The rate of delirium for pediatric patients mirrors that of adult patients, with about 25 per cent of pediatric patients experiencing delirium at some point during their ICU stay. As pediatric patients are often much more heavily sedated, the actual rate of delirium could be higher.
Last year, 10 paediatric teams and 31 adult acute care teams from ICUs across the country participated in a national initiative to learn more about pain, agitation and delirium.
PAD Your ICU was designed and delivered by the Faculty of the Canadian ICU Collaborative and supported by the Canadian Patient Safety Institute. The initiative helped participants to improve care of the critically ill patient through implementation of standardized screening, and prevention and management strategies.
When Dr. Paul Doughty took a staff position at the Alberta Children's Hospital in Calgary, he found that many times patients were delirious and on multiple medications to achieve adequate degrees of sedation. He was very keen to use his physiotherapy background to get pediatric patients in the ICU mobilized. However, he quickly learned that there was no way that some of his patients could participate in meaningful rehabilitation, as they were overly sedated and could not be aroused to participate. Generally, patients were spending a longer time on ventilators and were not engaged in rehabilitation to the extent that they could be.
Wendy Bissett and Dr. Paul Doughty
"At that time, there were no pediatric-specific tools in place to actually measure for the presence or absence or delirium," says Dr. Doughty. "We had a few champions on the unit who recognized there was a problem, and when we heard about the pain, agitation and delirium (PAD) Your ICU National initiative, the timing was perfect as we were at the beginning stages of trying to promote change," says Dr. Doughty. "If we wanted to achieve more engagement in rehabilitation on the unit, we first had to improve the patient's level of wakefulness."
The PAD team from the Alberta Children's Hospital included Dr. Doughty; Laurie Lee, nurse practitioner; and Wendy Bissett, nurse educator. The team has since expanded to a larger group that includes a speech language pathologist to help with communication tools that enable intubated pediatric patients to better communicate with caregivers; respiratory therapists (RTs); representatives from pharmacy and rehabilitation; and a larger number of nursing staff who are all act as champions within the unit. The team is really proud of what they have been able to accomplish so far and a number of initiatives are yet to be introduced into what they have built as a three-stage implementation plan.
First, was to introduce an objective scoring tool to better identify if the patient had pain or agitation, or if they were delirious. Previously, if the patient seemed unsettled, they would get a multitude of medications, including analgesic agents, sedative agents, and at times muscle relaxants to keep them calm while on a ventilator. "It was more of a shotgun, rather than a targeted approach," says Dr. Doughty. "By implementing a scoring tool, we are now better able to target what our patients need, rather than using a high dose or costly medications to address a patient's pain and agitation issues."
Second, was to introduce the scoring tool to bedside nurses who did the brunt of the work in terms of engagement and scoring. "Our program would not have been successful if it were not for the willingness of the bedside nurses to actually get involved with the program, score the patients and buy-in to our attempt to minimize PAD," says Dr. Doughty. "Our nurses recognized that this is an opportunity to take a leadership role. It has really been a team effort that has built a stronger, more successful program."
Third, was to incorporate the scoring tool into the patient's electronic medical record (EMR) so that everything can be entered at the bedside. The data drawn from the EMR provides a prospective data analysis to see how the unit is doing in terms of the optimization of pain, agitation and delirium.
The team is now looking at an early rehabilitation plan and linking that to an extubation readiness testing plan. "With further involvement of the RTs, we will be able to keep our patients more awake, assess them for earlier extubation in an objective way, and involve our patients with early rehabilitation strategies, which have shown to significantly decrease the rates of delirium in the adult world and we would expect the same outcome amongst our pediatric patients," says Dr. Doughty.
Alberta Children's Hospital involves both families and caregivers in the patient's care plan. A novel sleep hygiene program for pediatric ICU patients has been implemented as lack of sleep is a large contributor to the onset of delirium. "We have created a new program where patients map out day-to-day journal of what their child's activities would typically be and we try to replicate that to the best we can in the confines of the ICU," says Dr. Doughty. We are trying to promote a better regimen of sleep hygiene to decrease the rate of delirium amongst our patients."
The management of PAD has also been included in the hospital's family pamphlet that provides information on admission to the ICU. A large family communication board is placed in the patient's room and every day PAD goals are recorded on the board so that families are aware of them.
"Family members have a lot of questions, especially when a small patient on a ventilator wakes up and appears unsettled," says Dr. Doughty. "The first question they ask, is my child comfortable? Our goal is to keep pediatric patients comfortable and safe, while minimizing the risk of delirium and maximizing the family's involvement in the prevention of delirium."
PAD Your ICU National initiative, participants learned ways to engage families in the management of the patient's delirium. "A primary driver in reducing pain, agitation and delirium in the ICU is recognizing that patients and their families are an integral and important part of the care team," says Leanne Couves, Improvement Associates. "Developing mechanisms for effective two-way communication, such as discussions of PAD in family meetings and inclusion of family members in multi-disciplinary rounds, can help family members recognize PAD in their loved ones and assist in their care."