Individuals that are admitted to the Intensive Care Unit (ICU) are already critically ill, and now, according to the article by Rattray will be faced with a longer recovery time that could be weeks, months and in some cases years to return to pre-ICU health status. 25-76% of these patient suffer from muscle wasting, weakness, and fatigue from prolonged bed-rest and immobility, and the severity increases with the more critically ill the person is. She further states that these patients suffer psychological problems from their stay in ICU. Due to their perceived experience they suffer from anxiety, depression (28%), PTSD (20%), and cognitive problems including delirium (20-80%), that negatively affect their health status. The characteristics of patients most likely to suffer from delirium are those that are already cognitively impaired, respiratory disease, older age, smokers, and alcohol abuse. Additionally, the illness that this is most prevalent are sepsis, dehydration, prolonged stay in the ICU, and biochemical abnormalities. Environmental precipitants include but are not limited to physical restraints, noise, sleep deprivation, isolation, as well as benzodiazepine and opioid use. Rattray states that rehabilitation should begin while the patient is still in ICU, by daily sedation reductions and early mobilization. This would need to be done with a team of multidisciplinary care providers that begin rehabilitation as soon as the patient is admitted to ICU and continue after discharge.

According to the article Intensive care delirium: the new black by Egerod, it is unclear if ICU delirium is the result of the illness or the medications. However, she does state that these patients suffer from adverse health outcomes from prolonged delirium and stay in ICU. Egerod further promotes the use of interdisciplinary team to manage pain, sleep, circadian rhythm, lighter sedation and early ambulation. Additionally, use of family to participate in care as it gives the patient comfort and familiarity and connects them to the outside world.

Both authors promote reduced sedation, decreased use of benzodiazepines, avoiding sleep disruption and increased physical therapy and activity. Due to the high rate of patients suffering from delirium and other adverse effects from their stay in ICU that have developed standardized tests in which to assess their functioning and delirium. Further research is needed to understand these mechanisms so as to provide better treatment that will provide better health outcomes for the critically ill population.

References:
Egerod, I. (2013). Intensive care delirium: the new black. Nursing in Critical Care, 18(4), 164-165.
Rattray, J. (2014). Life after critical illness: an overview. Journal of Clinical Nursing, 3(5/6), 623-633.

The topic of delirium is nothing new to the nursing world… in fact I have had my fair share of pts suffering from delirium or new onset confusion.  Unlike dementia, delirium is typically an acute chane that may be reversed when the underlying problem is corrected. ICU delirium is actually a new topic for me.  Still keeping with the traditional definition, this acute change in mental status seems to affect pts that are sedated in the ICU while on a ventilator.  There is more recent research available on this topic, as it is still being explored and discovered.  It appears that after sedation is stopped and the pt is able to live in reality, the delirium may be reversed, but some emotional trauma
remains.  I found a recent peer reviewed article that details the main streamed assessment tool for ICU delirium.  This tool is called CAM-ICU, or Confusion Assessment Method for the Intensive Care Unit.  This article outlines an educational plan among people who are administering the test and utilizing the tool to ensure they are recording data accurately.  It was found that after the educational plan was implemented, less “unable to assess” ratings were recored and pts were able to receive a more appropriate grade.  As with most things in the medical world, the more knowledge medical professionals have the more meaningful outcomes pts may have.  Proper education for this assessment tool is instrumental in screening pts for delirium and reversing this confusion before mental health complications occur.  A copy of the CAM-ICU Assessment Worksheet is provided for review.

Reference

SWAN, J. DECREASING INAPPROPRIATE UNABLE-TO-ASSESS RATINGS FOR THE CONFUSION ASSESSMENT METHOD FOR THE INTENSIVE CARE UNIT. American Journal of Critical Care. 23, 1, 60-69, 2014. ISSN: 1062-3264.

 

Delirium is defined in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV as a disturbance of consciousness and cognition that develops over a short period of time (hours to days) and fluctuates over time. It is a common manifestation of acute brain dysfunction in critically ill patients, and occurs in up to 80% of the sickest intensive care unit (ICU) populations. People with delirium are unable to think clearly, have decreased attention, and may have auditory and/or visual hallucinations.

Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continue to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument such as, The CAM-ICU.

The CAM-ICU is modified from the Confusion Assessment Method (CAM) and assesses four features: acute change or fluctuation in mental status from baseline, inattention, altered level of consciousness, and disorganized thinking.

Delirium in the ICU is quite common. The pathophysiology of delirium is poorly understood but it is theorized to be a neurobehavioral manifestation of neurotransmitter imbalance.

Some causes of delirium include: poor oxygen perfusion of the brain, chemical changes in the brain, medications, infections or sepsis, and alcohol withdrawal.

People who are more likely to get delirium are those who have: dementia, depression, poor eyesight and/or hearing, heart failure, infection/sepsis, or take certain high-risk medicines.

Among medical ICU patients, delirium is associated with multiple complications and adverse outcomes, including self-extubation and removal of catheters, failed extubation, prolonged hospital stay, increased health care costs, and increased mortality.

When delirium is diagnosed or suspected, the underlying causes should be sought. Components of delirium management include supportive therapy and pharmacological management. Reorientation techniques or memory cues such as a calendar, clocks, and family photos may also be helpful. The environment should be stable, quiet, and well lit. Physical restraints should be avoided. Delirious patients may pull out intravenous lines, climb out of bed, and may not be compliant. Perceptual problems lead to agitation, fear, combative behavior, and wandering. Severely delirious patients should never be left alone or unattended and may benefit from constant observation to help avoid the use of physical restraints.

ICU Delirium: Nursing and Medical Staff Knowledge of Current Practices and Perceived Barriers
Delirium is a common problem in the ICU. It’s divided into three subtypes (hyperactive, hypoactive, and mixed delirium). It’s been known that delirium in the ICU is associated with prolonged hospital and ICU stays. It is also associated with an increased six month mortality rate. The Intensive Care Society recommends screening for delirium on a daily basis using a validated screening tool such as the CAM-ICU. Two thirds of cases could be missed if a validated screening tool isn’t used. This article is suggesting that there is a lack of knowledge on ICU delirium, the screening tools used to assess it and also that it is not screened for on a regular basis, partly due to perceived barriers to screening. A sample of 149 nurses and medical staff from three different hospitals were surveyed.
The results show that 44% of the respondents never received any training or education on ICU delirium and that 37% used a delirium screening tool. 51% said they did not use a screening tool. The rest checked off “did not know”. The majority of respondents said they knew about the CAM-ICU screening tool but did not use it on a regular basis. The second most recognized screening tool was the ICDSC (Intensive Care Delirium Screening Checklist). 52% said they screened for ICU delirium on a daily basis and 14% said they screened for it on a weekly basis and another 14% said they screened on a monthly basis. The ones that did not use a screening tool said they just observed for hallucinations, agitation, and confused patients.
Some of the respondents said they did not screen for delirium due to perceived barriers such as it was time consuming to complete, that it would take up valuable nursing and medical staff time. Some were also unconfident at detecting delirium.
This article also revealed that the nurses and medical staff had some knowledge of ICU delirium but the education they received was during school and not at bedside. They also found that the staff had a medium level of knowledge about the risk factors and complications of ICU delirium.
I agree with the article in that most of the staff at many hospitals lack education on ICU delirium. This article brings to light how serious ICU delirium is and how much training and education needs to be done. The CAM-ICU takes about 2-5 minutes and needs to be done at least on a daily basis, not weekly or monthly. The medical staff who do not use a structured validated tool to assess delirium confirms that many of the ICU delirium cases are missed or are identified as hyperactive (least common) when it should be identified as hypoactive or mixed.

Reference:

Elliott, Sara.  ICU delirium: A survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit, Intensive and Critical Care Nursing (2014) 30, 333-338.

Prior to discussion assignment, I was not aware of the condition know as ICU delirium. Watching the videos and researching articles gave me a better understanding of this condition associated with negative outcomes.

In the article, Preventing Delirium in the Intensive Care Unit, delirium in the ICU is characterized as acute organ dysfunction, which then manifest to both consciousness and cognitive disturbances and affects approximately 60-80% of ventilated patients and 20-50% on non-ventilated patients (Brummel & Girard, 2013). Risk factors for delirium in the ICU setting are sedatives, immobility, and sleep disturbances. Since, delirium is a multifactorial, a bundled approach known as the ABCDE approach has been proposed in preventing and reducing the duration of delirium (Brummel & Girard, 2013). This approach utilizes the Awakening and Breathing Coordination, Choice of sedatives, Delirium management, and Early mobility and Exercise components. Implementing these components has with positive improvements of outcomes, which include a decrease in the duration of mechanical ventilation, shorter length of stay in the ICU and hospital, and prevented adverse effects associated with critical illnesses, which can lead to delirium (Brummel & Girard, 2013).

Awakening and Breathing Coordination:
This component utilizes the ABC trial. This includes daily awakening trails that are coordinated with daily spontaneous breathing trials. This strategy has been shown to decrease the duration of brain dysfunction, patients were extubated 3 days sooner, discharged 4 days earlier from the hospital then the patients who received usual care, and a 14 % decrease in mortality rates (Brummel & Girard, 2013).

Choice of sedative:
There were three trials (MENDS, SEDCOM, MIDEX) which showed positive results when utilizing dexmedetomidine as a sedative as oppose to benzodiazepines, versed, and lorazepam. There was a reduction in the development of delirium, and a shorter duration in mechanical ventilation (Brummel & Girard, 2013).

Delirium monitoring and management:
It is important that all clinicians in the ICU setting utilize the CAM-ICU or ICDSC screening tools to monitor their patients. These screening tools assist with alerting the clinicians with identifying reversible and treatable risk factors (e.g. sleep deprivation, dehydration, immobility, visual and hearing impairment) associated with delirium (Brummel & Girard, 2013).

Early Mobility and Exercise:
Early physical rehabilitation resulted in positive outcomes for patients. One study showed that patients who received PT/OT therapy within the 72-hours of being intubated had a reduction in delirium, were discharged from the ICU 2 days earlier and discharged from the hospital 3.5 days earlier than patients receiving usual care (Brummel & Girard, 2013).

Even though, I do not work in the ICU and am not familiar with this common condition, I agree with the strategies this article suggests for the treatment and prevention of Delirium. The ABCDE approach utilizes evidence-based practice strategies that have shown improvement of outcomes associated with critical illness and ICU delirium. I think it is important for researchers to continue to find evidence based strategies that can prevent ICU delirium in patients. Also, it is important for clinicians to identify both modifiable and non modifiable risk factors that can be associated with ICU delirium on admission and include the patient’s family in the care of the patient and listen to their concerns and what they have to say about the patient’s history. Other than the patient, they are the best resource.

Reference:
Brummel, N. E., & Girard, T. D. (2013). Preventing delirium in the intensive care unit. Critical Care Clinics, 29(1), 51–65. Retrieved from: http://www.ncbi.nlm.nih.gov/articles/PMC3508697/pdf/nihms418369.pdf

Situation

              Patients that have serious illnesses often are admitted to the Intensive Care Unit (ICU). A majority of these patients are also on mechanical ventilation to assist with breathing after experiencing acute respiratory distress syndrome (ARDS) as a result of “either direct or indirect pulmonary injury” (Morton & Fontaine, 2013, p.233). Mechanical ventilation is used to  treat a patient that cannot breath on their own. Unfortunately, invasive artificial airways often come with their own complications and high costs.

Background

              Mechanical ventilation is well know to cause ventilator associated pneumonia (VAP) and other nosocomial infections. Studies also show that the longer the length of time on a ventilator, the higher it correlates with hospital re-admissions and a draining of ICU resources (Douglas, Daly, Brennan, Gordon & Uthis, 2011). There is evidence based support for getting patients off of ventilators and sedation, as quickly and safely as possible.

Assessment

              In the article, “Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation,” authors write about how patients are typically weaned off of the ventilator and identified a problem with the fact doctors decided subjectively to wean patients and it is not based on protocols (Grap, Strickland, Tormey, Keane, Lubin, Emerson, & … Sessler, 2003). The doctors would use different parameters and those parameters varied from each doctor and each hospital (Grap, 2003).

Resolution

               Grap et al., have focused on using a multidisciplinary approach to wean  patients off of their ventilators sooner; this approach utilizes a standardized protocol for weaning the patients (2003). The article researched the medical respiratory ICU (MRICU) protocol which is composed of several scales, guidelines, and assessment tools to help identify if the patient is ready to be weaned (Grap et al., 2003). The article showed that “[p]atients receiving mechanical ventilation have shorter hospital stays and lower costs when a weaning protocol is used” (Grap et al., 2003, p. 455). The article also supported nurses autonomy and working with the respiratory therapist to individualize the weaning process; this encouraged strong communication within the interdisciplinary team (Grap et al., 2003).

Douglas, S., Daly, B., Brennan, P., Gordon, N., & Uthis, P. (2001). Hospital

readmission among long-term ventilator patients. Chest, 120(4), 1278-1286.

Grap, M., Strickland, D., Tormey, L., Keane, K., Lubin, S., Emerson, J., & … Sessler,

C. (2003). Collaborative practice: development, implementation, and

evaluation of a weaning protocol for patients receiving mechanical

ventilation. American Journal Of Critical Care, 12(5), 454-460.

Morton, P. G., & Fontaine, D. K. (2013). Essentials of Critical Care Nursing; a

               holistic approach. Philadelphia, PA: Wolters Kluwer.

According to the article Delirium in Critically Ill Patients, ICU delirium affects 16-89% of all ICU patients, with the wide range attributed to ineffective delirium assessment on admission, lack of training for the medical staff, and the implementation of different sedation and analgesia protocols (Zaal & Slooter, 2012).  Those at a higher risk include the elderly, patients with pre-existing cognitive decline, history of alcohol abuse, sepsis, and immobility.

Although the cause of ICU delirium is unclear, Zaal and Slooter (2012) suggest that an alteration in neurotransmitter activity may be at fault, as patients with ICU delirium show a decrease in acetylcholine activity, resulting in disturbed pathways involving attention, concentration, and learning.  Another hypothesis is that delirium is caused by an aberrant stress response, in which the body releases an excess amount of stress hormones that cross the blood-brain barrier, resulting in cognitive impairment (Zaal & Slooter, 2012).

Early screening of ICU patients—with tools such as the intensive care delirium screening checklist (ICDSC) or the confusion assessment method (CAM-ICU)—results in better prognoses for those suffering with delirium.  Zaal and Slooter (2012) report that repeated re-orientation, early mobilization, noise reduction, and less interruptions during sleep are effective measures that reduce delirium by 40%.  Pharmacologically, intravenous low-dose Haloperidol is the drug of choice, as it has shown to decrease delirium in 23% of ICU patients (Zaal & Slooter, 2012).

Prior to researching this topic, I had no idea ICU delirium existed.  However, after reading the articles and watching Anthony Russo’s video, it is clear that more research is needed to not only prevent ICU delirium, but also to effectively treat and provide adequate ongoing psychological help—long after discharge—to those patients in need.

Reference:

Zaal, I. J., Slooter, A. J. C. (2012). Delirium in critically ill patients: Epidemiology, pathophysiology, diagnosis and management. Drugs, 72(11), 1457-1471. Retrieved from http://eds.a.ebscohost.com.summit.csuci.edu:2048/ehost/detail/detail?

Did you know that having an illness that requires a prolonged ICU stay, can lead to months of disability after discharge? As patients are grateful for overcoming a critical time in their lives, there is a high probability of having another difficult challenge ahead of them: not being able to function as they had been able to prior to their ICU stay. This may result from ICU delirium which affects 60% to 80% of patients that were on ventilators and 20% to 40% of patients that were not on ventilators (Brummel et al., 2014). In Nashville, Tennessee at St. Thomas Hospital, 126 ICU patients were studied between October 2003 and March 2006 and researchers found an association between the duration of ICU delirium and patients’ post ICU disability (Brummel et al., 2014). During the following year after discharge from the ICU, functional ability to perform activities of daily living (ADLs) were tested and the correlation of a longer period of ICU delirium and decreased ability to perform ADLs was found. After watching three videos on ICU delirium and reading the article on this study, I agree with Dr. Brummel et al., that treatment of delirium is essential in attempt to prevent months of diminished motor function since performing one’s ADLs is of high importance to most individuals. This article also pointed out another interesting study that showed reduced delirium in ICU patients at risk of atrophy and weakness who received physical and occupational therapy (PT/OT) within the first couple of days while on a ventilator. It appears steps that need to be taken are assessment of ICU delirium, attempt to reduce the duration of ICU delirium, have PT/OT work with patients at risk in the ICU sooner rather than later, and continue to research ways to reduce disability post ICU discharge.

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  References Brummel N E Jackson J C Pandharipande P P Thompson J L Shintani A K Dittus R SGirard T D 2014 Delirium in the Intensive Care Unit subsequent long-term disability among survivors of mechanical ventilation.Brummel, N. E., Jackson, J. C., Pandharipande, P. P., Thompson, J. L., Shintani, A. K., Dittus, R. S.,…Girard, T. D. (2014). Delirium in the Intensive Care Unit subsequent long-term disability among survivors of mechanical ventilation. Crit Care Med, 42(2), 369-377. doi:10.1097/ccm.0b013e3182a645bd 201509211616561221419573    

Week 4 Blog Post: Delirium (Janell Nunn)

Briefly summarize your findings. Do you agree with the article? Why or why not? What are the next steps needed? Share your “finds” from your own blog for this week.

 

This was a very short section of a larger article. It agreed with the article and videos we all read. Stating that the CAM ICU Delirium tool is extremely helpful in catching more cases of delirium. The article discussed adding this and other tools to help prevent long term effects of delirium and was concerned with having these tools added to hospital protocols, especially given the success of the trials (done in four stages at large hospitals in ICUs only).

I agree with the article, mostly due to the evidence presented in the other article we read and the videos. The next steps needed for this article are: getting the CAM ICU added into hospital protocols; putting interventions in place for those identified to have delirium based on these new protocols.

My “Finds” from the reading/videos: This is an issue of which I was entirely unaware. The testimony the patient gave on video was astounding and the quote he gave from his psychiatrist stating that it was as real to him as any Post Traumatic Stress Disorder (PTSD) sufferer from the military or police really made the issue come alive. This is what health care protocol is doing to survivors! It is made clear by the information given, that changes need to be made. Research for changes began back in the 1990s and is finally on its way into practice and needs to be taken seriously and swiftly added into daily best practice.

 

References:

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/

Nulles, S. (2008).  Improving goal-directed sedation practices and recognition of delirium in the MICU. Critical Care Nurse, 28(2), 11.