EBP Respiratory
I came across this study promoting no sedation for mechanically ventilated patients.
The study, originally published in 2010, demonstrated that patients who were not sedated during mechanical ventilation had a reduced length of mechanical ventilation as well as a reduction in both the ICU and hospital length of stay. Critics of the study stated that morphine, which was used for pain relief in the un-sedated control group, was used as a pseudo-sedation, suggesting that there was no real difference in patients’ consciousness between the two groups. In addition, critics pointed out that un-sedated patients would increase workload of nurses significantly adding cost to the hospital. This criticism prompted the authors of the study to present new data collected during the original trial.
The new data presented the results from the tool (Richmond Agitation and Sedation Scale [RASS]) used to assess the patients’ level of consciousness in both the sedated and un-sedated group. The results showed that the un-sedated group had significantly lower RASS scores than the sedated group demonstrating that there was a big difference in LOC between the groups. In addition, the authors presented the results from the tool used to measure the workload of the nurses (Nursing Care Recording System) which demonstrated that the work load of the nurses did not significantly increase when caring for un-sedated patients.
This study demonstrated that less sedation for a mechanically ventilated patient can mean better outcomes for the patient, cost efficiency for the hospital, and no perceived increase of workload to the nurse. I am curious to ask the nurses and MDs at VCMC about this topic. Check it out!
http://onlinelibrary.wiley.com.summit.csuci.edu:2048/doi/10.1111/nicc.12161/full
Laerkner, E., Stroem, T., & Toft, P. (2016). No-sedation during mechanical ventilation: impact
on patient’s consciousness, nursing workload and costs. Nursing In Critical Care, 21(1), 28-
35 Doi:10:1111/nicc.12161
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ICU Delirium from the Patient Perspective
This is a youtube video I came across that is a really interesting discussion about ICU delirium from the patient experience. Please watch. Great follow up and closure to last week.
Delirium in Hospitals Overlooked
If you’ve ever visited a family member or friend in the hospital it is an overwhelming emotional scene with the amount of machinery, loud constant noises, code calls over the intercom, and staff going in and out of the room. Not to mention the increase concern you have for your loved one, it can make anyone one in their right mind go delirious for that brief moment. Now imagine being one of those patients, critically ill, in bed most of the day where their physical, emotional, and mental abilities that have become altered. It came to my surprise that over 7 million Americans out of about 36 million of hospital admissions have been affected by cases of delirium each year (Boodman, 2015)
Delirium is a “sudden disruption of consciousness and cognition marked by vivid hallucinations, delusions, and an inability to focus”. It occurs suddenly and typically fluctuates throughout the day. One patient mentioned his delirium being like nightmares, although he knew that he was in the hospital and was sick he could not awaken from this terrible reality even after 3 years of being discharged from the hospital (Anthony Rossum, 2014). Some patients with delirium can be agitated and combative while other are lethargic and inattentive (Boodman, S., 2015), which makes me wonder, how many patients I have worked with in the hospital, whom had these horrible experiences and were silent about it. It wasn’t until recently that delirium was recognized or understood said Dr. Wes Ely from Vanderbilt University. Nearly, two thirds of Ely’s patients from the ICU reported signs of delirium, which led to his research and developed successful protocols in improving care and decreasing delirium in over six well known hospitals. The main interventions he utilized were the following ICU measures, in acronym: “ABCDEF,” which includes: Assessing and managing pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of Sedation/Analgesia, Delirium Monitoring, Early Mobility and Family engagement which after these interventions studied over 50% of the drugs normally given for sedation were decreased or cut cold turkey, showing a 4 day decrease stay in the ICU, and decreasing mortality rate up to 15%.
If you get a chance, please watch the story of Anthony Russo delirium he explains in the video above, I am a loss of words what he experienced in the ICU. I believe it will help in opening the eyes of what can be reality for these patients we care for everyday, as well as identifying how the long term complications can even occur after their discharge home from the ICU.
The astonishing fact is researchers have estimated that about 40% of delirium cases are preventable, which surprises me that so many people are still experiencing this reality this last year 7 million cases, especially for those elderly whom are at higher risk due to their sensitivity receiving large doses of anti-anxiety drugs and narcotics.
Brain injury is preventable by lowering exposure to potent sedative meds and shortening the duration of delirium with assessment and monitoring with the ABCDEF method. Think about it, it costs more than 143 billion annually to care for such delirium patients due to their longer hospital stays and complications, more is needed to be done in these preventable cases to reach out to those whom needs us most. Educate yourself and follow such articles on assessment tools in detecting delirium in patients.
Here are some examples:
Confusion Assessment Method (CAM)
Delirium Assessment and Management
References:
Boodman, S. (2015). The Overlooked Danger of delirium in Hospitals. The Atlantic Article. Published by Kaiser Public Health News. Retrieved from: http://www.theatlantic.com/health/archive/2015/06/the-overlooked-danger-of-delirium-in-hospitals/394829/
Landro, L. (2011). Informed patient: changing sedation status quo in the ICU. Health Blog, Wall Street Journal. Retrieved from http://blogs.wsj.com/health/2011/02/15/changing-the-sedation-status-quo-in-the-icu/
Delirium in the ICU
Delirium, a sudden onset and fluctuating cause of mental status often occurs in critical ill patients hospitalized in the ICU. Memory and language difficulty, disorientation, paranoid ideas are part of delirium with an increase in morbidity and mortality in the elderly (Svenningsen & Tonnesen, 2011). ICU delirium can be divided in hyperactive delirium with symptoms such as restlessness, aggression, and psychomotor hyperactivity. Hypoactive delirium portrays symptoms such as lethargic, and decreased psychomotor responds. Mixed delirium consist out of hyper-and hypoactive delirium. A study was performed in three ICU’s in Denmark with the goal to identify the correlation of delirium regarding analgesics, sedatives, opiods and age. Intubated and non-intubated patients participated in the study. In this particular study a correlation was detected between delirium and the length of stay in the ICU and an increase in mortality was observed in patients who died in the ICU with delirium. 40% of the patients in the ICU developed delirium. The usage of Fentanyl as an analgesic occurred to show also an increase in delirium. In order to reduce the incidence of delirium in the elderly it is important to manage cognitive impairment, immobility, and sleep deprivation, visual and hearing impairment.
Delirium is frightening experience for the patient and needs to be addressed immediately. It is interesting to read 40% of patients in ICU develop delirium, a concerning number. The article does not elaborate too much in the prevention of delirium which is disappointing. As nurses we are the patient’s advocates and have a unique role in the prevention and detection of delirium.
References
(Svenningsen H Tonnesen E 2011 Delirium incidents in three Danish intensive care units)Svenningsen, H., & Tonnesen, E. (2011). Delirium incidents in three Danish intensive care units. Nursing in critical care, 16(4), 186-192.
Delirium in the ICU
On a daily basis, 30,000 to 40,000 ICU patients in the United States suffer from delirium. Delirium is an acute brain dysfunction. It is believed the problem will only get bigger due to the increased age of our population. The article written by Maniou states multiple studies concluded delirium in mechanically ventilated patients is seen in 60-80% of ICU patients. The article also states that each day a patient spends in a state of delirium their risk of death is increased by 10%. Hypoactive delirium may be difficult to diagnose but it is important to recognize it because it may be an early sign of a serious medical condition, such as sepsis, pneumonia, MI, or PE. Delirium may also be linked to longer hospital stays and increased cognitive impairment on discharge. Risk factors associated with delirium include: increased age, severity of disease, use of medications such as psychoactive drugs, opiates and benzodiazepines. Other risks include the patient’s loss of control, loss of personal space, and loss of their ability to communicate. For these reasons it is important for nursing staff to be aware of this medical problem. Nurses must know how to recognize it and how to treat it, as delirium is harmful to patients and costly to hospitals. The Confusion Assessment Method-Intensive Care Unit is the most commonly used method to diagnose delirium, other tools include the delirium check list and The Intensive Care Delirium Screening Checklist. Nurses should be educated on effective methods to identify patients at increased risk for delirium, how to asses for delirium and appropriate interventions to manage the medical problem.
I do agree with the article. Medicine has many new advances and people are living longer than before. The older population is more fragile and sensitive, thus increasing their risk for delirium. It also seems that patients admitted to the hospital are more fragile and sick then in past years. It is important for all nurses to identity patients at risk, assess and implement nursing interventions to prevent complications. I think the next step needed to bring about awareness of this issue is staff education. As this is a big problem, nursing staff especially nurses caring for patients in ICU should be educated on the issue. I think nurse education is the most important step to identify and treat these patients. Nurses are the primary caregivers and we are the ones who interact with the patients the most. We are in the perfect position to assess and identify patients at increased risk for delirium. We are also in the perfect position to intervene to prevent long term complications.
As a nurse working in med/surg and acute rehabilitation I often encounter older patients who become disoriented when taking narcotics, sleeping and psychoactive medications. I believe that it is important to for all nursing staff not just ICU staff to get educated on delirium. Often the patients change in LOC is not associated or linked to these medications and it is important to recognize it and to be aware of the possible causes to prevent its reoccurrence. As nurses we are the doctor’s eyes and we are also the patient’s advocate and it is our responsibility to monitor, prevent and intervene in these situations. We must prevent long term complications and limit hospital costs.
Recourses
Maniou, M. (2012). Delirium: A distressing and disturbing clinical event in a intensive care unit. Health Science Journal, 6(2) 587-597.
The Dangers of Delirium
The dangers of delirium
Patient safety is an important part when it comes to nursing care. Nursing intervention can be done prior to help better patient outcomes. For example, patient’s that are treated in intensive care units need interventions that will provide safety before and after care. These patients are heavily sedated and on ventilators are particularly likely to become delirious; some studies place the rate as high as 85 percent. Delirium is basically inattention and confusion that represents the brain temporarily failing. A person who is delirious is unable to think clearly and can’t make sense of what is going on around him. But the condition is common among patients recovering from surgery and in those with something as easily treated as a urinary tract infection.
Regardless of its cause, delirium increases the risk of longer stays in the hospital, higher cost of care, can persist for months after discharge, more long-term cognitive impairment up to one year later and even death. Therefore it is important to provided safe care before and after treatment. Researchers estimate that about 40 percent of delirium cases are preventable. Many cases are triggered by the care patients receive like Mechanical ventilation is well known to cause ventilator associated pneumonia (VAP) and other nosocomial infections. Another example includes large doses of anti-anxiety drugs and narcotics or the environments of hospitals themselves, such as, a busy, noisy, brightly lit place where sleep is constantly disrupted and staff changes frequently. Overall there is evidence based support for getting patients off of ventilators and sedation, as quickly and safely as possible. Also, non-drug interventions, which included making sure patients’ sleep-wake cycles were preserved, that they had their eyeglasses and hearing aids and that were not dehydrated.
References
The Washington Post: Health and Science- “The perils of delirium” (2015). Retrieved on September 21, 2015 from: https://www.washingtonpost.com/national/health-science/the-perils-of-delirium/2015/06/01/0f263996-ed22-11e4-8666-a1d756d0218e_story.html