2013 Guidelines on Pain, Agitation & Delirium

Anne S. Pohlman, APN-CNS, FCCMCritical Care Clinical Nurse Specialist

Department of Medicine

Section of Pulmonary and Critical Care

University of Chicago

This CE activity is supported by an educational grant from Hospira, Inc.A ProCE-publication

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IMPLEMENTING THE NEW PAD GUIDELINES: DELIRIUM ASSESSMENT

ACTIVITY DESCRIPTION

Delirium is an acute change in consciousness that is accompanied by inattention and a change in cognition or perceptual disturbance. A serious complication of ICU sedation, delirium affects up to 80% of ICU patients and is associated with increased length of stay, time on the ventilator, mortality, and long-term neuropsychological deficits. Yet, delirium goes undetected and untreated in more than 65% of cases. New SCCM guidelines for the management of pain, agitation, and delirium (PAD) in adult ICU patients were published in January 2013. Capitalizing on recent advances in assessment-scale development, the PAD guidelines emphasize the use of valid, reliable tools for routine monitoring of ICU patients; these include the CAM-ICU and ICDSC to screen for delirium. This monograph focuses on the delirium component of the PAD guidelines. The author, Anne Pohlman, reviews the development of the guidelines and the importance of using validated assessment tools for detection and monitoring of delirium. She also presents the guidelines on delirium management, with strategies to improve ICU outcomes.

LEARNING OBJECTIVES The target audience for this activity is nurses. At the completion of this activity, the participant will be able to:

Describe the components and utility of validated tools for routine delirium assessment

Identify strategies to perform, document, and communicate delirium assessments for critically ill patients

Evaluate patients for delirium risk factors, including review of medications

FUNDING

This program is supported by an educational grant from Hospira, Inc.

ACCREDITATION

Nurses: Nursing credit is provided for this home-study activity through collaboration between ProCE, Inc. and Wild Iris Medical Education, Inc. This activity provides 0.5 contact hour of nurse CE credit. Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Release Date: August 19, 2013 Expiration Date: August 19, 2016 FACULTY DISCLOSURE

It is the policy of ProCE to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer of any commercial product(s) discussed in an educational presentation. Anne Pohlman reports having no relevant financial and/or commercial relationships. Peer review of the material in this CE activity was conducted to assess and resolve potential conflict of interest. Reviewers unanimously found that the program is fair balanced and lacks commercial bias. The opinions expressed in this program should not be construed as those of the CE provider or Hospira, Inc. The information and views are those of the faculty through clinical practice and knowledge of the professional literature. Portions of this program may include the use of drugs for unlabeled indications. Use of drugs outside of labeling should be considered experimental and participants are advised to consult prescribing information and professional literature.

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ABOUT THE AUTHOR

Anne S. Pohlman, APN-CNS, FCCM

Anne S. Pohlman is Critical Care Clinical Nurse Specialist and Coordinator of Critical Care Clinical

Research in the Department of Medicine, Section of Pulmonary and Critical Care Medicine, at the

University of Chicago. Ms. Pohlman received her master’s degree in nursing with a focus in critical care

from Loyola University of Chicago, and her BSN from Northern Michigan University in Marquette. Ms.

Pohlman has worked in the areas of critical and intensive care since 1986. During this time, she has

spoken nationally and internationally to various groups regarding critical care, including topics such as

sedation in the ICU, mechanical ventilation, and evidence-based practice. She has co-authored numerous

articles and abstracts published in the New England Journal of Medicine, Critical Care Nurse, JAMA,

AJRCCM, and Critical Care Medicine. She is a member of the American Association of Critical-Care

Nurses, Society of Critical Care Medicine, and Sigma Theta Tau.

4 INTRODUCTION

Delirium is a frequent complication of critical illness and is associated with poor outcomes. Results of recent studies have challenged critical care practitioners to consider a change in practice related to care of patients in the intensive care unit (ICU) with delirium. New Society of Critical Care Medicine (SCCM) guidelines for the management of pain, agitation, and delirium (PAD) in adult ICU patients were published in January 2013.1 These guidelines provide recommendations for optimizing the management of pain, agitation, and delirium. This monograph will focus specifically on delirium by targeting outcomes, detection and monitoring, risk factors, prevention, treatment, and management strategies.

EVIDENCE-BASED RECOMMENDATIONS

The objective of the 2013 PAD guidelines was to revise and update the clinical practice guidelines for the use of sedatives and analgesics previously published in 2002.2 A multidisciplinary team of experts worked for 6 years to create the latest guidelines. The resulting publication provides clinicians with a roadmap for developing integrated, evidence-based, patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients. The final guidelines include 22 descriptive statements and 32 recommendations, which are actionable items. One of the differences in the new PAD guideline publication is the use of a methodology – Grades of Recommendation, Assessment, Development and Evaluation (GRADE) – that focuses on quality of evidence and strength of recommendation (Table 1).3 The quality of evidence is an evaluation of the available data on the subject and identifies the quality as high (grade A), moderate (grade B), or low/very low (grade C). The strength of the recommendation involves the confidence that following the recommendation will cause more good than harm as strong (grade 1: “we recommend”) or weak (grade 2: “we suggest”). A recommendation “in favor of” is marked with a plus sign (+), and a recommendation “against” is marked with a minus sign (-). In addition to the written PAD recommendations, the published guidelines provide excellent tables and figures to assist bedside staff with implementation of the material.

Table 1. GRADE Method for the PAD Recommendations3

Quality of Evidence Strength of Recommendation

A = High

B = Moderate

C = Low/very low

1 = strong

2 = weak

+ = in favor of

– = against

DELIRIUM: IMPACT ON THE ICU PATIENT

Delirium is a clinical syndrome characterized by a disturbance of consciousness that develops acutely (hours to days) and fluctuates over time.4 It is accompanied by inattention and a change in cognition or perception. The cardinal features of delirium are:4

A disturbed level of consciousness (i.e., a reduced clarity of awareness of the environment), with a reduced ability to focus, sustain, or shift attention  

Either a change in cognition (memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance (e.g., hallucinations, delusions). 

5 Looking specifically at the current PAD recommendations, the impact of delirium on patient outcomes is significant (Table 2).1 Numerous studies have demonstrated that patients who develop delirium are at increased risk for adverse outcomes, both in the ICU and after discharge. This risk is independent of preexisting comorbidities, severity of illness, age, and other covariates that might otherwise be considered only associative. In the current literature, 11 prospective cohort studies provide a high quality of evidence linking delirium with increased mortality in adult ICU patients.1 As discussed in the guidelines, numerous studies show that delirium is also associated with prolonged ICU and hospital length of stay. Furthermore, development of long-term, post-ICU cognitive impairment – consistent with a dementia-like state – has been associated with delirium. In an attempt to optimize patient outcomes associated with delirium, bedside clinicians need to understand the predictable, preventable, and treatable features of this syndrome.

Table 2. PAD Recommendations: Delirium Outcomes1

Delirium is associated with increased mortality (A)

Delirium is associated with prolonged ICU length of stay and hospital length of stay (A)

Delirium is associated with the development of post-ICU cognitive impairment (B)

TOOLS TO DETECT AND MONITOR DELIRIUM

Recent landmark studies on delirium have shown important implications for a large number of ICU patients, and have led to additional studies targeting bedside detection and monitoring tools. The PAD guidelines offer a strong recommendation in favor of routine monitoring of delirium based on a moderate quality of evidence (Table 3). With the use of valid and reliable tools, delirium has been identified as common in both mechanically ventilated and non-mechanically ventilated patients. Numerous implementation studies have shown with a moderate quality of evidence that routine monitoring of delirium is feasible in clinical practice. Furthermore, delirium assessment tools enable clinicians to potentially detect and treat delirium sooner, and possibly improve outcomes. Although implementation of these tools is feasible, they often pose additional challenges to the staff responsible for changing bedside behavior. Successful implementation strategies include involvement of all multidisciplinary staff in the education process as well as ongoing surveillance of bedside competencies. A recent 3-year study of delirium monitoring implementation that included more than 500 ICU patients and more than 600 ICU nurses underscored the conclusion that routine delirium monitoring is feasible in clinical practice.5

Table 3. PAD Recommendations: Delirium Detection and Monitoring1

Recommend routine monitoring of delirium (1B)

CAM-ICU and ICDSC are the most valid and reliable delirium monitoring tools (A)

Routine monitoring of delirium is feasible in clinical practice (B)

6 Figure 1. Confusion Assessment Method for the ICU.6,7

Figure 2. Intensive Care Delirium Screening Checklist.8

The most valid and reliable delirium monitoring tools strongly recommended by the PAD guidelines are the Confusion Assessment Method for the ICU6,7 (CAM-ICU) and the Intensive Care Delirium Screening Checklist8 (ICDSC) (Figures 1 and 2). Both tools have shown high inter-rater reliability when tested by multidisciplinary ICU clinicians. The CAM-ICU and ICDSC have been translated worldwide, and recently the Pediatric CAM-ICU has been published targeting the pediatric ICU population.9 The CAM-ICU was adapted for use in nonverbal ICU patients from the original Confusion Assessment Method.6 A complete training manual is available from Vanderbilt University (click here to access). Designed to be a serial assessment tool for use by bedside clinicians, the CAM-ICU is easy to use; it requires less than 2 minutes to complete and minimal training. Inattention is evaluated with either a letters (auditory) test or a pictures (visual) test. CAM-ICU assessment results are usually documented in the hourly portion of the nursing flow sheet. Most institutions document the overall CAM-ICU score and not the individual features. A system of spot-checking can be helpful to identify misunderstandings about the CAM-ICU and areas that need further clarification and teaching. This can be done in a variety of ways, but typically a couple of nurses (e.g., charge nurses, nurse educators) become very familiar with the CAM-ICU and periodically do delirium rounds on the unit – going from bed to bed spot-checking the staff nurses. The bedside nurse and the spot-checker share their findings and have an opportunity to correct any mistakes or misconceptions. The ICDSC is an 8-item checklist that it designed to be completed based on data from the previous 24 hours.8 The 8 items are scored 1 (present) or 0 (absent), for a total of 8 points. A score of 4 or greater is a positive screen for delirium.

7 DELIRIUM RISK FACTORS

Four baseline risk factors have been positively associated with development of delirium in the ICU with a moderate quality of evidence (Table 4).1 These risk factors include pre-existing history of dementia, history of hypertension, history of alcoholism, and a high severity of illness at admission. In addition, coma has been identified as an independent risk factor for the development of delirium.

Table 4. PAD Recommendations: Delirium Risk Factors1

Baseline risk factors positively associated with development of delirium in ICU (B)

― Pre-existing dementia

― History of hypertension

― History of alcoholism

― High severity of illness at admission

Coma (independent risk factor) (B)

Recent studies have identified a number of other factors that are possibly linked to delirium (Figure 3).10-12 These include patient-specific characteristics (e.g., age and gender) and predisposing diseases – all of which tend to be less modifiable – and environmental factors (e.g., noise and restraint use), and factors associated with acute illness (e.g., sepsis, metabolic disorders, and some medications) – all relatively more modifiable. Figure 3. Factors Potentially Linked to Delirium.10-12

DELIRIUM PREVENTION

ICU patients should be evaluated for identifiable and avoidable delirium risk factors, and therapeutic interventions should be assessed for their likelihood of causing or worsening delirium in individual patients.1 However, the quality of evidence supporting these strategies for the prevention of delirium has been low or very low. Indeed, more studies are needed in this area. Given the lack of compelling data, the PAD guidelines offer no recommendation for pharmacologic prevention protocols, combined

8 nonpharmacologic and pharmacologic prevention protocols, or prevention protocols using dexmedetomidine.1 A change from the 2002 guidelines is the recommendation against the use of haloperidol or atypical antipsychotics to prevent delirium. Previous guidelines included a Level C recommendation on the use of haloperidol to treat delirium, based only on a case series; these data did not meet the higher standard of evidence for the current 2013 guidelines.1,2 The only nonpharmacologic intervention shown to reduce the incidence and duration of delirium is early mobility. Studies suggest that, when combined with targeted light sedation goals, early and aggressive mobilization is unlikely to harm ICU patients, and may not only prevent delirium but also improve functional outcomes, reduce depth of sedation, and shorten ICU and hospital length of stay.13,14 The PAD guidelines strongly recommend early mobilization whenever feasible to reduce the incidence of delirium and improve functional outcomes. Other nonpharmacologic protocols in step-down and rehabilitation units have shown favorable results but have not been adequately studied in the ICU environment. These interventions include environmental changes (e.g., noise reduction), sensory aids (e.g., hearing aids, glasses), reorientation and stimulation, and sleep preservation and enhancement.

TREATMENT STRATEGIES

Much attention has been devoted to pharmacologic treatments for delirium, such as antipsychotics. There is no published evidence that treatment with haloperidol reduces the duration of delirium.1 The lack of a pharmacologic treatment plan for delirium remains a challenge to bedside staff. Despite there being no adequately powered prospective trials verifying the safety and efficacy of antipsychotic agents for delirium in the ICU, drugs such as haloperidol are frequently administered for this indication. The PAD care bundle suggests that the pharmacologic treatment for delirium includes avoidance of benzodiazepines unless alcohol or benzodiazepine withdrawal is suspected, avoidance of antipsychotics if the patient is at increased risk of Torsades de pointes, and the avoidance of rivastigmine. A variety of drugs are used in the ICU to treat pain, agitation, and delirium. The clinical effects of each class of drug (Table 5) as well as adverse-event profiles (Table 6) must be taken into account when determining which agents to administer to ICU patients.15-20

Table 5. Sedatives, anxiolytics, and analgesics: Comparison of clinical effects.15-18

Benzos Propofol Opioids Alpha-2 Agonists Haloperidol

Sedation X X X X X

Alleviate anxiety15,16 X X

Analgesic properties15-18 X X

Promote arousability during sedation16-18

X

Facilitate ventilation during weaning16-18

X X

Control delirium15-18 X X

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Table 6. Sedatives, anxiolytics, and analgesics: Comparison of adverse effects.18-20

Benzos Propofol Opioids Alpha-2 Agonists Haloperidol

Prolonged weaning19 X X X*

Respiratory depression19 X X X

Hypotension18-20 X X X X X

Constipation19 X

Deliriogenic X X X

Tachycardia19 Morphine

Bradycardia19 X Fentanyl X X

* Excluding remifentanil.

Benzodiazepines, such as midazolam and lorazepam, are effective for sedation and alleviating anxiety, but they offer no analgesic effects. However, they have been associated with prolonged weaning, respiratory depression, hypotension, and the risk for transition to delirium.2

Propofol is an ideal sedative, with sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant properties, but no analgesic effects.21,22 Because it is short acting, it facilitates ventilation during the weaning process and ease of titration. Like the benzodiazepines, propofol has been associated with prolonged weaning, respiratory depression, hypotension, and bradycardia with rapid administration, and may also be a risk factor for transition to delirium.2

The opioids, such as fentanyl and morphine, are the primary medications for managing pain in critically ill patients. Opioids have effective analgesic properties but also cause some sedation. These drugs have been associated with prolonged weaning, respiratory depression, constipation, tachycardia, and bradycardia, and they may be a risk factor for transition to delirium.2

Alpha-2 agonists, such as dexmedetomidine, have clinical effects that include sedation, mild analgesia, and anxiolysis, and they allow improved arousability during sedation.23,24 Dexmedetomidine does not affect respiratory drive, and one study has shown that it may decrease the prevalence of delirium.25 Two recently completed prospective, randomized, multicenter trials compared dexmedetomidine infusions with midazolam or propofol infusions, and showed that patients receiving dexmedetomidine were more arousable than those receiving propofol or midazolam (Table 7).26 In the study comparing dexmedetomidine with midazolam, time to extubation and total duration of mechanical ventilation were both shorter with dexmedetomidine.

Table 7. Dexmedetomidine trials vs midazolam (MIDEX) and vs propofol (PRODEX)26

Arm Time at

RASS Target Median MV, h

ICU LOS, h

Arousability (total VAS) Hypotension Bradycardia

MIDEX

Midazolam 56.6% 164 243 30.0 11.6% 5.2%

DEX 60.7% 123 211 49.7 20.6% 14.2%

P-value 0.15 0.03 < 0.001 0.007 < 0.001

PRODEX

Propofol 64.7% 118 185 40.1 13.4% 10.1%

DEX 64.6% 97 164 51.3 13.0% 13.0%

P-value 0.97 0.24 < 0.001 DEX = dexmedetomidine; ICU LOS = intensive care unit length of stay; MV = mechanical ventilation; RASS = Richmond Agitation-Sedation Scale; VAS = visual analogue scales.

10 Haloperidol has clinical effects that include hypnosis, and in case reports it has been used for

managing agitation.27 The FDA has not approved haloperidol for this use, and there are no studies that demonstrate haloperidol is effective for the treatment of delirium. Adverse effects of haloperidol include prolonged QT intervals that can lead to Torsades de pointes, as well as hypotension and bradycardia.28

TEAM APPROACH TO OPTIMIZING OUTCOMES

The 2013 PAD guidelines take an additional step to optimize patient outcomes by emphasizing the importance of a patient-centered, integrated, interdisciplinary approach to managing pain, agitation, and delirium in the ICU (Table 8).1 Management strategies include a strong recommendation based on moderate evidence to incorporate daily sedation interruption or light target level of sedation in all mechanically ventilated ICU patients. Evidence also supports a strong recommendation for using an interdisciplinary team approach that includes provider education, preprinted protocols and order forms, and the use of quality ICU rounds checklists.

Table 8. PAD Recommendations: Management Strategies1

Recommend daily sedation interruption or light target level of sedation (1,B) Suggest analgesia-first sedation (2,B) Suggest sleep-promotion strategies by optimizing patient environments (1,C) Recommend interdisciplinary team (1,B)

― Education ― Protocols ― Checklists

The ABCDE Bundle is an example of a bundled care approach that incorporates many of the evidence-based practice recommendations from the PAD guidelines (Figure 4).29,30 The components of the ABCDE bundle include awakening and breathing coordination, delirium monitoring and management, and early exercise and mobility. Each of these components includes safety screens, predefined success and failure criteria, as well as processes to help bedside practitioners implement the interventions in their units. Figure 4. The ABCDE Bundle Components: Protocols to Help Implement Guidelines29,30

11 Another tool, specifically related to delirium management, is the Stop and THINK mnemonic (Figure 5). This tool encourages critical thinking related to medication administration, as well as consideration of alternative causes of delirium in patients in the ICU. Figure 5. Stop and THINK Mnemonic for Delirium Management.

CONCLUSION

ICU delirium occurs frequently and is independently associated with poor outcomes. Critical care nurses who understand the components of delirium, and who are knowledgeable about the most recent recommendations and guidelines, will be better able to optimize implementation of evidence-based interventions at the bedside.

12 REFERENCES

1. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306.

2. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002; 30:119-141.

3. Guyatt GH, Oxman AD, Bost GE, et al. GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendation. BMJ. 2008;336:924-926.

4. American Psychiatric Association. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Compendium 2006. Arlington, Va. American Psychiatric Association; 2006: pp 72-74.

5. Vasilevskis EE, Morandi A, Boehm L, et al. Delirium and sedation recognition using validated instruments: Reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J Am Geriatr Soc. 2011;59(suppl 2):S249-S255.

6. Inouye S, van Dyck C, Alessi C, et al. Clarifying confusion: the confusion assessment method. Ann Intern Med. 1990;113:941-948.

7. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29:1370-1379.

8. Bergeron N, Dubois MJ, Dumont M, et al. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27:859-864.

9. Smith HA, Boyd J, Fuchs DC, et al. Diagnosing delirium in critically ill children: validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit. Crit Care Med. 2011;39:150-157.

10. Van Rompaey B, Elseviers MM, Schuurmans MJ, et al. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care. 2009;13(3):R77.

11. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA.1996;275:852-857.

12. Skrobik Y. Delirium prevention and treatment. Crit Care Clin. 2009;25:585-591.

13. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet. 2009; 373:1874- 1882.

14. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010; 91:536-542.

15. Blanchard AR. Sedation and analgesia in intensive care. Medications attenuate stress response in critical illness. Postgrad Med. 2002;111:59-74.

16. Kamibayashi T, Maze M. Clinical uses of alpha2 -adrenergic agonists. Anesthesiology. 2000;95:1345-1349.

17. Evers AS, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. Churchill Livingstone; 2004.

18. Maze M, Scarfini C, Cavaliere F. New agents for sedation in the intensive care unit. Crit Care Clin. 2001;17:881-897.

19. Harvey MA. Managing agitation in critically ill patients. Am J Crit Care. 1996;5:7-18.

13 20. Aantaa R, Kallio A, Virtanen R. Dexmedetomidine, a novel a2-adrenergic agonist. A review of its

pharmacodynamic characteristics Drugs Future. 1993;18:49-56.

21. McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs. 2003;17:235-272.

22. Marik PE. Propofol: therapeutic indications and side-effects. Curr Pharm Des. 2004;10:3639-3649.

23. Triltsch AE, Welte M, von Homeyer P, et al. Bispectral index-guided sedation with dexmedetomidine in intensive care: a prospective, randomized, double blind, placebo-controlled phase II study. Crit Care Med. 2002;30:1007-1014.

24. Belleville JP, Ward DS, Bloor BC, et al. Effects of intravenous dexmedetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology. 1992;77:1125-1133.

25. Riker RR, Shehabi Y, Bokesch PM, et al; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group: Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009; 301:489-499.

26. Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307:1151-1160.

27. Riker RR, Fraser GL, Cox PM. Continuous infusion of haloperidol controls agitation in critically ill patients. Crit Care Med. 1994;22:433-440.

28. Riker RR, Fraser GL. Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit. Pharmacotherapy. 2005;25:8S-18S.

29. Pandharipande P, Banerjee A, McGrane S, Ely EW. Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Crit Care. 2010;14:157-159.

30. Balas MC, Vasilevskis EE, Burke WJ, et al. Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Crit Care Nurse. 2012;32(2):35-48.

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IMPLEMENTING THE NEW PAD GUIDELINES: DELIRIUM ASSESSMENT

POST-TEST

1. Which of the following symptoms is required to make a diagnosis of delirium? a. Hallucinations b. Disturbed level of consciousness c. Delusions d. Change in cognition

2. Delirium has been associated with which of these patient outcomes?

a. Decreased ICU length of stay b. Increased functional status at discharge c. Prolonged hospital length of stay d. Increased drug costs

3. Which of these tools do the PAD guidelines recommend to assess delirium in the ICU?

a. RASS b. Cognitive Test for Delirium c. Delirium Detection Score d. CAM-ICU

4. Risk factors positively associated with the development of delirium include:

a. History of hypertension b. History of alcoholism c. Pre-existing dementia d. All the above

5. Of the following nonpharmacologic strategies, which is recommended in the PAD guidelines

to minimize delirium? a. Early mobilization b. HOB elevation to 30 degrees c. Use of restraints during mechanical ventilation d. None of the above

6. As recommended in the PAD guidelines, an interdisciplinary ICU team approach to

optimize patient outcomes includes: a. Standardized protocols and order forms b. Multidisciplinary education sessions c. Quality ICU rounds checklists d. All the above

Complete Post-Test and Evaluation online at

www.ProCE.com/DeliriumAssessment

Continuing Education for this activity is processed through the ProCE online CE Center. To receive CE credit: Go to www.ProCE.com/DeliriumAssessment to enroll and complete the Post-Test and Evaluation. With a passing score of 70% or better, you will be able to print your CE certificate online.