Up to 80 per cent of critically ill patients in an ICU will have delirium or subsyndromal delirium; pain and agitation are risk factors for delirium. While pharmacologic treatments are used to manage symptoms, they may precipitate delirium and are associated with additional risks. Studies have shown that a systematic evaluation of pain and agitation, coupled with "actionable interventions" can provide cost-savings and have a significant impact on patient outcomes, including length of stay and complications.
Last year, ICU teams from across Canada, including 10 paediatric teams and 31 adult acute care teams participated in an initiative to learn more about pain, agitation and delirium. During the
PAD Your ICU National initiative, teams shared ideas and knowledge, set specific aims, implemented iterative tests of change, measured progress and shared successful methodology for organizational change.
Taking the time to highlight the word delirium on the patient's 24-hour care sheet has made a significant impact on patient outcomes at the Royal Inland Hospital in Kamloops, British Columbia (RIH Kamloops). Over the course of a year, the practice of documenting delirium assessments has increased from 40 to 85 per cent.
The Confusion Assessment Method for the ICU (CAM-ICU) is a widely-used instrument for the assessment of delirium in the ICU. The RIH Kamloops team set an aim that 80 per cent of ICU patients would be identified and documented every shift (q shift) and as needed (prn) with the use of the CAM-ICU by March 31, 2017.
RIH Kamloops PAD team (left to right): Brad Holowachuk, Physical Therapist; Tina Chard, Occupational Therapist; and Holly Delitzoy, Registered Nurse|
"The CAM-ICU assessment takes less than a minute to complete," says Tina Chard, Occupational Therapist at RIH Kamloops. "Some of the staff did not understand the purpose behind the CAM-ICU and how important it is to the patient's care and therapy. This information is critical for physical, occupational and speech-language therapists. In order for a patient's cognition to be addressed by OT, they have to be CAM negative for at least two to four days."
Starting in January 2016, surveys at RIH Kamloops indicated that only 40 per cent of ICU charts had delirium identified (+ or -) on the patient's chart. A number of changes were implemented to increase awareness, including Patient Care Coordinator rounds; educational emails from the nurse educator; and whiteboard posters. Through these changes, 50 per cent of charts had delirium identified by June 2016.
"In November 2016, we then implemented daily reporting over an 11-day period and found that while staff where reporting CAM-ICU scores to the Patient Care Coordinators when asked, the scores were still not being documented on the patient's care record," says Tina Chard. "We started highlighting delirium on the record sheet; placed posters in staff washroom displaying a cartoon with key facts; attended bi-weekly huddles; and the ICU Educator sent educational packages to the nursing staff. By January 2017, we were proud to report that 85 per cent of records had a score for delirium recorded."
The PAD team continued to highlight delirium on the record sheets until April 1, 2017 and will conduct another survey in June 2017 to see if the practice of recording delirium is being maintained. The team is also looking at ways to spread their work to other hospitals across the Interior Health region and continue the work to increase awareness of the PRISME tool to identify the underlying factors that lead to and perpetuate delirium; and to narrow down the options to three to five steps on how to improve delirium.
PAD Your ICU was designed, delivered and hosted by the Faculty of the Canadian ICU Collaborative and supported by the Canadian Patient Safety Institute. Over the 10-month period (February to December 2016), the program consisted of five webinars and 11 team connection calls where participants were provided with clinical content, coupled with improvement science on how to go about making changes.
Participating teams chose one or two goals to work on for the prevention, assessment and treatment of pain, agitation and delirium, and to track their performance through to March 2017.
"Through the support of the Canadian Patient Safety Institute, together with the Canadian ICU Collaborative, we were able to connect medical staff from different systems," says Bruce Harries, Improvement Associates Ltd. and Director, Canadian ICU Collaborative. "The ability to learn from faculty experts was invaluable in sharing information that was not well-known across the group. Participants also told us that it was great to talk to their Canadian colleagues who have similar issues and to make some progress on addressing delirium, pain and agitation."
"One of the themes that the teams worked on was teamwork and communication," adds Bruce Harries. "We want to pull together a one-pager on the outcome of that work to provide guidance on things that you could be doing. Participants had different approaches on how you can make this work on your unit."
There was a fairly active discussion group that was created through the
Pad Your ICU National initiative. The group will be migrated to the Critical Care Canada Google Group, so that they can stay connected with their colleagues in ICUs across the country.