Patient Safety Tip of the Week
March 21, 2017 Success at Preventing Delirium
Our many columns on
delirium have stressed the importance of prevention, since treatment of
delirium is difficult. Two of the most common settings in which we see delirium
are the ICU and the postoperative setting.
Weve frequently
mentioned multi-component non-pharmacological interventions such as HELP, the Hospital Elder Life Program (see
our October 21, 2008 Patient Safety Tip of the Week Preventing
Delirium and our September 2011 What's New in the Patient Safety World
column Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery) or tools like
the ABCDEF Bundle (see our September 20, 2016 Patient Safety Tip of the Week Downloadable
ABCDEF Bundle Toolkits for Delirium).
Another recent study examined the impact of a delirium
prevention bundle (DPB) on ICU patients (Smith
and Grami 2017). Bundle components were similar to many from the above mentioned bundles
and included sedation cessation, pain management, sensory stimulation, early
mobilization, and sleep promotion. The bundle was implemented on one ICU and
another ICU with comparable patients served as the control. Nurses assessed
patients with the CAM-ICU and RASS tools that weve described in multiple
columns.
For those patients
on mechanical ventilation a spontaneous awakening trial, if successful, was
followed by a spontaneous breathing trial. The sensory stimulation included not
only placing familiar objects (clock, calendar) nearby
but also opening/closing window blinds to create diurnal variation, and wearing
any devices (hearing aids, glasses) that a patient would wear at home.
Mobilization was tailored to the physical capabilities of the patient and
ranged from range-of-motion exercises to actual ambulation. Sleep was promoted
by clustering nursing interventions in a manner to avoid waking the patient as
much as possible, dimming lights and closing blinds, and minimizing ambient
noise.
The odds of delirium
were reduced by 78% on the intervention unit compared to the control unit.
But perhaps the
biggest contribution of the study is the description of the difficulties
encountered in delivering the delirium prevention bundle. Implementing a bundle
like this is not easy. Smith and Grami point out that
barriers were encountered with almost every facet of the multicomponent
intervention. For example, families were often reluctant to bring in the
patients hearing aids or glasses for fear of these items getting lost. And not
all physicians were using the sedation cessation protocol. And the sleep
promotion was less than satisfactory because of lights and sound in the ICU.
And the early mobilization program suffered from lack of staff and equipment
plus the incongruity between physical therapy and more aggressive mobilization
guidelines. And some details about the pain management were missing (their
intended data collection included information about not just pain levels but
also pain medication doses and times and pain scores one hour following
administration).
So its pretty
remarkable that they were still able to demonstrate a 78% reduction in
delirium. But it really demonstrates that a predominantly nurse-led
intervention bundle can have a significant impact on preventing this serious
complication. Kudos to the dedication of that nursing staff for their
persistence in doing the right thing!
Postoperative delirium is the other very problematic entity
that needs prevention. Our December
2014 What's New in the Patient Safety World column American
Geriatrics Society Guideline on Postoperative Delirium in Older Adults
discussed the work done by the American Geriatrics Society Expert Panel on Postoperative
Delirium in Older Adults. They developed a clinical practice guideline (AGS
2015a) that was followed by a best practice statement published in the
Journal of the American College of Surgeons (AGS
2015b). The guideline describes the nonpharmacologic
prevention and treatment of postoperative delirium. It recommends that
hospitals and healthcare systems have educational programs with frequent
refresher sessions on delirium. It recommends that an interdisciplinary team
implement a multicomponent nonpharmacologic
intervention program.and follow that patient
throughout the hospital course. It notes such interventions have reduced the
incidence of delirium 30-40%. It also describes the medical evaluation that
should be undertaken once a patient is diagnosed as having delirium. It notes
again that multicomponent interventions have been successful in reducing
delirium duration and severity, length of stay, etc. but that it is not
possible to conclude which specific component(s) are responsible.
So the results of a recent survey of anesthesiologists who
were attendees of the 16th World Congress of Anaesthesiologists
in Hong Kong last year were somewhat bothersome (Agres
2017). Though the vast majority of respondents acknowledged they
frequently or occasionally encountered postoperative delirium, 77% lacked a
process to screen for at-risk patients. Moreover, 84% said their hospital or
clinic did not have protocols to prevent postoperative delirium and 73% lacked
protocols to manage delirium. The survey was commissioned by POND Awareness.
Our January 24, 2017
Patient Safety Tip of the Week Dexmedetomidine
to Prevent Postoperative Delirium focused on the study by Su et al. (Su
2016) on using low dose dexmedetomidine to prevent postoperative delirium. However,
in that column we also mentioned several of the other interventions, primarily
non-pharmacological, used to prevent delirium.
We noted the recent pragmatic clinical trial that addressed
delirium prevention in patients age 65 and older who underwent surgery for hip
fracture (Freter 2016).
Rather than intervene with all the elements of multifactorial interventions
that have been used for delirium prevention, the researchers used only those
that lent themselves to easy incorporation into postoperative preprinted
orders. Those that fit included interventions for nausea, nighttime sedation,
pain control, and bowel and bladder care. The postoperative preprinted orders
had the same elements as the standardized postoperative orders for hip surgery
patients with several differences:
- Acetaminophen was ordered
on a scheduled, rather than prn, basis and the doses and frequency of
as-needed opioid analgesics were lower.
- Trazadone was used for
required nighttime sedation (control patients often received chloral
hydrate or zopiclone).
- For nausea, domperidone was used instead of dimenhydrinate.
- Urinary catheters were
removed on POD#2, followed by determination of post-void residuals.
- Laxatives were given on a
scheduled, rather than prn, basis.
- For severe agitation low
doses of haloperidol were specified.
Delirium occurred significantly less frequently (27% vs. 42%
in controls on POD#1 and 7% vs. 30% in controls on POD#5) despite the fact that
more patients in the intervention group had pre-existing dementia, a known risk
factor for delirium. More patients in the intervention group had early
postoperative bowel movements and more urinary catheter removals on POD#2.
Significantly, intervention patients received less opioid analgesia (24 mg
morphine equivalents vs. 44 mg morphine equivalents in controls). But, although
the intervention group had less postoperative delirium, there were no
differences in length of stay, mortality, or nursing home placement rates.
As an aside, in
follow up to the article in our January 24, 2017 Patient Safety Tip of the Week
Dexmedetomidine
to Prevent Postoperative Delirium by Su et al. on use of dexmedetomidine
to prevent postoperative delirium (Su
2016), there was a recent discussion in The Lancet about the potential
neuroprotective effects of dexmedetomidine (Avramescu
2017, Su
2017). They note its effects could be due to reducing sedative drug
consumption, enhancing sleep quality, and relieving surgical stress and
inflammatory responses after surgery.
However, they note that dexmedetomidine use is
still only recommended in highly monitored settings because of its potential
cardiorespiratory effects but express hope that safety and efficacy studies in
other venues might be performed.
So while you are waiting for the dexmedetomidine
study to be replicated and validated in other clinical settings, take the
opportunity to implement one of the non-pharmacologic multicomponent
interventions that have proven successful. The very practical protocols put in
place by Smith and Grami and by Freter
and colleagues show good results are possible. But be prepared to encounter
some of the barriers that Smith and Grami described.
Some of our prior
columns on delirium assessment and management:
·
October
21, 2008 Preventing
Delirium
·
October
14, 2008 Managing
Delirium
·
February
10, 2009 Sedation
in the ICU: The Dexmedetomidine Study
·
March
31, 2009 Screening
Patients for Risk of Delirium
·
June 23,
2009 More
on Delirium in the ICU
·
January
26, 2010 Preventing
Postoperative Delirium
·
August
31, 2010 Postoperative
Delirium
·
September
2011 Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery
·
December
2010 The
ABCDE Bundle
·
February
28, 2012 AACN
Practice Alert on Delirium in Critical Care
·
April 3, 2012 New
Risk for Postoperative Delirium: Obstructive Sleep Apnea
·
August
7, 2012 Cognition,
Post-Op Delirium, and Post-Op Outcomes
·
February
2013 The
ABCDE Bundle in Action
·
September
2013 Disappointing
Results in Delirium
·
October
29, 2013 PAD:
The Pain, Agitation, and Delirium Care Bundle
·
February
2014 New
Studies on Delirium
·
March
25, 2014 Melatonin
and Delirium
·
May 2014
New
Delirium Severity Score
·
August
2014 A
New Rapid Screen for Delirium in the Elderly
·
August
2014 Delirium
in Pediatrics
·
November
2014 The
3D-CAM for Delirium
·
December
2014 American
Geriatrics Society Guideline on Postoperative Delirium in Older Adults
·
June 16,
2015 Updates
on Delirium
·
October
2015 Predicting
Delirium
·
April
2016 Dexmedetomidine
and Delirium
·
April
2016 Can
Antibiotics Lead to Delirium?
·
July
2016 New
Simple Test for Delirium
·
September
20, 2016 Downloadable
ABCDEF Bundle Toolkits for Delirium
·
January
24, 2017 Dexmedetomidine
to Prevent Postoperative Delirium
References:
Smith CD, Grami P. Feasibility and
Effectiveness of a Delirium Prevention Bundle in Critically Ill Patients. Am J Crit Care 2017;
26(1): 19-27
http://ajcc.aacnjournals.org/content/26/1/19.full?sid=bbc68db0-bd05-4271-bfc6-1346268290de
The American Geriatrics Society Expert Panel on
Postoperative Delirium in Older Adults. American Geriatrics Society Abstracted
Clinical Practice Guideline for Postoperative Delirium in Older Adults. J Am Geriatr Soc 2015; 63(1): 142-150
The American Geriatrics Society Expert Panel on
Postoperative Delirium in Older Adults. Postoperative delirium in older adults:
best practice statement from the American Geriatrics Society. J Am Coll Surg 2015; 220: 136-148.e1
http://www.journalacs.org/article/S1072-7515%2814%2901793-1/fulltext
Agres T. Protocol Lacking for
Post-op Delirium. Anesthesiology News 2017; February 6, 2017
POND Awareness website.
Su X, Meng Z-T, Wu X-H, et al. Dexmedetomidine for prevention of delirium in elderly
patients after non-cardiac surgery: a randomised,
double-blind, placebo-controlled trial. The Lancet 2016; 388(10054): 1893-1902
Published: 15 October 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30580-3/fulltext
Freter S, Koller
K, Dunbar M, MacKnight C, Rockwood
K. Translating Delirium Prevention Strategies for Elderly Adults with Hip
Fracture into Routine Clinical Care: A Pragmatic Clinical Trial. J Am Geriatr Soc 2016; Early View 22
NOV 2016
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14568/epdf
Avramescu S, Wang D-S, Choi S, Orser BA. Preventing delirium: beyond dexmedetomidine.
The Lancet 2017; 389: 1009
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30661-X/fulltext
Su X, Wang D-X, Ma D. Preventing delirium: beyond dexmedetomidine Authors' reply. The Lancet 2017; 389:
1009-1010
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30658-X/fulltext
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