Transcript Hotel-Dieu Grace Hospital Storyboard

Hotel-Dieu Grace Hospital
Delirium
Background
• Inner-city Hospital in Windsor, Ontario
• 20 bed Neurosurgical/Medical/Trauma ICU
• Team consists of Intensivist, RN clinical
educators, NP, Staff RN’s, and Pharmacist
• Goal: improve the management of delirium
through education, early identification,
prevention, and optimal treatment.
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Aim
• Implement & reinforce routine screening
• Educate staff
– identification
– prevention
– treatment
• Determine baseline incidence at 3 months
• Determine incidence at 12 months
– Goal 10-15% reduction
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Team Members
• Dr. Natalie Malus, MD FRCPC, Medical
Director ICU
• Sue Elliott, RN, BScN, CNCC(C) ICU PPL
• Anne Marie Marsigliese, NP
• Chim Seng, RN
• Dianna Thorn, RN
• Marc Conte, RN
• Frank Foote, B.Sc., Pharm. D.
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Delirium Initiative Timeline
• 2007 ICDSC built into our 24hr flow sheet
• Feb 2012 Survey/brainstorming re: barriers to
consistent completion of Q-shift delirium
screening
• Feb 2012 Nursing worksheet updated to
encourage delirium discussion at rounds
• March/April 2012 Delirium presentation made at
yearly requalification for all ICU RN’s
• April 2012 Delirium PowerPoint slides posted on
education board and scroll monitor
20-Jul-15
Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
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Results
• Goal: Optimize use of ICDSC screening
tool
– Baseline compliance with ICDSC completion 79%
% COMPLETE
0.9
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0.5
0.4
0.3
0.2
0.1
0
% COMPLETE
0
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Results
• Goal: Reduction in delirium incidence
– Baseline rate of delirium 17%
% DELIRIOUS
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% DELIRIOUS
0.3
0.2
0.1
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0
20-Jul-15
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Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
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Changes Tested
• Delirium education will improve
compliance with ICDSC screening tool and
preventative measures
– Screening rate is variable
– Screening rate has not improved
– When ICU Physician requests delirium score at
rounds completion rate of Q-shift ICDSC improved
(94% vs. 71/81/69%)
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Changes Tested
• Delirium education will promote the use of
consistent treatment modalities
– Educating the Nursing staff has not influenced
prescribing practices
– We should re-test this following physician continuing
education
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Lessons Learned
• Education on delirium has been ineffective
in improving compliance with screening
• Future nursing education needs to focus
on clinical significance of delirium
• We need to empower RNs to gain buy-in,
initiate preventative strategies, be
proactive in identification of delirium
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Lessons Learned
• Barriers to consistent screening include:
– Perception of low clinical significance among RNs
– Perception that our large Neurosurgical population
cannot be reliably assessed for delirium
– If the information goes unused, why collect it?
20-Jul-15
Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
11
Lessons Learned
• Physician practices have not changed
– ICU physicians are aware of the impact of delirium
but this has not translated into a focus of care
• (like CLI/VAP/DVTP)
• Physicians requesting ICDSC score at
rounds will improve consistency in
screening
– Assessment of delirium at daily rounds need to
become part of our routine
20-Jul-15
Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
12
Next Steps
• Continue to monitor for screening
compliance
• Continue to monitor delirium rates
• Ongoing education
– Key education slides added to ICU “scrolling monitor”
– Organize a series of “lunch and learn” sessions with
focus on our problem areas
– Delirium info sheet posted in patient rooms as RN
reminder and to educate families
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Next Steps
• Consider the use of (gentle) peer pressure
to improve screening and prevention
practices
– Use our Delirium Collaborative RNs as facilitators to
educate peers
20-Jul-15
Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
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Next Steps
• Organize a ‘delirium dinner’ for physicians,
NPs and Educators
– Create buy-in and make assessment routine
• Consider modification of ICU standardized
orders to include delirium treatment
– Promote a consistent approach to treatment
– Allow RNs to immediately treat delirium
20-Jul-15
Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
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Next Steps
• Reevaluate our pain control and sedation
practices
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Use of narcotic infusions
Use of Midazolam infusions
Use of Propofol
Potential addition of Dexmedetomidine for sedation
• Ultimate goal:
– Develop a ‘Delirium Bundle’ integrating Sedation
Vacation practice and Spontaneous Breathing Trials
20-Jul-15
Delirium and Med Rec Collaborative
Collaboration sur le delirium et le BCM
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