Steps for managing and preventing Delirium can be addressed through implementing the elements of the
Safer Healthcare Now! Delirium change package (2013) that include:
- Recognize/manage/mitigate risk factors for every patient ("universal precautions").
- Assess for Delirium every shift and as required.
- Develop standardized protocol for prevention and/or management of Delirium including:
Support patients and families of patients with Delirium and integrate them in the management of Delirium (e.g. encourage adequate rest, stay positive, physical contact, bring familiar objects or pictures, glasses or hearing aids and patient reassurance).Include a multidisciplinary team in planning and managing care (i.e. physician, nurse, psychiatry, pharmacy, RT/OT and social worker).Create a unit culture that is sensitive to Delirium by raising awareness and improving knowledge and skill to identify and manage Delirium.Manage hand-offs (communication, documentation, information within ICU, pre- and post-ICU stay).Sedate critically ill adult patients who screen positive for Delirium using dexemedetomidine, rather than another sedative such as a benzodiazepine, as evidence indicates that this results in less time on the ventilator, less Delirium, and less tachycardia and hypertension. (Riker 2009). Note: For additional information regarding the efficacy of dexmedetomidine refer to Additional Resources below.
- Identifying and treating underlying causes of Delirium.
- Use of non-pharmacological strategies (i.e. early mobility, optimize sleep routines, daily reassessment of sedation needs, paired with readiness to wean, provide need for communication adjuncts and reassess restraints* daily).
- Use of environmental strategies (i.e. visible daylight, allow visitors, display calendar and clocks in the room, avoid restraints*, etc.).
- Use of pharmacological strategies appropriately and only after underlying causes addressed.
- A plan for withdrawal of anti-psychotics if they have been administered as part of Delirium management (before transfer to ward and/or other location).
- Daily reassessment of sedation needs.
*Restraints increase adverse events and have never been shown to improve safety. Consider removal of all unnecessary catheters and tubes e.g. urinary catheters, central lines, endotracheal tubes etc. unless specifically contraindicated.
Conduct Clinical and System Reviews (see details below)
Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.
Clinical and System Reviews, Incident Analyses
Occurrences of harm are often complex with many contributing factors. Organizations need to:
Measure and monitor the types and frequency of these occurrences.
Use appropriate analytical methods to understand the contributing factors.
Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.
Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.
Useful resources for conducting clinical and system reviews: