Professional Documents
Culture Documents
Yuliya Moroz, RN
11/28/16
The intensive care unit (ICU) is a busy place filled with excitement. Seems like the
engagement and the high-spirited collaboration amongst team members is ongoing, with a rare
occasional stillness to the day. With this demanding workflow there are certain aspects that can
easily be overlooked, and possibly result in adverse outcomes, which can haunt patients for a
long time or even result in death. One of these aspects is delirium. Delirium is a state of acute
confusion that is characterized with a reduced ability to focus, with perceptual and cognitive
disturbances that were not present in a patient prior to admission to the ICU. This can be
hypoactive delirium with somnolence and decreased arousal. Between 35-75% of all patients
will experience at least one delirious episode while in the ICU (Darbyshire, Greig, Vollam,
As a registered nurse working on the ICU floor I was able to see patients quickly
transition from being cognitively alert and oriented to delirious. There was one patient who came
into the ICU with septic shock. After days of resuscitation and treatment he was trending to be
reoriented more often. During change of shift report, a couple of days after the patients
admission, the night shift nurse grimly stated what occurred during the night. Throughout the
night the patient had become more confused and ended up pulling out his left radial arterial line.
Thankfully, the arterial pressure alarms were set properly on the monitors which alerted the nurse
in time to come in and apply pressure. Sometimes the alarms dont help and result with patients
pulling out endotracheal tubes, central lines, catheters and falling, all of which can seriously
harm a patient.
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Delirium is a common problem in ICUs and can affect up to 80% of the patients. It
prolongs extubation, increases the amount of time a patient spends in the ICU, and is associated
with higher mortality in the years following after its occurrence. ICU delirium also is costly,
raising costs to surpass $18 billion in the United States (Brenda & Devlin, 2013). Working as a
new graduate nurse I quickly learned all the protocols in the ICU, took critical care courses,
attended classes and yet through all my education I heard nothing about delirium prevention and
the importance of a delirium protocol. Conferences and staff meetings are frequently held to
educate staff about preventing pressure ulcers, but the education on delirium is so limited. If
research shows the adverse effects delirium has on mortality, outcomes, and finances then why
Although studies have examined the mortality rates associated with ICU delirium, they
have missed the importance of implementing an ICU delirium protocol upon patients admission
to the ICU. I will explore the essential components of an ICU delirium protocol. This includes
proper and early screening using an approved screening tool. I will also discuss the importance
of non-pharmacologic and pharmacologic interventions which can decrease the severity or onset
of delirium. I will also introduce the bundle approach which utilizes many different aspects of
delirium prevention and treatment. This will serve as building stone and reinforce the importance
for a delirium protocol that can be implemented in intensive care units across the nation.
The information and sources in this paper were all found through a search engine
CINHAL which contains full-text nursing journals. This was a systemic search with articles
ranging from the year 2011 to 2016. Keywords used in this research process were delirium,
ICU delirium, delirium prevention, delirium protocol, and delirium treatment. This
yielded over 1,000 results which were further narrowed down by full-text only and peer-
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reviewed articles. From the search I narrowed down to five articles which specifically had key
words including prevention, protocol, and ICU. The articles utilized are primary and
secondary sources highlighting the importance of delirium treatment, prevention, and protocols.
Review of Literature
One of the preventive measures in lowering the occurrence and severity of ICU delirium
is accurate detection. There are many delirium screening tools that are available for the clinical
staff in the ICU. The Clinical Practice Guidelines for Pain, Agitation, and Delirium (PAD)
reviewed many screening tools and came to the conclusion that the Confusion Assessment
Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC)
are the most reliable and valid delirium screening tools. By completing screening early on upon
admission caregivers are able to get a baseline to look upon to see if the patient is progressing
into delirium. It also allows clinicians to correctly identify ICU delirium and treat it
appropriately. Although many can argue that it is difficult to implement a screening tool in the
busy ICU setting, research has shown that implementing the ICU delirium screening tool is
maintainable, with a compliance that is beyond 80% (Pun & Devlin, 2013).
Between the two screening tools highlighted PAD doesnt think one is greater than the
other, the important factor is that ICU clinicians are regularly using them. Nurses are shown to
be the best administrators of delirium screening because they spend more time next to the
bedside. By doing these screenings nurses can proactively incorporate the findings into their
multidisciplinary rounds. By discussing their findings with the ICU team of pharmacists,
intensivists, physical therapists, spiritual care, and respiratory therapists the team can formulate
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an all-sided approach to treating the patient which is shown to have the most benefit (Pun &
Devlin, 2013).
understanding how the CAM-ICU and ICDS differ from one another. The ICU-CAM screening
tool evaluates four indicative features of delirium: (1) acute changes or fluctuations in mental
status from baseline, (2) inattention, and (3) altered level of consciousness, and (4) disorganized
thinking (Pun & Devlin, 2013, p. 181). This assessment takes no more than two minutes to
complete. If features one and two and either three or four are present, then the CAM-ICU is
considered to be positive. This tool has been corroborated for use in verbal or non-verbal patients
The ICDSC screening tool evaluates eight features of delirium: (1) altered level of
psychomotor agitation or retardation, (6) inappropriate speech or mood, (7) speak/wake cycle
disturbances and (8) symptom fluctuation (Pun & Devlin, 2013, p 182). Both the ICU-CAM
and ICDSC are not reliable in patients who are sedated with a Richmond Agitation-Sedation
Score (RASS) that is less or equal to -4 or a Sedation-Agitation Scale (SAS) less or equal to 2
appropriately. There is a lack of understanding of what delirium is, how to treat it, and how to
accurately utilize the screening tools. It is important to educate clinicians for optimal patient
outcomes. This means educating new hires during orientation about delirium; how to screen for
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it, how to properly treat it and prevent it. It is important to hold in-services, hang posters or have
staff regularly go through on-line learning modules. ICU delirium is a common occurrence in the
ICU setting thus it is highly important to accurately educate staff members of delirium and how
to properly use a screening tool to catch it early (Pun & Devlin, 2013).
non-pharmacologic methods to see if their implementation reduced the number of time patients
spent delirious in a medical intensive care unit (MICU). This was a prospective quality project
that bundled music, opening/closing of blinds, reorienting, cognitively stimulating patients, and
eye/ear care. The results showed that there was a 50.6% reduction in the time a patient spent
delirious in the MICU. The findings showed that implementing a non-pharmacologic delirium
prevention protocol greatly decreased the risk and effect of delirium (Rivosecchi, Kane-Gill,
favoring light sedation. Patients were evaluated daily for spontaneous breathing trials and daily
awakenings which helped guide the implementation of early mobility. Light sedation and early
mobility were shown to reduce the amount of time a patient spent delirious. In combination with
the two protocols, the study implemented a non-pharmacologic protocol with nine interventions
labeled Give your patient M.O.R.E This acronym is defined as music, opening blinds,
Prior to implementing this protocol didactic lectures, handouts, and one-to-one nursing
education was done for two weeks. This allowed nurses to be more educated about the protocol
and gave them the knowledge of how to implement it into their daily practice. Some of the non-
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massage, dimmed hallways, daily schedule, opening blinds, calendar, providing ear plugs and
eye masks. After implementing this protocol, they found that the use of M.O.R.E non-
pharmacologic strategies combined with early mobility and light sedation lowered the amount of
the effect of delirium. A systemic review and a meta-analysis of peer-reviewed studies were
done from January 1980 to September 2014. The team reviewed 2646 citations, 15 studies on
prevention, and seven studies on treatment. After their systemic review, they found that
ventilated as compared to propofol or benzodiazepine use. Four studies were done by Rubino et
al. (2009) as presented by Serafim et al. (2015) showed that use of dexmedetomidine also
reduced the amount of time spent on the ventilator. There are some downsides associated with
dexmedetomidine, such as bradycardia and increased costs, but overall dexmedetomidine was
found to be the most effective pharmacological approach to reducing the effects of delirium
In summary, the systemic review found that the use of antipsychotics for surgical ICU
reduce delirium in the ICU. Although these studies have shown the efficacy of some non-
pharmacological methods there are not enough studies done to state that medications alone can
lower mortality and delirium in ICU patients. The study suggests that early mobility and non-
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pharmacological methods should also be implemented for the reduction of ICU delirium
Finally, studies have shown that implementing a bundle of interventions is the most
effective measure in preventing and treating delirium. The bundle method was researched
through peer-reviewed articles prior to its implementation in small rural hospitals, University of
Maryland Shore Medical Center at Dorchester and University of Maryland Shore Medical Center
at Easton. The bundle protocol was labeled ABCDE Bundle. This stands for Awakening,
spontaneous Breathing trials, Coordination, Delirium prevention and management, and Early
physical mobility. This bundle approach can be used as a protocol that clinicians can utilize as a
guide in preventing delirium (Bounds, Kram, Speroni, Brice, Luschinksi, Harte, Daniel, 2016).
outcomes and a reduction in delirium. As explained by Bounds et al. (2016), the A component
signifies sedation awaking trial (SAT) which stated that all patients who passed the SAT
screening undergo a SAT in 24 hours if mechanically ventilated. Post SAT the results of failure
or success are to be discussed at interdisciplinary rounds to get all parts of the healthcare team
involved. The second component B is the spontaneous breathing trial (SBT) which indicates
that all patients receiving mechanical ventilation receive a spontaneous breathing trial within 24
hours of being ventilated if they pass the SBT screening. The acronym C signifies coordination
and choice of sedation and analgesia. It is important for nursing staff to coordinate with
Respiratory Therapists about SBT and SAT. Correct analgesia and sedation is also an important
component of the bundle with assessing pain and completing a Richmond Agitation Sedation
assessment every 12 hours, discussing the delirium score at rounds, and implementing non-
rest periods, cognitive stimulation, covering catheters, tubes, and dressings, educating
Lastly in the bundle E is early physical mobility which includes passive movements for patient
three times a day, repositioning every two hours, sitting, physical and occupational therapy if
After the implementation of the ABCDE Bundle Bounds et al. (2016) found that the
occurrence of delirium decreased from 38% to 23%. Also the amount of time a patient spent
delirious decreased from 3.8 days to 1.72. The ABCDE Bundle implementation increased the
number of time patients spent sitting up at the side of the bed but not the amount they spent
ambulating out of bed. Bounds et al. (2016) recommended implementing more aggressive
mobility protocols for improved outcomes. Although the ABCDE Bundle was shown to lower
the occurrence of delirium Bounds et al. stated that accurate assessment and use of ICU-CAM
and IDSC is highly important. Thus, in order for the ABCDE Bundle to be most effective early
screening and accurate assessment is critical for optimized patient outcomes (Bounds et al.,
2016).
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Conclusion
Synthesis
If delirium is a common occurrence in the ICU then why are we not educating the care
team on how to catch it early and prevent it? Studies all have shown that ICU delirium increases
mortality, costs, and duration on mechanical ventilation. Patients that suffered delirium self-
reported in a study that they experienced PTSD many months after being discharged from the
hospital. They recall feelings of abandonment, fear, isolation, paranoia, and blurred reality
(Darbyshire et al., 2016). The septic shock patient mentioned earlier is just one case among
many. Although the arterial line removal by the patient was caught, and the patient did not bleed
out, there was a greater problem at hand, delirium. I believe that by implementing a delirium
protocol to have team members and clinicians to follow will reduce the incidence of delirium and
its effects.
A crucial part of the protocol is proper screening using a PAD approved tool such as the
ICU-CAM or ICDS which all studies agreed upon. Rivosecchi et al. (2016), Bounds et al.
(2016), Pun & Devlin (2013), and Darbyshire et. al (2016) all stated the importance of non-
pharmacological methods which should be implemented upon the occurrence of ICU delirium.
Medical team members should be educated what this entails and have a protocol in place to
guide them. Serafim et al. (2015) explored pharmacologic methods that are most effective in
treating delirium and concluded that dexmedetomidine can greatly reduce the amount of time
spent on a ventilator, decreasing the risk of delirium. The downsides are that this medication is
expensive and can lower heart rate. Further research needs to be done on proper medication for
delirium but the ICU delirium protocol should entail proper pharmacologic interventions.
Finally Bounds et al. (2016) discussed a ABCDE Bundle approach which is a protocol that has
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been proven to be effective in hospitals across the nation. This bundle includes pharmacologic
Whats Next?
A team approach should be utilized when proceeding to create a protocol and education
materials for the hospital team members to follow. This should include extensive research and
time. Although the costs in creating a team to come up with a protocol may seem burdensome to
the budget, the hospital administration team must consider the implications delirium has on
costs, costing the United States 18 billion per year (Brenda & Devlin, 2013). In-services, didactic
classes, online education and posters should be used to educate clinicians and team members of
proper screening tool use, which non-pharmacological interventions should be used, and how to
Although team members may state that the hustle and bustle of the ICU is too
overwhelming to implement another protocol, research has shown otherwise. On the contrary it
can reduce the risks of self extubation, the use of restraints, falls and many more adverse effects.
Having a proactive method in screening and treating delirium has been shown to decrease the
effects of delirium in the ICU. Many studies have found that delirium increases costs and
mortality. Studies also now show that prevention is crucial and I believe it can be accomplished
with an implementation of a delirium protocol across the nation to reduce costs, mortality, and
References
https://doi.org/10.4037/ajcc2016209
Darbyshire, J. L., Greig, P. R., Vollam, S., Young, J. D., & Hinton, L. (2016). I Can Remember Sort
of Vivid Peoplebut to Me They Were Plasticine. Delusions on the intensive care unit: what do
https://doi.org/10.1371/journal.pone.015377
Pun, B. T., & Devlin, J. W. (2013). Delirium Monitoring in the ICU: Strategies for initiating and
sustaining screening efforts. Seminars in Respiratory & Critical Care Medicine, 34(2), 179188.
https://doi.org/10.1055/s-0033-1342972
Rivosecchi, R. M., Kane-Gill, S. L., Svec, S., Campbell, S., & Smithburger, P. L. (2016). The
Serafim, R. B., Bozza, F. A., Soares, M., do Brasil, P. E. A. A., Tura, B. R., Ely, E. W., & Salluh, J. I.
https://doi.org/10.1016/j.jcrc.2015.04.005