are mechanically ventilated have
delirium.2-4
 It is frequently undetected by health care providers.5-8
 Confusion Assessment Method for the ICU
(CAM-ICU) is one of the most valid and
reliable delirium-monitoring tools.2-4,9
6
Delirium: Bad for Patients
 30% of ICU survivors experience clinically significant
depression.10
 15%-40% may experience post traumatic stress disorder.10
 Longer durations of delirium in the hospital are associated
with worse global cognition and executive function scores
at 3 and 12 months.6
 Delirium has real-life consequences.
Delirium: Bad for Business
 $4 to $16 billion is the annual cost of delirium.4,6,9,11-12
 The incremental cost for total the episode of care is
$8,199.13
 Each additional day having delirium increases risk of
prolonged hospitalization by 20%.14
 Increases ventilator days
 Increases mortality
Sleep
 Almost all medical disorders and injuries can cause sleep
disturbances during acute care hospitalizations.
 Adults typically have 4-5 sleep cycles of 60-110 minutes.
 Promotion of sleep and use of an interdisciplinary team
approach is specifically recommended to reduce
delirium.15
Interdisciplinary ICU Team Approach
MD
Champion
RN
Champion
Family
RT
Champion
Hospital
Leadership
PT/OT
Champion
Nutrition
Champion
Pharmacy
Champion
Journey to Interventions
Enrolled in CSI Academy
Met with senior leadership stakeholders
Used measurement tools for data collection
 Nursing survey
 Delirium rate using CAM-ICU tool
 Measured decibel levels in MICU/SICU
Planned lecture and video
Video: Sleepless in the ICU
 Signed contract with marketing department for video
 Wrote original lyrics and script
 Hired music composer
 Engaged choreographer for the dance
Staff Engagement
 Attached M&Ms to nursing survey
 Slogan contest
 Open casting call for stars and
dancers
Kickoff Lecture and Video
Lecture
 Delirium and sleep facts
 Introduced THINK mnemonic
 Emphasized Clinical Practice Guidelines for the
Management of Pain, Agitation and Delirium to promote
sleep
 Reduce noise
 Control light
 Cluster care activities
 Decrease nocturnal stimuli
Red Carpet Event
https://www.youtube.com/watch?v=vv3W20POzNw&list=UULfwo_7M8Mf2m5hPwUJmzjQ
Nursing Survey Results
 More than 50% of staff responded
 Four-point Likert scale used
 Sample of responses:
 “I consider lack of sleep a risk factor for delirium”
— 100% answered yes before and after interventions
 “I decrease stimuli in room to promote sleep or nap”
— 60% compared to 40% responded ALWAYS
 “The physicians value the CAM-ICU data”
— 13% improvement
Collaboration Outcomes
 CAM-ICU on Multidisciplinary Rounds Sheets
 Sleep listed on Multidisciplinary Rounds Sheets
 THINK poster placed outside each patient’s room to
refer to during rounds discussion
 Physicians asked for nursing
input on development of
CAM-ICU RASS
SLEEP
delirium protocol
THINK
Nightime Decibel Readings
 Environmental Protection Agency recommends avoiding
noise levels above 45dB in hospitals.16
 World Health Organization recommends noise levels lower
than 35dB for daytime and lower than
30dB at night.17
Nurses’ Station 0100-0400
 Noise levels less
90
than 55dB are
80
recommended for 70
60
16
intellectual work.
50
40
30
20
10
0
Average
High
Low
April 2013 Jan 2014
MICU
MICU
April 2013 Jan 2014
SICU
SICU
Fiscal Outcomes
 5% less CAM-ICU+ scores in the MICU
 0.05 x $8,199 (total incremental cost per patient)18 = $409.95
 $409.95 x 2,100 (annual census) = $860,895 annual savings
CAM-ICU POSITIVE EVENTS
50%
49%
48%
47%
46%
45%
44%
43%
42%
41%
April 2013
Jan 2014
Future Plans and Sustainability
 Audit sleep interventions
 Obtain monthly delirium rates
 Ongoing education of nurses and physicians
 Reinforce the use of ABCDE bundle within ICU team
 Share information
 Other critical care units in Baystate Health Systems
 Hospital-wide Delirium Group
 YouTube
CSI Academy Investment
 CSI Academy’s belief in the value of investing in frontline
nurses has had a profound effect on us and the imprint of
this experience has forever changed us as professionals.
 We gained insight regarding the process of change from
both a unit and organizational level.
 We have become change agents.
References
1.
2.
3.
4.
5.
6.
7.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.
Washington, DC: American Psychiatric Publishing; 1994.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the
confusion assessment method. A new method for detection of delirium. Ann Intern Med.
1990;113(12):941-948.
Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and
reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA.
2001;286(21):2703-2710.
Lin SM, Liu CY, Wang CH, et al. The impact of delirium on the survival of mechanically
ventilated patients. Crit Care Med. 2004;32(11):2254-2259.
Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after
elective noncardiac surgery. JAMA. 1994;271(2):134-139.
Pisani MA, Murphy TE, Van Ness PH, Araujo KL, Inouye SK. Characteristics associated with
delirium in older patients in a medical intensive care unit. Arch Intern Med. 2007;167(15):16291634.
Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and
evaluation of delirium in hospitalized elderly medical patients. Am J Med. 1994;97(3):278-288.
References
8.
Sanders AB. Missed delirium in older emergency department patients: a quality-of-care
problem. Ann Emerg Med. 2002;39(3):338-341.
9. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of
the Confusion Assessment Method for the Intensive Care Unit (CAMICU). Crit Care Med.
2001;29(7):1370-1379.
10. VUMC Center for Health Services Research. ICU delirium and cognitive impairment study
group. 2013. http://icudelirium.org/outcomes.html. Accessed October 1, 2013.
11. Pandharipande P, Cotton BA, Shintani A, et al. Prevalence and risk factors for development of
delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65(1):34-41.
12. Mcnicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care
unit: occurrence and clinical course in older patients. J Am Geriatr Soc. 2003;51(5):591-598
References
13. Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium in mechanically
ventilated patients. Crit Care Med. 2004;32(4):955-962.
14. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically
ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753-1762.
15. Barr J, Pandharipande PP. The pain, agitation, and delirium care bundle: synergistic benefits of
implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and
interdisciplinary fashion. Crit Care Med. 2013;41(9 suppl 1):S99-S115.
16. Information on levels of environmental noise requisite to protect public health and welfare
with an adequate margin of safety, Report No. 5509-74-004, Environmental Protection Agency,
Office of Noise Abatement and Control (Government Printing Office), Washington DC (1974).
17. Berglund B, Lindvall T, Schwela DH. Guidelines for community noise. World Health
Organization, Geneva, Switzerland. 1999.
18. Research Triangle Institute for Center for Medicare & Medicaid Services. Analysis report:
Estimating the incremental costs of hospital-acquired conditions (HACs). 2012.
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/index.html. Accessed April 1, 2014. (Click Incremental Updated
Cost Report).