October 14, 2008
As we anticipated, delirium did not make the final cut on the CMS list of conditions (“never events”) for which payment will be withheld (see our April 22, 2008 Patient Safety Tip of the Week “CMS Expanding List of No-Pay Hospital-Acquired Conditions”). But that doesn’t mean that managing delirium is not important for your bottom line. Quite frankly, it is very important for both your patients and your bottom line and you need to have a systematic approach to both recognizing delirium and managing it.
Numerous studies have shown that patients with delirium have excess morbidity and mortality, excess hospital resource consumption, and are more likely to suffer cognitive and functional decline, institutionalization and death in the year following hospitalization. Leslie et al (Leslie et al. 2008) showed that delirium is associated with prolonged lengths of stay and excess costs. Average costs per day survived among patients with delirium were more than 2 times the costs among patients without delirium and total healthcare cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient in the year following delirium.
There are some excellent delirium resources available for free on the Internet. National guidelines “Clinical Practice Guidelines For The Management Of Delirium In Older People” published in Australia in late 2006 provide some excellent recommendations on identification, prevention, and management of delirium. Vanderbilt University’s ICU Delirium and Cognitive Impairment Study Group website is also an excellent resource for information on delirium. And the National Guideline Clearinghouse has several resources available for delirium, including “Delirium: prevention, early recognition, and treatment. In: Evidence-based geriatric nursing protocols for best practice.”
For those interested in the pathophysiology of delirium, we refer you to the discussion in the Girard (Girard 2008) and Fricchione (Fricchione 2008) papers. There has been much speculation about the role of inflammatory processes in the etiology of delirium, particularly since the time course of post-operative delirium (typically occurring 2-7 days post-op) tends to parallel the inflammatory response seen after surgery.
Delirium has long been underrecognized in hospital settings. One of the problems is that the agitated or hyperactive subtype of delirium is more easily recognized than the more common hypoactive subtype. A number of structured clinical tools have been developed and validated to aid in identifying delirium in patients in several different hospital settings. These include the Confusion Assessment Method (CAM), Confusion Assessment Method for the ICU (CAM-ICU), the Intensive Care Delirium Screening Checklist (ICDSC), the Delirium Detection Score (DDS), and the Nursing Delirium Screening Scale (Nu-DESC). We also previously noted that if the Hazards of Hospitalization Questionnaire tool (Fernandez 2008) can be validated in several settings or populations, it has tremendous potential to help us prevent complications such as delirium.
Delirium is commonly precipitated by acute intercurrent illnesses such as infections, metabolic derangements, surgery and medications. Post-operative delirium is very common and especially likely to occur after major orthopedic or vascular or cardiovascular surgery or major abdominal or head/neck surgery. Risk factors for delirium include advanced age, smoking, hypertension, pre-existing dementia, depression, prior history of delirium, visual impairment, hyponatremia, alcohol-related illness, indwelling urinary catheters, use of physical restraints, and sleep deprivation.
A series of articles out of Vanderbilt University recently have looked at the prevalence and risk factors associated with delirium in the ICU setting. Girard and colleagues (Girard 2008) noted that delirium may be present in up to 80% of ICU patients. Pandharipande et al (Pandharipande 2008), using the Richmond Agitation Sedation Scale (RASS) and the CAM-ICU tools, found 73% of surgical ICU patients and 67% of trauma ICU patients had delirium. While many of the traditional risk factors for delirium that apply to all hospitalized patients also occur in ICU’s, certain risk factors are much more prevalent in ICU’s. Sleep deprivation is very frequent in the ICU setting and use of sedatives and analgesics is very high in ICU patients. Midazolam and lorazepam, but probably benzodiazepines as a class, have been implicated as strong risk factors for delirium in the ICU setting as well as other settings. Such drugs are used almost universally in patients being mechanically ventilated in ICU’s.
Benzodiazepines are a treatment of choice in alcohol withdrawal. However, alcohol withdrawal may often be inappropriately diagnosed in patients with delirium of other cause. Hecksel and colleagues (Hecksel 2008) at the Mayo Clinic looked at use of a widely utilized symptom-directed protocol for managing alcohol withdrawal. However, when they looked at its use on med-surg units, they found it was administered inappropriately in a substantial proportion (over 50%) of patients, many of whom suffered adverse events related to the treatment. Many of the patients had causes of delirium unrelated to alcohol withdrawal. This was particularly so in post-operative cases. These findings stress the importance of a thorough search for etiology and precipitants in patients who develop delirium in the hospital.
Opiates have also been implicated as risk factors for development of delirium. Just about every opiate preparation, administered via a variety of routes, has been implicated in one study or another. Meperidine especially seems to be related to development of delirium. However, inadequately treated pain is also a risk factor for delirium. So judicious use of opiates may be necessary but alternative analgesics should be considered if they provide adequate pain relief.
Drugs on Beer’s list (see our January 15, 2008 Patient Safety Tip of the Week “ ” and June 2008 What’s New in the Patient Safety World “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”) should generally be avoided.
Important to remember is the risk of falls and injury is much higher in patients with altered cognition and this is especially the case in patients with delirium. One of the benefits of a delirium management protocol may be a reduction in the rate of falls (Kratz 2008).
So what strategies can be used to prevent delirium? Environmental modifications may be helpful. Using lighting appropriate to the time of day, noise reduction, providing familiar clues from the home environment, avoiding room changes, adequate hydration, good bowel/bladder care, early mobilization, use of vision and hearing aids, involvement of family and friends, avoiding catheters and restraints are some of the interventions commonly used. Careful review of all medications is critical and where possible benzodiazepines and drugs on Beer’s list should be avoided. There is no good evidence that use of specific drug therapy can prevent delirium, though there is some evidence that use of haloperidol may reduce the duration and severity of delirium.
Several studies have demonstrated that multifactorial interventions targeted at elderly inpatients at risk for delirium may shorten hospital length of stay, reduce duration of delirium, and reduce mortality (Lundstrom et al. 2005; Naughton et al 2005). The Lundstrom study showed that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients. The Naughton study showed that a multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings. So there does appear to be some evidence that such programs make sense from quality, patient safety, and financial perspectives. An evidence-based nursing protocol (Kratz 2008) focusing on orientation, nonpharmacologic sleep and early mobilization resulted in significant reductions in falls, restraint use, medication use, and sitter usage.
For those patients with delirium severe enough to merit pharmacologic intervention, we refer the reader to the paper by Fricchione et al (Fricchione 2008). Though the evidence base for any pharmacologic intervention is scant at best, haloperidol (particularly by the IV route) appears to be the mainstay of treatment and is in the APA guidelines. The Fricchione paper also discusses the potential hazards of haloperidol use, including the risks of hypotension, extrapyramidal syndromes, and Q-T interval prolongation and torsade de pointes. They also discuss the use of other pharmacologic therapies and future strategies.
We strongly encourage organizations to develop policies and protocols for identification, prevention and management of delirium. Most of the interventions have little cost involved and the cost savings can be substantial.
Since we originally posted this Tip we’ve come across another incredibly useful resource. The Hartford Institute for Geriatric Nursing at ConsultGeriRN.org, a site that we often recommend for useful resources, does a great job of demonstrating how to use the CAM tool. These include an article with a case study to show how CAM is used and a well-done video showing techniques that can be used in different scenarios.
See the second part in our series on delirium in our Patient Safety Tip of the Week for October 21, 2008 “Preventing Delirium” and see also our February 10, 2009 Patient Safety Tip of the Week “Sedation in the ICU: The Dexmedetomidine Study” and our March 31, 2009 Patient Safety Tip of the Week “Screening Patients for Risk of Delirium” and our June 23, 2009 Patient Safety Tip of the Week “More on Delirium in the ICU” and our January 26, 2010 Patient Safety Tip of the Week “Preventing Postoperative Delirium”.
Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch Intern Med 2008; 168(1): 27-32. http://archinte.ama-assn.org/cgi/content/abstract/168/1/27
Clinical Epidemiology and Health Service Evaluation Unit, Melbourne
Health in collaboration with the Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines For The Management Of Delirium In Older People.
Victorian Government Department of Human Services: Melbourne, Victoria,
Australia October 2006
National Guideline Clearinghouse. Delirium: prevention, early recognition, and treatment. In: Evidence-based geriatric nursing protocols for best practice. Updated Jan. 2008
Girard TD. Pandharipande PP. Ely EW. Delirium in the intensive care unit. [Review] [69 refs] Critical Care (London, England) 2008; 12 Suppl 3:S3 http://ccforum.com/content/12/S3/S3
Fricchione GL. Nejad SH. Esses JA. Cummings TJ Jr. Querques J. Cassem NH. Murray GB. Postoperative delirium. American Journal of Psychiatry 2008; 165(7):803-12
Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House Staff Member Awareness of Older Inpatients' Risks for Hazards of Hospitalization. Arch Intern Med. 2008;168(4):390-396 http://archinte.ama-assn.org/cgi/content/abstract/168/4/390
Pandharipande P. Cotton BA. Shintani A. Thompson J. Pun BT. Morris JA Jr. Dittus R. Ely EW. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. Journal of Trauma-Injury Infection & Critical Care 2008; 65(1):34-41 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200807000-00006.htm;jsessionid=L0GJH75CtGJ553LJLJnN9gh7Jg5NrMnwnfZCSxd9xV951X3skKQ0!-1763103798!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search
Hecksel KA, Bostwick JM, Jaeger TM, Cha, SS. Inappropriate Use of Symptom-Triggered Therapy for Alcohol Withdrawal in the General Hospital. Mayo Clinic Proceedings 2008; 83(3):274-279 http://www.mayoclinicproceedings.com/inside.asp?AID=4611&UID
Kratz A. Use of the Acute Confusion Protocol: A Research Utilization Project. Journal of Nursing Care Quality2008; 23(4):331-337 http://www.jncqjournal.com/pt/re/jncq/abstract.00001786-200810000-00008.htm;jsessionid=L0gPLp4fCkkb2Z391xs1Nzq2y2vLh1JKcKHy9rk2zhtsbHZQV5Dy!-1763103798!181195628!8091!-1
Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005; 53(4): 622–628 http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53210.x?prevSearch=allfield%3A%28Lundstrom%29
Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R, Mylotte JM. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005; 53(1):18–23 http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53005.x?prevSearch=allfield%3A%28naughton%29