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Delirium Prevention in the ICU: A Literature ReviewStephanie Chakonas, Aubree Mandell, Brianna German, Ana Regan, Yesenia Rosa

Florida Gulf Coast University, Marieb College of Health & Human Services, School of Nursing

Abstract

ReferencesBounds, M. (2016). Effect of ABCDE bundle implementation on prevalence of delirium in

intensive care unit patients. American Journal of Critical Care, 25(6), 535-544. doi:10.4037/ajcc2016209

DiSabatino Smith, C. & Grami, P. (2017). Feasibility and effectiveness of a delirium prevention bundle in critically ill patients. American Journal of Critical Care. 26(1). doi:10.4037/ajcc2017374

Elliott, S. R. (2014). ICU delirium: A survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive & Critical Care Nursing, 30(6), 333-338. doi:10.1016/j.iccn.2014.06.004

Hannon, S. (2015). ICU delirium: Impacts & interventions. Alaska Nurse, 66(5), 6-7. Retrieved from: http://www.aknurse.org

Hicken, S. L., White, S., & Knopp-Sihota, J. (2017). Delirium in the intensive care unit: A nursing refresher. Canadian Journal of Critical Care Nursing, 28(2), 19-23. doi:10.4103/0974-2700.199520

Martínez, F., Donoso, A. M., & Marquez, C. (2017). Implementing a multicomponent intervention to prevent delirium among critically ill patients. Critical Care Nurse, 37(6), 36-47. doi:10.4037/ccn2017531.

McNamara, L., (2018). Patient care and delirium assessment. American Journal of Critical Care, 17(6), 576. Retrieved from http://ajcc.aacnjournals.org/

Munro, C. L., Cairns, P., Ji, M., Calero, K., Anderson, W. M., & Liang, Z. (2017). Delirium prevention in critically ill adults through an automated reorientation intervention: A pilot randomized controlled trial. Heart & Lung: The Journal of Critical Care, 46(4), 234-238. doi:10.1016/j.hrtlng.2017.05.002

Pereira, J. M., Dos Reis Barradas, F. J., Caetano Sequeira, R. M., Mendes Pinto Marques, M. C., Batista, M. J., Galhardas, M., & Santinho Santos, M. (2016). Delirium in critically ill patients: Risk factors modifiable by nurses. Revista De Enfermagem Referência, 4(9), 29-36. doi:10.12707/RIV16006

Smithburger, P. L., Korenoski, A. S., Kane-Gill, S. L., & Alexander, S. A. (2017). Perceptions of family members, nurses, and physicians on involving patients' families in delirium prevention. Critical Care Nurse, 37(6), 48-58 doi:10.4037/ccn2017901.

Yang, J., Zhou, Y., Kang, Y., Xu, B., Wang, P., Lv, Y., & Wang, Z. (2017). Risk factors of delirium in sequential sedation patients in intensive care units. Biomed Research International, 1-9. doi:10.1155/2017/3539872

PICO QuestionIn ICU patients, can nurses better prevent delirium through quality improvement and patient-centered care practices in order to

decrease mortality rates, reduce incidences of long term cognitive impairment, avoid prolonged

length of stays, and mitigate prolonged mechanical ventilation?

Patients admitted to the intensive care unit have beenidentified as having an affinity for delirium, placingthem at high risk for negative outcomes. It has beenestimated that roughly 60-80% of patients receivingmechanical ventilation, and 20-50% who are notventilated, are affected by delirium in the ICU(Bounds, 2016).

Delirium is a condition thought to be caused by animbalance of the neurotransmitters dopamine,acetylcholine, and gamma aminobutyric acid andgoes undiagnosed in nearly 60% of critical carepatients (McNamara, 2018).

Delirium has both short and long-term effects onpatients’ levels of functioning and cognition that areadverse in nature (DiSabitino Smith & Grami, 2017).

Delirium generally results in poor outcomes in ICUpatients, including prolonged duration of mechanicalventilation, increased length of stay (LOS), highermortality, and greater hospital costs (Yang et al.,2017).

Delirium can add, on average, 10 days to the patients’mean LOS in the hospital and with each additionalday spent in a delirious state, the patient is at anincreased risk for prolonged hospitalization and anincreased risk of mortality by 20% and 10%respectively (DiSabitino Smith & Grami, 2017).

Nurses spend a great amount of time with theirpatients and it is their duty to provide both safe andpatient-centered care. Nurses have the greatestadvantage in their position at the bedside to detectand prevent delirium in the ICU. For this literaturereview, the authors set out on a quest to seekknowledge and interventions related to deliriumprevention that could be put into practice in order tobetter care for patients in their most vulnerable time,during an ICU stay.

Upon review of the 10 studies used for this project, a plethora of interventions were shown to prevent delirium in the ICU. These interventions are as follows:

• Awakening and breathing coordination• Early mobilization• Physical therapy• Reorientation • Cognitive stimulation• Drug reviews• Environmental stimulation and avoidance of sensory deprivation• Pain control• Restraint use avoidance• Family participation• Early participation of the entire interdisciplinary team• Shared leadership• Providing adequate nutrition• Fluid and electrolyte monitoring• Use of the patient’s glasses or hearing aids• Prevention of infection• Promotion of family visits and activities• Use of the “THINK” pneumonic• Minimizing the use of sedative medications and choice of

medications, avoiding benzodiazepines• Adequate oxygenation• Sleep promotion• Use of observational screening tools• Frequent status checks

Predisposing and non-modifiable risk factors of delirium: Alcohol orsubstance abuse, smoking, hypertension, dementia, mental illness. severity ofillness and older age.

By raising awareness through education and implementation of the itemsdiscussed, nurses can in fact better prevent delirium through qualityimprovement and patient-centered care practices in order to decreasemortality rates, reduce incidences of long term cognitive impairment, avoidprolonged length of stays, and mitigate prolonged mechanical ventilation.

Available KnowledgeAuthor(s) Study Results

Bounds, M. (2016). Effect of ABCDE bundle implementation on prevalence of delirium in intensive care unit patients.

Using electronic medical records, Bounds (2016) sought to quantify the prevalence and duration of delirium in patients in the intensive care unit before and after implementation of the ABCDE bundle. Delirium prevalence was defined as the percentage of patients who had at least 1 positive delirium score on the Intensive Care Delirium Screening Checklist (ICDSC) during their ICU stay.

Outcomes from the implementation of the ABCDE bundle included reduction in the prevalence and duration of delirium in ICU patients and showed that the ABCDE bundle can be implemented within an inter-professional team in a rural hospital setting with much success.

Yang, J., Zhou, Y., Kang, Y., Xu, B., Wang, P., Lv, Y., & Wang, Z. (2017). Risk factors ofdelirium in sequential sedation patients in intensive care units.

Yang et al. (2017) conducted a random controlled experimental study in the MICU and SICU in the West China Hospital of Sichuan University, Sichuan, China. Patient demographic characteristics included age, gender, body mass index, allergies, drinking/smoking status, and medical history. Other factors accounted for included the use of sedative and analgesic medications, mechanical ventilation, and sedation characteristics. Patient evaluations were implemented using the CAM-ICU scale every 4 hours daily for a maximum of 28 days or until ICU discharge.

Yang et al. (2017) demonstrated that older age (≥51), regular smoking, higher SOFA(sequential organ failure assessment) score (≥14), and increased maintenance ofmidazolam and fentanyl when patients met sequential criteria were significant risk factorsof delirium in patients who received sequential sedation. The results of this study alsodemonstrated that sequential sedation with dexmedetomidine (Precedex) was aprotective method to prevent delirium.

Martínez, F., Donoso, A. M., & Marquez, C. (2017). Implementing a multicomponent intervention to prevent delirium among critically ill patients.

Martinez et al. (2017) conducted a random controlled clinical experimental study between May 2014 and August 2015 in an intensive care unit in Yale-New Haven Hospital. Components studied included early mobilization, physical therapy, reorientation, cognitive stimulation, drug reviews, environmental stimulation, avoidance of sensory deprivation, pain control, restraint use avoidance, and family participation. Incident of delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit and Multivariate logistic regression was used to control for confounders.

This program was successful in reducing incidents of delirium among critically ill patients, with a rate reduction of 36% . The authors also found that patient self-removal of invasive impediments also decreased instances of delirium. Early participation with an interdisciplinary team, shared leadership, and the provision of concrete tasks were key to the success of their study.

Smithburger, P. L., Korenoski, A. S., Kane-Gill, S. L., & Alexander, S. A. (2017). Perceptions of family members, nurses, and physicians on involving patients' families in delirium prevention

Smithburger et al. (2017) conducted a qualitative study taking place from March 2015 to July 2015 in a medical ICU at an academic medical center. Two surveys, one for intensive care unit nurses and physicians and one for patients’ families, were developed and administered. The goal of this qualitative study was to evaluate the beliefs and knowledge of family members, physicians, and nurses in regards to delirium.

93% of physicians and all nurses believed that families played a pivotal role in preventingdelirium in ICU patients. Families of ICU patients felt comfort when providing delirium-prevention activities. This not only helps reorient the patient with familiar people andsurroundings, but it also assists the nurse to focus on other aspects of care, such asdiscontinuing medications that have been known to increase the risk delirium.Unfortunately, only 38% of family members reported that a physician spoke to themabout delirium and how to reduce the risk. Thus it was concluded that providers, nurses,and family members need to be further educated about delirium, ways to prevent it, andfor all to work collaboratively in order to provide the best care.

Hicken, S. L., White, S., & Knopp-Sihota, J. (2017). Delirium in the intensive care unit: A nursing refresher

Hickin et al. (2017) conducted a literature review in 2017 comprising of 25 compiled articles to provide nurses with a better understanding of delirium, its risk factors and treatment.

According to the 2013 Pain, Agitation and Delirium (PAD) Guidelines, the four most common risk factors to developing delirium are a history of hypertension, previously diagnosed dementia, the severity of illness, and a history of alcohol or drug use. Some other risk factors associated with delirium include iatrogenic causes including hypoxia, acute infection, intracranial events, electrolyte imbalance, seizures, benzodiazepine infusions, metabolic disturbances, uncontrolled pain, medication, withdrawal states, and dehydration. Some environmental risk factors include sleep deprivation, immobilizations, sensory overload, noise levels, unfamiliar surroundings, visual/hearing impairment, lack of windows, lack of daylight, disorientation, and isolation from family. Nurses play a pivotal role in preventing, managing, and treating delirium for they are at the patient’s bedside 24-7. Thus it is crucial that nurses stay educated on delirium and always screen for delirium in their patients. The 2013 PAD has two validated tools nurses and other healthcare team members can use to screen for delirium, which are The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). Assessment should occur at least once per shift.

Pereira, J. M., Dos Reis Barradas, F. J., Caetano Sequeira, R. M., Mendes Pinto Marques, M. C., Batista, M. J., Galhardas, M., & Santinho Santos, M. (2016). Delirium in critically ill patients: Risk factors modifiable by nurses.

Pereira et al. (2016) conducted a random controlled exploratory-descriptive study in a level two intensive care unit. The authors’ goal was to identify the risk factors that are associated with the development of delirium in patients, which could be modified by nurses

Nurses can implement interventions, such as providing adequate nutrition, maintainingfluid & electrolyte status, providing the patient’s sensory items (dentures, hearing aides,glasses, etc.), prevention of infection, promotion of family visits and activities, reorientingpatients (to their surroundings, family, healthcare team, etc.) and use of non-pharmacological measures (proper positioning, oxygen, etc.) to help reduce theincidence of delirium.

Munro, C. L., Cairns, P., Ji, M., Calero, K., Anderson, W. M., & Liang, Z. (2017). Delirium prevention in critically ill adults through an automated reorientation intervention: A pilot randomized controlled trial.

Munro et al. (2017) conducted a pilot randomized controlled trial was conducted with 30 ICU patients divided into three groups .Ten patients received hourly recorded messages in a family member's voice during waking hours over 3 ICU days, 10 received the same messages in a non-family voice, and 10 (control) did not receive any automated reorientation messages. The primary outcome was delirium free days during the intervention period (evaluated by CAM-ICU).

This study implemented the use of a 2-minute long recorded scripted message to help reorient ICU patients to their current situation played repeatedly every hour for eight hours during waking hours (Munro, Cairns, Calero, Anderson, & Liang, 2017). Three different groups were used for the study: ICU patients who received the message recorded with a family member’s voice, ICU patients who received the message recorded with a non-family member’s voice, and a control group that did not receive a message at all (Munro, Cairns, Calero, Anderson, & Liang, 2017). Study results showed that the ICU patients who repeatedly heard a message recorded with a family member’s voice had more delirium free days than the non-family voice group, and even more delirium free days than the control group (Munro, Cairns, Calero, Anderson, & Liang, 2017).

Hannon, S. (2015). ICU delirium: Impacts & interventions.

Hannon (2015) stated that delirium, specifically in ICU patients, is vastly under detected and thus it tends to go untreated, therefore her goal is to understand how we could improve outcomes.

Risk factors predisposing patients to delirium include alcohol and/or substance abuse,hypertension, dementia and/or other mental illnesses and severity of presenting illness.Preventable risk factors include use of sedating medications such as benzodiazepines.Sedatives should be used cautiously and at a minimal rate. Non-pharmacologicalstrategies need to be provided and should include reorienting the patient, timely removalof restraints and catheters, scheduled pain management, minimal stimulation and noisecontrol, early ambulation and the use of the patient’s visual and hearing prosthesisshould be used to orient the patient and reduce the risk of delirium. Prevention is themain goal and key to success for reducing delirium in the ICU patient population.Hannon suggests using a pneumonic called “THINK”: T- toxic situations such ascongestive heart failure, shocks, dehydration, medications (specifically sedatives), andorgan dysfunction/failure; H- hypoxemia; I- infection/sepsis and immobilization; N- non-pharmacological interventions; such as providing hear aids, glasses, cluster care, noisecontrol, ambulation, and sleep protocols; K- potassium and/or other electrolyte problems.

DiSabatino Smith, C. & Grami, P. (2017). Feasibility and effectiveness of a delirium prevention bundle in critically ill patients

DiSabatino Smith and Grami (2017) conducted a controlled interventional cohort study, which took place in two similar medical-surgical ICUs in Houston, Texas Researchers used the Confusion Assessment Method-ICU to assess delirium incidence with bundle components consisting of sedation cessation, pain management, sensory stimulation, early mobilization, and sleep promotion.

Interventions surrounding the concept of ‘bundle care’ reduced the incidence of delirium by 78%. The bundle of care is known as the Delirium Prevention Bundle (DPB). The DPB includes sedation cessation, pain management, sensory stimulation, early mobilization, and sleep promotion. The sample population was 447 ICU patients.

Elliott, S. R. (2014). ICU delirium: A survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit.

Elliot (2014) conducted an experimental study which included a survey using a sample of 149 nursing and medical staff .The study was conducted in the United Kingdom 2011 in the ICU of 3 hospitals. The goal of this research study was to assess the knowledge base of the ICU staff on the subject of delirium.

It was found that, while there is a national and validated screening tool for delirium, it isnot being used in ICU settings (Elliott, 2014). The conclusion was that ICU delirium isunder recognized and is not being assessed and screened for appropriately (Elliott,2014).