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Patient Safety Tip of the Week 

August 31, 2010 

Postoperative Delirium

While we were preparing our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” we came across a good article on postoperative delirium (Mantz 2010) in the anesthesiology literature. We’ve previously discussed extensively the issue of postoperative delirium (see our October 2008 back-to-back columns “Managing Delirium” and “Preventing Delirium” and our March 31, 2009 Patient Safety Tip of the Week “Screening Patients for Risk of Delirium” and our January 26, 2010 Patient Safety Tip of the Week “Preventing Postoperative Delirium”). In those prior columns we’ve discussed the incidence of postoperative delirium and the serious long-term effects and the cost burden of delirium. A recent meta-analysis (Witlox 2010) confirmed the significant risks of death, institutionalization, and dementia in patients discharged after a bout of delirium.

But the Mantz article does a nice job of summarizing some of the practical aspects of preventing, identifying and managing postoperative delirium. It includes a case report (with the nuance that the patient also has a second discrete episode of delirium), and a good description of the clinical features of delirium and the tools used to help identify it. They note that the CAM-ICU may be inferior to some of the other tools in patients in the PACU (remember, their perspective is that of the anesthesiologist). They have a thorough discussion of the causes and precipitating factors, stressing some that are especially likely to be present in the PACU (eg. pain from bladder distension, hypoxemia related to residual neuromuscular relaxation, residual effects of anesthetic agents or sedating agents or anticholinergic agents). In their case they suspect the initial episode of delirium was related to occult infection (it was a clue she had peritonitis) and a second episode several days later may have been related to benzodiazepine withdrawal. Potential pathophysiological mechanisms underlying delirium are discussed, including the potential influence of many of the drugs used perioperatively on some of the postulated neurotransmitter abnormalities in delirium. They also discuss many of the components of a multimodality approach that is discussed below in more detail. And they provide the view of the geriatrician (one of the authors is a geriatrician), which stresses the relationships of delirium to dementia and depression and the issues of physical and cognitive autonomy and activities of daily living.

In the prior columns we noted above we have discussed identification of risk factors for postoperative delirum. The most salient predictors of postoperative delirium are the presence of dementia or disordered executive function. Those previous columns noted some of the validated prediction tools that can be used but often you can screen for delirium risk using simple tests like the MMSE or the clock drawing test. Our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” also discussed the importance of preoperative assessment for vision or hearing impairment, thorough review of the patient’s medications, and preparation of the patient and family/caregivers for the possibility of delirium.

NICE has just published a 662-page guidance “DELIRIUM: diagnosis, prevention and management” that is probably the most comprehensive single-source document available on all aspects of delirium. Fortunately, the important lessons have been distilled into a much more manageable summary document and a recent BMJ issue had an even briefer summary. The most important recommendation from the NICE guidance is: “THINK DELIRIUM”. Basically, we need a high index of suspicion in patients with risk factors for delirium and constant awareness of factor that might precipitate delirium and then constant vigilance to identify it early and manage it effectively.

NICE identifies 4 risk factors for delirium as really standing out:

• Age 65 or older
• Cognitive dysfunction or dementia
• Current hip fracture
• Any severe illness

They stress, both at presentation and throughout the patient’s course, asking about and observing for signs of change in behavior or fluctuations in behavior. Family or caregivers may first point these out. In particular, the hypoactive form of delirium may be the hardest to detect. Look also for changes in cognitive function, perception, physical function, and social behavior. While we typically think about confusion, hallucinations, delusions, agitation, restlessness, and sleep disturbances as signs of delirium, those with hypoactive delirium may have poor concentration, slowed responses, reduced mobility and reduced movements, changes in appetite, and social withdrawal. If signs suggestive of possible delirium are present, someone trained in delirium recognition should do a formal clinical assessment. They discuss the use of validated tools such as the CAM and CAM-ICU to screen for delirium. Note there was also just published a review (Wong 2010) on multiple different tools that are used to screen for delirium, comparing the pros and cons of each and including such practical considerations as how long the provider can spend doing such assessments. While they concur that the CAM is probably the best tool to use, they point out the simple GAR (Global Attentiveness Rating) may also be an effective tool. In the GAR you simply have a 2-minute conversation with the patient and ask yourself “how well did the patient keep his mind on interacting with you during the interview?” (you rate him on a 1-to-10 visual analogue scale).

In addition to identifying and managing underlying causes and precipitating factors (eg doing a full drug review, looking for electrolyte disturbances, hypoxemia, infection, etc.), they offer practical suggestions on managing the patient with delirium:

• Try to maintain as much consistency and familiarity of staff for the patient as possible
• Avoid moving the patient from room to room or ward to ward if possible
• Involve family, friends and familiar caregivers as much as possible
• A multicomponent intervention package (delivered by a multidisciplinary team) should be tailored to the individual needs of the patient
• Reorientation
• Reassurance
• Appropriate lighting
• Clear signage
• Consider a readily visible clock and calendar
• Assess and modify any sensory deficits (eg. hearing, vision)
• Regular visits from family and friends
• Avoid dehydration, attend to nutritional status
• Prevent constipation
• Look for and treat infection, hypoxia, etc.
• Assess for and manage pain
• Avoid catheters, restraints
• Mobilize early
• Promote natural sleep (minimize noise, avoid procedures or meds when sleeping, etc.)
• Use verbal or non-verbal de-escalation techniques where possible for the distressed patient
• Only when the above fail, consider short-term haloperidol or olanzapine, beginning in very low doses and titrating to effect on the patient’s symptoms.

They note the importance of documenting the occurrence of delirium not just in the hospital record but also in the ambulatory record, given the serious long-term associations seen with delirium.

We also refer you back to our January 26, 2010 Patient Safety Tip of the Week “Preventing Postoperative Delirium”) for a discussion on the role of depth of sedation/anesthesia, type of opioids used, and pre-op hydration management in preventing postoperative delirium.

References:

Mantz J, Hemmings H, Boddaert J. Case Scenario: Postoperative Delirium in Elderly Surgical Patients. Anesthesiology 2010. 112(1): 189-195  January 2010

http://journals.lww.com/anesthesiology/Fulltext/2010/01000/Case_Scenario__Postoperative_Delirium_in_Elderly.32.aspx

Wong CL; Holroyd-Leduc J, Simel DL, Straus SE. Does This Patient Have Delirium?: Value of Bedside Instruments. JAMA 2010; 304(7): 779-786

http://jama.ama-assn.org/cgi/content/abstract/304/7/779

Witlox J,  Eurelings LSM, de Jonghe JFM et al. Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia: A Meta-analysis. JAMA. 2010; 304(4):443-451

http://jama.ama-assn.org/cgi/content/abstract/304/4/443

NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010

full guidance:

http://www.nice.org.uk/nicemedia/live/13060/49908/49908.pdf

NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010

summary document:

http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf

Young J, Murthy L, Westby M, Akunne A, O’Mahony R, on behalf of the Guideline Development Group.Guidelines: Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ 341:doi:10.1136/bmj.c3704 (Published 28 July 2010)

http://www.bmj.com/content/341/bmj.c3704.extract?sid=4453e855-9632-412d-9028-89422c5ff442

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What's New in the Patient Safety World?

August 2010

·Sedation Costs for Pediatric MRI

·Surgical Case Listing Accuracy

·ISMP Advice on Catheter Misconnections

·Suicide Risk By Method Of First Attempt

·SCIP: Disappointing Outcomes on SSI’s. What’s Next?

Sedation Costs for Pediatric MRI

In our May 25, 2010 Patient Safety Tip of the Week “Propofol Issues” we noted that propofol has quietly become the procedural sedating agent of choice in many venues, particularly when dealing with pediatric patients. In fact, at the recent Pediatric Academic Societies meeting research was presented on over 25, 000 cases using propofol sedation in areas outside the OR by emergency physicians. That abstract (Mallory et al 2010) presented data from the Pediatric Sedation Research Consortium. The vast majority of these (22,068) were performed in radiology. We discussed some of the safety issues in that column.

Now a new study (Vanderby 2010) addresses the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively.

The Toronto group used their analyis to significantly redesign workflow and scheduling. This article has a good discsussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.

References:

Smith M. PAS: Propofol Widely Used to Sedate Children. MedPageToday.com. May 3, 2010

http://www.medpagetoday.com/MeetingCoverage/PAS/19892

Mallory MD, Baxter AL, Yanosky DJ,  Cravero. JP. Use of Propofol for Sedation of Pediatric Patients by Emergency Physicians: A Report from the Pediatric Sedation Research Consortium (abstract). Pediatric Academic Societies meeting May 1, 2010

http://www.abstracts2view.com/pas/view.php?nu=PAS10L1_3860

Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237

http://radiology.rsna.org/content/256/1/229.abstract

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Surgical Case Listing Accuracy

Wrong site/wrong patient surgery continues to occur despite use of universal protocol, surgical timeouts, and various surgical checklists like the WHO Surgical Safety Checklist.

One opportunity for errors to occur that could lead to wrong site/wrong patient surgery is when surgical cases are “booked”. A new paper (Cima 2010) looked at the frequency of errors in the surgical case listing at a large academic medical center and found such errors in 1.38% of cases. Fortunately, there were no cases of wrong site/wrong patient surgery in their organization because the errors were picked up by a variety of healthcare workers preoperatively or in the OR. But the sheer number of cases with errors in booking highlights the serious potential during his step to set the stage for a wrong site surgery to occur.

They found that missing laterality was the most common error (66%), followed by incorrect laterality (14%) and incorrect listing besides laterality (11%). Such listing errors were found across the gamut of surgical specialties.

The findngs prompted the organization to revise its procedures for surgical case listing. They implemented an electronic surgical listing system using standardized case descriptions that required input of the laterality. Implementation of that system in ob/gyn surgery reduced the frequency of errors from 1.50% to 0.54% and in colorectal surgery from 2.06% to 0.49%.

We recommend you do this sort of audit in your organization to see what your potential vulnerability is during the booking process. Equally importantly, look at how your other “defenses” would pick up such potential problems prior to surgery. Are 100% of your cases reviewed the day prior to surgery by healthcare workers trained to identify such errors? Any case not reviewed until the day of surgery is one step closer to being a sentinel event. Who do you allow to book cases? Do you require formal designation of laterality at the time of booking? How do you ensure that all cases with imaging findings have laterality reconciliation prior to surgery?

References:

The Joint Commisssion. Universal Protocol. Updated 2010.

http://www.jointcommission.org/PatientSafety/UniversalProtocol/

WHO Surgical Safety Cheklist

http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

Cima RR, Hale C, Kollengode A, et al. Surgical Case Listing Accuracy: Failure Analysis at a High-Volume Academic Medical Center. Arch Surg. 2010; 145(7): 641-646

http://archsurg.ama-assn.org/cgi/content/abstract/145/7/641

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ISMP Advice on Catheter Misconnections

ISMP (Institute for Safe Medication Practices) reported two more cases of catheter misconnections last month but noted progress in initiatives to get industry to adopt standards that would render certain catheter fittings incompatible with tubing sets intended for other purposes.

One case involved administration of cholestyramine into an IV catheter and the other administration of barium into a central venous line. The article lists many other published examples of catheter misconnections and a link to a page with all their previous articles dealing with catheter misconnections.

References:

ISMP. Preventing catheter/tubing misconnections: Much needed help is on the way.

ISMP Medication Safety Alert (Acute Care Edition) 2010; 15(14): 1-2  July 15, 2010

http://www.ismp.org/newsletters/acutecare/articles/20100715.asp

ISMP. Collection of all their catheter misconnection articles.

http://www.ismp.org/newsletters/acutecare/articles/Catheter-Misconnections.asp

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Suicide Risk By Method Of First Attempt

Most studies show about a 10% risk of suicide in a patient who has previously attempted suicide and that the risk is highest in the year following the attempt. Therefore, most assessments of patients after a suicide attempt focus on identification of risk factors for current and future suicide. Such assessments focus on known risk factors like male sex, older age in women, presence of a psychiatric disorder, and level of suicidal intent (considering things like “was there a well-thought out plan?”).

Now a new study (Runeson 2010), using data from linked databases in Sweden, has captured long-term data on the risk of successful suicide after a prior attempted suicide. In this study, 12% of patients committed suicide after a prior attempted suicide during a followup period of 21-31 years.

The most important finding, however, was that the risk varied significantly by the method used during the first attempted suicide. Whereas poisoning (overdoses) and cutting are far and away the most common methods of attempted suicide, the highest relative risk for successful suicide was for those whose index attempt was by hanging, strangulation, or suffocation/drowning and 87% of these suicides occurred within one year of the initial attempt. The risks were also higher for those whose index attempt involved firearms or explosives, gassing, or jumping from heights. Most successful suicides also used the same method that had been tried in the index attempted suicide.

The presence of a psychotic or affective disorder were additional independent risk factors for suicide. So a patient with such a severe psychiatric disorder and a suicide attempt by a method such as hanging, drowning or firearms would be at particularly high risk.

The implications of this study are that method of attempted suicide should be included in the overall risk assessment and that those patients deemed to be at the highest risk merit close followup, especially during the first year. The editorial accompanying the study (Hawton 2010) points out that the study was unable to determine whether the method used in the index attempt may have simply reflected the degree of lethality or intent on the part of the patient. It also notes that while these statistics accurately describe a population, it is still difficult to apply them in individual cases. Would you followup a patient who had attempted suicide by overdose any less rigorously than one who attempted suicide by hanging? Probably not. But you can expect the key points of this study to probably be incorporated into some existing suicide risk assessment tools.

References:

Runeson B, Tidemalm D, Dahlin M, et al. Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study.

BMJ  2010; 341: c3222

http://www.bmj.com/cgi/reprint/341/jul13_1/c3222

Hawton K. Completed suicide after attempted suicide. BMJ  2010; 341:c3064

http://www.bmj.com/cgi/content/extract/341/jul13_1/c3064

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SCIP: Disappointing Outcomes on SSI’s. What’s Next?

Most of us read with a certain degree of disappointment the recent publication (Stulberg 2010) of outcomes using the SCIP (Surgical Care Improvement Project) measures. Adherence reported on individual SCIP measures was not associated with a significantly lower probability of infection, though adherence to the global all-or-none composite infection prevention score was associated with a lower incidence of SSI’s (surgical site infections).

But some empirical observations have led to another possible approach for reducing SSI’s: selection of anesthesia type. A new population-based study (Chang 2010) showed that patients having total hip or total knee replacement surgery done under general anesthesia are 2.21 times more likely to develop an SSI within 30 days of surgery compared to those done under epidural or spinal anesthesia.

The authors propose several potential biological explanations for the findings, all of which should be considered hypotheses at this time. Because this was a retrospective analysis and not a randomized controlled trial, one cannot be sure that there was not patient selection bias or some confounding variable that led to these results. Nevertheless, this empirical observation is striking and should lead to a randomized controlled trial.

The accompanying editorial (Sessler 2010) notes that the magnitude of difference here is similar to that seen with timely use of prophylactic antibiotics. He points out that other promising interventions, such as potential use of supplemental oxygen, did not hold up when assessed under the scrutiny of randomized controlled trials.

References:

Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections
JAMA 2010; 303: 2479-2485 June 23/30, 2010

http://jama.ama-assn.org/cgi/content/abstract/303/24/2479?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=scip&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Chang C-C, Lin H-C; Lin H-W, Lin H-C. Anesthetic Management and Surgical Site Infections in Total Hip or Knee Replacement: A Population-based Study. Anesthesiology 2010; 113(2): 279-284 August 2010

http://journals.lww.com/anesthesiology/Fulltext/2010/08000/Anesthetic_Management_and_Surgical_Site_Infections.10.aspx

Sessler, DI. Neuraxial Anesthesia and Surgical Site Infection. Anesthesiology 2010; 113(2) :265-267  August 2010

http://journals.lww.com/anesthesiology/Fulltext/2010/08000/Neuraxial_Anesthesia_and_Surgical_Site_Infection.3.aspx

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