Transcript Presentation: WRHA Surgical Program Delirium Guidelines

WRHA Surgical
Program Delirium
Guidelines
Cheryl Bilawka
April 18, 2012
Purpose
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The WRHA Surgery Program had identified that
there was no formal regional guidelines in place
to identify, screen or manage postoperative
delirium.
Process
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A working group was created with members
representing all the acute care sites chaired by
Wendy Rudnick, WRHA Surgery Program
Director.
The objective of this group was to develop a
standardized approach to delirium care for
surgical patients in the WRHA.
Methodology
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The group complied existing tools and protocols
from all the acute care sites and with the
assistance of the experts in delirium and surgical
management, the WRHA Delirium
Implementation Tools will be rolled out across
the region May 14, 2012.
Delirium Tools
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Delirium Brochure for patients and their families
WRHA Surgery Program PREoperative Assessment
Questionnaire
Delirium Clinical Practice Guidelines
Delirium Decision Tree
Lanyard Cards
Audit tool for evaluation
Evidence Informed Practice Tool (coming soon)
Opportunity for Interventions
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Preoperatively
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Postoperatively
The Surgical Patient
Preoperatively
All patients will
be screened for
delirium in PAC
If patient
assessed as at
risk for
delirium,
slating
department to
be notified.
Slating to
identify
patient at risk
for delirium
on the OR
slate.
If patient at risk and patient is seen,
PAC will give patient or family a
Delirium brochure
Preoperative Screening
The WRHA Surgery Program Preoperative
Assessment Patient Questionnaire, has been
revised to have delirium screening criteria
embedded using flags
Example from the PREoperative
Assessment Patient Questionnaire
The last time that you were hospitalized, did you
experience confusion, hallucination or behaviour
that was unusual for you?........ No Yes
Delirium Elderly At-Risk
(DEAR) Tool
For patients greater than 65 years of age, flag at risk for delirium if:
□ greater than 80 years of age
□ benzodiazepines and/or alcohol greater than 3 x/week
□ glasses and/or hearing aides
□ Mini Mental Status Exam less than 24 or previous
delirium
□ assistance with any activities of daily living
Delirium Risk Flags:
_____________/5
Delirium Risk if greater than 2 flags. Implement facility protocol.
□ N/A patient less than 65 years of age
Communication of Delirium Risk
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Each hospital will develop a process so that the
delirium risk will be identified on the OR slate.
Inpatient postoperative units will have access to
the delirium risk information.
Delirium Brochure
DELIRIUM
A Medical Emergency
Delirium Decision Tree
Delirium Decision Tree
WHAT ARE THE RISK FACTORS?
• Severe Illness
• Sensory Impairment (hearing/vision)
• Age (age 65 years and over)
• Cognitive Impairment (dementia)
• Dehydration
• Multiple Medications (Sedatives/Hypnotics/Narcotics/Anticholinergics/
Psychotropics)
• ETOH/Substance abuse
• Previous Delirium
• Infection
• RECOVERY FROM SURGERY
• Impairment of Activities of Daily Living
(bathing/dressing/toileting/grooming/feeding)
• Pain
The Surgical Patient
Postoperatively
Administer CAM within the
1st 8 hours of admission.
Positive CAM
Assess using CAM
Q shift and prn
Negative CAM
Assess Q 24 hours and prn
(with any cognitive and/or
functional changes)
Delirium Decision Tree
Search for reversible
causes and treat:
,/ CXR
,/ EKG
,/ CBC
,/ Electrolytes
,/ BUN/CR
,/ TSH/B12
,/ Urinalysis
,/ Medication Review
Nurses Assess:
,/ Vital Signs/02 sat
,/ Assess/treat pain
/ Fluid balance
,/ Blood Sugar
,/ Elimination
Delirium Decision Tree
INTERVENTIONS
Environmental
• Clocks/Calendars
Cognitive
• Frequent orientation
Communication
• Simple short sentences
Safety
• Fall prevention/Safe environment
Psychological
• Don't dispute delusions; reassurance
Pharmacology
Avoid Polypharmacy
Avoid Benzodiazepines
For agitated delirium please consider an
antipsychotic
Function
• Balance, rest, activity
Delirium Decision Tree
CONFUSION ASSESSMENT
METHOD (CAM)
Need presence of (1) & (2) and either
(3) or (4)
1. Abrupt change?
2. Inattention, can't focus?
3. Disorganized thinking?
Incoherent, rambling, illogical?
4. Altered level of consciousness?
(Hyper-alert to stupor?)
Trigger Questions
1. Acute changes in behavior?
2. Changes in function?
3. Changes in cognition? MMSE
4. Changes in medications?
5. Physiologically stable?
Lanyard Card of CAM
CONFUSION ASSESSMENT METHOD (CAM)
Answer these four questions:
1) Was the onset acute and does behaviour fluctuate?
AND
2) Is there evidence of inattention?
(difficulty focusing attention, shifting and keeping track)
AND EITHER
3) Is there evidence of disorganized thinking? (Incoherent,
rambling, illogical flow of ideas)
OR
4) Is there evidence of disorganized thinking?
(i.e. any state other than alert) (Alterations include hyperalert,
lethargic, stuporous and comatose)
FEATURES 1 AND 2, AND EITHER 3 OR 4 ARE REQUIRED FOR A
DIAGNOSIS OF DELIRIUM
Delirium Clinical Practice Guideline
Goals of Implementation
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Awareness of postoperative delirium
Screen for delirium and communicate risk
Routine utilization of the CAM as the standard
method for detecting delirium
Use of the CAM tool when communicating with
other Health Care Professionals
Proactive interventions
Audit Tool
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Screened for delirium in PAC
Delirium Risk on Slate
CAM done within 8 hours postop
If CAM positive, are interventions and plan
documented in IPN
Physician notified
If CAM positive, is CAM reassessed 8 hours later
If CAM is negative, is CAM reassessed q 24 hours.
Metrics
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Length of stay
Constant Care Use
Falls Reduction
Future Opportunity?
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Pose the question:
“What if the patient is flagged as high risk for
delirium, yet does not actually go on to experience a
delirium?”
 Examination looking for evidence of proactive care
planning
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Early Mobilization
 Adequate Pain Management
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Delirium Working Group Members
and Contributors
Wendy Rudnick
Karen Murphy
Michele Lepp
Lisa Anthony
Graciana Mederios
Ann Reichert
Cheryl Bilawka
Christine Johnson
Leslie Dryburgh
Rayan Horswill-Tees
Valerie Hiebert
Vera Duncan
Karen Gutknecht
Carol Knudson
Bruce Anderson
Claire Dionne
The PAC Working Group