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Running head: ICU DELIRIUM 1

ICU Delirium: The Importance of Implementing a ICU Delirum Protocol

Yuliya Moroz, RN

Western Washington University

NURS 301: Information Literacy to Support Academic Discourse

Julie Samms, MSN

11/28/16

ICU Delirium: The Importance of Implementing a ICU Delirium Protocol


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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

hyperactive delirium characterized by agitation, hallucinations, autonomic hypervigilance or

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,

Young, Hinton, 2016).

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

hemodynamically stable. Neurologically he was becoming more confused and had 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

are we not educating about delirium and implementing protocols?

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

Initiate Screening Methods Early

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).

ICU-CAM and ICDSC Differences

Delirium screening is most beneficial when it is administered correctly. This means

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

(Pun & Devlin, 2013).

The ICDSC screening tool evaluates eight features of delirium: (1) altered level of

consciousness, (2) inattention, (3) disorientation, (4) hallucinations or delusions, (5)

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

(Pun & Devlin, 2013).

Screening is an important component to be able to recognize and quickly treat delirium

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).

Implement Proper Non-Pharmacologic Methods


A study was conducted by the University of Pittsburgh Medical Center, that evaluated

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,

Svec, Campbell, & Smithburger, 2016).

A sedation protocol was implemented which included non-benzodiazepine sedation

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,

reorientation, cognitive stimulation, and eye/ear protocols (Rivosecchi et al., 2016).

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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pharmacologic interventions included noise reductions, mobilization, family involvement, back

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

time a patient spent delirious in the ICU (Rivosecchi et al., 2016).

Importance of Pharmacologic Methods in Delirium Prevention

One study explored the effectiveness of certain pharmacological approaches in reducing

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

dexmedetomidine was effective in preventing delirium in patients that were mechanically

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

(Serafim, Bozza, Soares, Emanuel, Tura, Ely, Salluh, 2015).

In summary, the systemic review found that the use of antipsychotics for surgical ICU

patients and dexmedetomidine in mechanically ventilated patients used prophylactically could

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

(Serafim et al., 2015).

ABCDE Bundle Implementation

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).

The ABCDE Bundle incorporates multidisciplinary measures for optimal patient

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

Scale (RASS) every four hours (Bounds et al., 2016).


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The D is delirium prevention and management. This includes completing a delirium

assessment every 12 hours, discussing the delirium score at rounds, and implementing non-

pharmacological methods to prevent and manage delirium. Nonpharmacologic methods include:

Assessment for catheter removal, bed alarms, bundling of care to allow

rest periods, cognitive stimulation, covering catheters, tubes, and dressings, educating

family/support system, maintaining sleep/wake cycle, reviewing medications, minimizing

environmental stimuli, assessing pain, reorientation, range-of-motion exercises, and

sensory aids (Bounds et al., p. 537, 2016).

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

indicated after mobility screen (Bounds et al., 2016).

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

and non-pharmacologic interventions.

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

properly to medicate patients to prevent and treat delirium.

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

adverse patient outcomes.


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References

Bounds, M. (2016). Effect of ABCDE bundle implementation on prevalence of delirium in intensive

care unit patients. American Journal of Critical Care, 25(6), 535544.

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

patients think is going on? PLOS ONE, 11(4), e0153775.

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

implementation of a nonpharmacologic protocol to prevent intensive care delirium. Journal of

Critical Care, 31(1), 206211. https://doi.org/10.1016/j.jcrc.2015.09.031

Serafim, R. B., Bozza, F. A., Soares, M., do Brasil, P. E. A. A., Tura, B. R., Ely, E. W., & Salluh, J. I.

F. (2015). Pharmacologic prevention and treatment of delirium in intensive care patients: A

systematic review. Journal of Critical Care, 30(4), 799807.

https://doi.org/10.1016/j.jcrc.2015.04.005

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