“Delirium shouldn’t be the norm.”
January 21, 2019
by Sandra Gordon for ASA
Making Delirium Prevention the Standard of Care at VUMC
Christopher Hughes, M.D., medical director of the Neuro Intensive Care Unit and program director of the Anesthesia Critical Care Medicine Fellowship at Vanderbilt University Medical Center (VUMC), discusses the pioneering efforts his intensive care unit (ICU) is making to decrease delirium.
When meeting with older patients and their family members before surgery, Christopher Hughes, M.D., is often surprised by their attitude about delirium. “The ease with which people act like delirium is expected and no big deal really bothers me,” he says. “Delirium shouldn’t be the norm.”
Another disconcerting but common scenario, especially in the ICU, isn’t just patients who develop hyperactive delirium, but the look on the faces of the patient’s family members when they witness their loved one, for example, pulling out tubes, acting aggressively and making inappropriate comments.
“It’s pure terror in their eyes,” Hughes says. “We try to explain that we don’t have good therapies for delirium, that we’re trying to prevent it. Still, family members ask, ‘Isn’t there something you can do?’ As a physician who is knowledgeable, you feel helpless,” he says. “Then, we have to break the news that delirium is a risk factor for having issues with thinking for months after getting out of the hospital.”
Delirium Prevention at VUMC
Still, Hughes and his team at VUMC have been making major strides to reduce the incidence of delirium. “Overall, it’s still not zero and delirium is still common. But it’s not in the 75 percent to 80 percent range in the ICU. And when it does occur, it’s shorter in duration,” Hughes says. Within the past two years, their prevention strategies have been become routine. They include:
- Assess, Prevent and Manage Pain
- Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
- Choice of Analgesia and Sedation
- Delirium: Assess, Prevent and Manage
- Early Mobility and Exercise
- Family Engagement and Empowerment
“In the post-op period, we’re making delirium assessment routine and talking about the results on the rounds daily to trigger the next plan. That’s the most important thing we’re doing,” Hughes says. Nurses use CAM-ICU [pdf] to assess delirium.
- Using minimal sedation strategies. In the postsurgical period, “we’re trying to promote patient interaction as much as possible and using sleep hygiene to allow patients to have an environment where they can get natural sleep at night,” Hughes says.
- Discontinuing delirium-promoting medication when patients leave the ICU. “Most inappropriate medications that patients are sent home with get started in the ICU, medication like antipsychotics for delirium, stress ulcer prevention and PRN medication for pain or anxiety. We’re trying to stop the polypharmacy, especially during transitions of care,” Hughes says. Some medications, such as an antipsychotic for patients with hyperactive activity, may convert patients from hyperactive delirium to hypoactive without fixing the delirium.
- Encouraging early mobility. After surgery, patients are awake as soon as possible and up and moving, including those on a ventilator. “Taking care of patients on a ventilator who are awake requires more communication and interaction with patients, but it’s ultimately better for them,” Hughes says.
Promoting family involvement
“We have 24/7 family visitation in our hospital,” Hughes says. Conversation, a familiar voice and the calming presence of family members helps patients avoid delirium, especially when lighter sedation is used, and patients are awake in the ICU. “It benefits the family too, because it gives them a task to help them cope,” Hughes says. They feel like they want to do something.
To help patients and their families understand the benefit of being intubated while awake, Hughes and this team involve them in the patient’s care. “We tell them why we’re doing certain things and about what’s going on. Patients require less medication to keep them calm,” he says.
Hughes at his team at VUMC began using these delirium prevention techniques with the older patients in the ICU. They’re now the standard of care for every perioperative patient because the rate of delirium in the ICU has been declining. But more work needs to be done. Next steps: “We’re working to further systemize delirium prevention by developing a scoring system to determine delirium risk and allocating resources based on that risk,” Hughes says.
For more information about delirium prevention, Hughes recommends ICUdelirium. The website features training resources for clinical staff, families and patients. He presented “Postoperative Delirium: The Known Knowns, Known Unknowns and Unknown Unknowns” at the ANESTHESIOLOGY® 2018 annual meeting. His presentation is available through ANESTHESIOLOGY OnDemand, under the Critical Care Medicine track. His article What do we know – and not know – about postoperative delirium? appeared in the ANESTHESIOLOGY 2018 Daily News in October.
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