THINK delirium in intensive care

Aim:

To implement NICE CG103 Delirium: prevention, diagnosis and management, 2010 and NICE QS63 Delirium in adults 2014 into a critical care ICU.

Objectives:

• To organise an ICU Delirium Study Day involving all staff develop a delirium Strategy: THINK Delirium
• To assess patients on admission to ICU for delirium using a new delirium training tool CAM-ICU
• To introduce a tailored multicomponent intervention delirium package as recommended by NICE
• New delirium checklist based on NICE QS63's 5 statements to ensure we are compliant.

We are a 600-bed, large district general hospital. Our ICU is a general 20-bedded unit opened in 2010. We have around 900 admissions /year to the ICU.

Delirium is a syndrome, an acute confused state, potentially reversible. What defines it is the cardinal sign-inattention (loss of concentration).

The DSM-5 definition describes 4 domains: disturbance in attention, awareness, cognition and develops acutely and fluctuates. There are 3 types, hyperactive (agitation) hypoactive (lower GCS) and mixed. The diagnosis is clinical, there are no diagnostic tests.

Differential diagnosis: depression, dementia, acute psychosis. Trigger: look for change in behaviour. NICE lists 15 changes e.g.: confusion, slow response, hallucinations, restless, sleep, withdrawn. NICE guidelines highlight 4 risk areas: age 65, dementia, #NOF and critical illness.

In Warrington ICU we care for the most critically ill patients in the hospital. We wanted to ensure that our patients are assessed, treated for delirium in line with the NICE clinical guidelines and quality standards.

NICE CG 103 Delirium: prevention, diagnosis and management 2010 addresses the diagnosis and treatment of delirium.

NICE QS 63 Delirium in adults 2014 provides 5 Quality Statements for Delirium:

QS1: Assessing Recent Changes in Behaviour: Adults newly admitted to hospital or long-term care who are at risk of delirium are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour.

QS2: Interventions to Prevent Delirium: Adults newly admitted to hospital or long-term care who are at risk of delirium receive a range of tailored interventions to prevent delirium

QS3: Use of Antipsychotic Medication: Adults with delirium in hospital or long-term care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless de-escalation techniques are ineffective or inappropriate

QS4: Information and Support: Adults with delirium in hospital or long-term care, and their family members and carers, are given information that explains the condition and describes other people's experiences of delirium.

QS5: Communication of Diagnosis: Adults with current or resolved delirium who are discharged from hospital have their diagnosis of delirium communicated to their GP.

In November 2018 we organised a multi-professional Delirium Study Action Day on Warrington ICU. The agenda included presentations on: The evidence base for delirium on ICU, new education and training project, NICE guidelines and quality standards on delirium. We also presented the findings from our baseline delirium audit which had been completed in August 2018.

The day concluded with an open interactive discussion and the development of our Strategy for delirium for 2019.

We called our New Strategy: THINK DELIRIUM

Goals:

• Communicate our strategy to all ICU Staff
• Complete a training programme on the Delirium CAM ICU Tool (PP).
• All patients to be assessed on admission and twice daily
• Introduce a multicomponent intervention package: clocks, lights, calendar, orientation, games, family and friends
• Develop a new T.H.I.N.K alphabet checklist for delirium from the NICE QS standards
• 5 audit activity based on the QS standards

Following our delirium day, a summary was forwarded to all staff. By January 2019 the training programme on delirium assessment CAM-ICU had been completed for all ICU staff. There was a large number of staff that needed training approx. 50 in this project. Staff turnover is quite high and so consistency is difficult.

We developed an audit which was designed to include the five quality standard statements. We purchased 19 calendar clocks to enhance patient orientation to date and time and a SoundEar system to monitor and alert staff to noise levels above acceptable level. The Sound Ear cost £2567 for two units and the 19 clocks cost £2007 in total. Other than this, the cost to implement was minimal. Although we have no figures to date the cost savings will be in decreased length of stay.

The ICU booklet was given to relatives of all new cases of delirium. Our ICU GP discharge summary included a section which alerted if their patient had developed delirium. In November 2019 we introduced a daily ward round checklist to prompt patient assessment Throughout 2019 we gradually introduced a number of measures to improve the quality of prevention and management of delirium. This helped us to continue the momentum from our study day, raising awareness and repeating the mantra: THINK Delirium.

We carried out 3 audits to plot improvement with the new process.

Audit 1). August 2018. A pre-audit. 20 Patients randomly selected on the ICU who had tested CAM Positive were reviewed.

Our findings: CAM assessment was incomplete on many patients’ notes. No prevention guidelines were in place before or during this audit. The management was almost entirely confined to drug treatment. There was inconsistency with olanzapine used in half of cases and haloperidol in the other half. There was no clear guidance on the use of anti-psychotics or escalation with treatment failure. There was increased efficacy with olanzapine compared with haloperidol. The percentage treated successfully was 25%.

Audit 2). November-March 2019 Patient data was collected from 19th November 2018 to 8th March 2019 (14 weeks in total). We looked at 2 areas: 79 new admissions on ICU were used to assess for daily CAM-ICU assessment in the first 48 hours and 30 CAM positive patients used to assess for commensal on olanzapine

Our findings: The results show increased CAM assessment following the delirium day and following the nurse training. There is some variation throughout the 14-week study period but overall there was an increase from 20% to 65% in the number of patients CAM assessed on admission 30 of the new CAM positive 60% were started on olanzapine. Not all patients needed olanzapine but the results show a consistency in treatment with our recommended drug whereas previously other agents were used.

Audit 3): September 2019. A 9-week audit from July to September 2019 looking at compliance with delirium guidelines. 29 new admissions to ICU were assessed. Outcome: 50% compliance, a slight drop-off.

Our outcomes: 20% to 60% Increase in compliance with NICE guidelines within 6 months of introduction. Mortality ICNARC Intensive Care SMR (mortality) reduced from 0.99 to 0.89 over the period our THINK delirium was introduced.

We started our project with a delirium study day. This was a multi-professional approach to involve as many ICU staff as possible. An interactive session on the delirium day allowed us to develop a joint strategy and this was then communicated to the whole ICU Team.

Key to success:

• The delirium management checklist and audit tool were organised around the NICE five quality standard statements giving us a framework to measure improvement.
• Education and training for all staff.
• Periodically introducing new measures and re-auditing to energise the message: THINK Delirium.