Shared learning database

Herts and Beds Critical Care Network
Published date:
January 2013

Delirium is a common manifestation of acute brain dysfunction in the critically ill, often not accredited with the same level of importance as other organ failures. NICE CG 103 provided the opportunity to describe current practices and consequently implement standardised, evidence based service improvement initiatives and education across the network within 6 months of commencement of the project. Positive outcomes of the project are evident in increases in preventative measures, delirium assessment and documentation practices on the critical care units as well as increasing recognition of delirium as an organ failure.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

1. To achieve maximum clinician engagement in the recognition, diagnosis, management and prevention of delirium in critically ill patients, thus increasing ownership of the condition amongst critical care teams and igniting changes in clinical practice and subsequent service improvement.
2. Improved knowledge and understanding of delirium amongst critical care teams, ensuring delirium assessment is integrated within daily patient assessment and is given the same priority of approach as other organ failures.
3.To generate a culture of improved patient experience by the embedding of delirium recognition and preventative measures, and a defined plan of care for those who are diagnosed as being delirious.
4. 100% compliance to NICE CG 103 Delirium Delivery of evidenced based practice into clinical areas.

1. To facilitate audit of current practices in the management of delirium on critical care
2. To measure or evidence improved recognition of delirium in our patient group and management of the condition in accordance with NICE CG 103 Delirium
3. To ascertain the clinical need for the implementation of new, alternative therapies and innovate locally.
4. To promote/deliver best practice within the critical care teams, in 4 acute trusts.
5. To provide staff with the tools and knowledge required to support compliance to NICE CG103

Reasons for implementing your project

Herts and Beds Critical Care network is currently a clinical, managed network, with 4 acute trust members. Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients (Girard et al 2008), with up to 80% of patients experiencing at least one episode during their time on a critical care unit. Delirium is associated with significantly adverse outcomes for patients, including long-term cognitive impairment (Page and Ely 2011) Delirium is known to be an independent predictor of higher 6-month mortality and longer hospital stay in patients receiving mechanical ventilation (Ely et al 2004).

Previous work had been undertaken across the network to implement Richmond Agitation Sedation Scale (RASS) (Sessler et al 2002) and Confusion Assessment Method ICU (CAM ICU) scoring (Ely 2001) in all the units to support the early recognition and treatment of Delirium and to promote more positive outcomes for these patients. NICE CG 103 provided further structure for the management of this patient group, and it was clinically recognised after its publication that compliance was not adequate and levels of care could be improved for this patient group. As part of the HBCCN business plan 2012-2013, objectives were set to improve compliance and deliver quality improvements in the services for patients at risk of delirium. Assessment of patients on a daily basis supports early recognition and intervention as well as a preventative scope. This could support cost savings within critical care services and potentially reduce length of stay and provide a better patient experience. Using the NICE template, an audit tool was designed to ascertain a baseline of current practices in all 4 trusts who agreed to a peer audit. The results of this provided the evidence to build a project around service improvement for this patient group. Changes were implemented and following re audit within 6 months, compliance was improved across the board with few exceptions. Justification for lack of improvement was quickly forthcoming and a further audit will be undertaken in 6 months time. Benefits to patients can be described as increased application of preventative measures and management plans for delirium and an increase in the assessment for delirium. These service changes will provide a base for further innovation and quality improvements for patients within Critical Care.

How did you implement the project

1. Delirium champions identified in each trust, a critical care consultant and a band 6 or band 7 critical care nurse.
2. Baseline audit of current practices utilising the NICE audit tool as a template.
3. Audit results analysed collaboratively and local action plans devised with network support, with short time frames for completion. NICE implementation tools employed in support of this.
4. Local educational opportunities availed of including promotion of bedside teaching, use of education boards, raised delirium focus on in house teaching days, all motivated by local champions.
5. Consultant champion encouraged daily assessment for delirium on unit rounds and led by example.
6. Nursing team handover sheets included CAM ICU assessment scoring box to serve as a reminder.
7. One unit had a 'Delirium Month' to keep the profile high.
8. HBCCN hosted 'Delirium: the forgotten organ failure?' a 5 CPD point accredited conference, programme of events attached. This was a free conference, offered to all critical care units in the East of England, which attracted delegates nationally having being advertised by Dr Valerie Page on
9. Delirium as a consistent agenda item at all network meetings with clinicians.
10. Practice sharing by units that trialled new drug therapies.

The challenges faced during this process were lack of clinician interest in the condition 'Delirium', scepticism regarding the evidence currently available, and the lack of importance accredited to Delirium as an organ failure. The conference on Delirium ignited a mindset change in those who attended, the evaluations of the day were a testimony to this and further interfacing with the teams and the audit results support this. Cost were conference costs and workforce time, both network staff and unit champions.

Key findings

Preventative measures showed improvement in noise management and early mobilisation, with some poorer results in clock visibility due to theft of clocks from one of the units!

The greatest success was seen in the diagnosis, management and documentation of care. Daily assessment for delirium are occurring, admittedly with room for improvement, but further planned collaborative working with unit champions and ongoing educational measures should yield positive results at the next audit planned for June 2013.

Measurement will be consistent, with plans for greater monitoring of patient outcome in the longer term. For now, success looks like increased recognition of delirium as an organ failure by clinicians, with increasing daily assessments and care planning.

Key learning points

1. Identify delirium champions early, building on existing relationships to promote the cause.
2.Be innovative with resources, and generous with personal time. Engagement of unit staff makes the difference between success and failure, people are the most valuable resource and champions avail of every opportunity to educate. Use of the network as an information resource was encouraged and effective.
3.Ensure delirium is on every relevant meeting agenda, welcome scrutiny of the project as all interest is a positive thing.
4. Support education at all levels, the hosting of the conference opened minds and eyes to delirium as an organ failure and provided an opportunity for peer networking at national level.
5.Peer review promotes competition and subsequently perhaps, higher compliance and facilitated practice sharing.
6. Become synonymous with your cause, think network, think delirium.

Contact details

Emer Corbett
Service Improvement Lead
Herts and Beds Critical Care Network

Secondary care
Is the example industry-sponsored in any way?