WRHA Surgical WRHA Surgical Program Program Delirium Delirium

GuidelinesGuidelinesCheryl BilawkaCheryl Bilawka

April 18, 2012April 18, 2012

PurposePurpose

The WRHA Surgery Program had The WRHA Surgery Program had identified that there was no formal identified that there was no formal regional guidelines in place to regional guidelines in place to identify, screen or manage identify, screen or manage postoperative delirium.postoperative delirium.

ProcessProcess

A working group was created with A working group was created with members representing all the acute members representing all the acute care sites chaired by Wendy care sites chaired by Wendy Rudnick, WRHA Surgery Program Rudnick, WRHA Surgery Program Director.Director.

The objective of this group was to The objective of this group was to develop a standardized approach to develop a standardized approach to delirium care for surgical patients in delirium care for surgical patients in the WRHA.the WRHA.

MethodologyMethodology

The group complied existing tools The group complied existing tools and protocols from all the acute care and protocols from all the acute care sites and with the assistance of the sites and with the assistance of the experts in delirium and surgical experts in delirium and surgical management, the WRHA Delirium management, the WRHA Delirium Implementation Tools will be rolled Implementation Tools will be rolled out across the region May 14, 2012.out across the region May 14, 2012.

Delirium ToolsDelirium Tools

Delirium Brochure for patients and their Delirium Brochure for patients and their familiesfamilies

WRHA Surgery Program PREoperative WRHA Surgery Program PREoperative Assessment QuestionnaireAssessment Questionnaire

Delirium Clinical Practice GuidelinesDelirium Clinical Practice Guidelines Delirium Decision TreeDelirium Decision Tree Lanyard CardsLanyard Cards Audit tool for evaluationAudit tool for evaluation Evidence Informed Practice Tool (coming Evidence Informed Practice Tool (coming

soon)soon)

Opportunity for Opportunity for InterventionsInterventions

PreoperativelyPreoperatively

Postoperatively Postoperatively

The Surgical PatientThe Surgical Patient

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.

Preoperatively

If patient at risk and patient is seen, PAC will give patient or family a

Delirium brochure

Preoperative ScreeningPreoperative Screening

The WRHA Surgery Program The WRHA Surgery Program Preoperative Assessment Patient Preoperative Assessment Patient Questionnaire, has been revised to Questionnaire, has been revised to have delirium screening criteria have delirium screening criteria embedded using flags embedded using flags

Example from the Example from the PREoperative Assessment PREoperative Assessment

Patient Questionnaire Patient Questionnaire

The last time that you were The last time that you were hospitalized, did you experience hospitalized, did you experience confusion, hallucination or confusion, hallucination or behaviour that was unusual for behaviour that was unusual for you?........ you?........ No No Yes Yes

Delirium Elderly At-Risk Delirium Elderly At-Risk (DEAR) Tool(DEAR) Tool

For patients greater than 65 years of age, flag at risk For patients greater than 65 years of age, flag at risk for delirium if:for delirium if:

□ □ greater than 80 years of age greater than 80 years of age □ □ benzodiazepines and/or alcohol greater than benzodiazepines and/or alcohol greater than

3 x/week3 x/week□ □ glasses and/or hearing aidesglasses and/or hearing aides

□□ Mini Mental Status Exam less than 24 or Mini Mental Status Exam less than 24 or previous previous delirium delirium

□ □ assistance with any activities of daily livingassistance with any activities of daily living

Delirium Risk Flags:Delirium Risk Flags:_____________/5_____________/5

Delirium Risk if greater than 2 flags. Implement Delirium Risk if greater than 2 flags. Implement facility protocol.facility protocol.

□ □ N/A patient less than 65 years of ageN/A patient less than 65 years of age

Communication of Communication of Delirium RiskDelirium Risk

Each hospital will develop a process Each hospital will develop a process so that the delirium risk will be so that the delirium risk will be identified on the OR slate.identified on the OR slate.

Inpatient postoperative units will Inpatient postoperative units will have access to the delirium risk have access to the delirium risk information.information.

Delirium BrochureDelirium Brochure

DELIRIUM A Medical Emergency

Delirium Decision TreeDelirium Decision Tree

Delirium Decision TreeDelirium 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 PatientThe Surgical Patient

Administer CAM within the 1st 8 hours of admission.

Positive CAM

Assess using CAMQ shift and prn

Negative CAMAssess Q 24 hours and prn(with any cognitive and/or

functional changes)

PostoperativelyPostoperatively

Delirium Decision TreeDelirium 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 TreeDelirium 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 TreeDelirium 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 CAMLanyard 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 Delirium Clinical Practice GuidelineGuideline

Goals of ImplementationGoals of Implementation

Awareness of postoperative deliriumAwareness of postoperative delirium Screen for delirium and communicate Screen for delirium and communicate

riskrisk Routine utilization of the CAM as the Routine utilization of the CAM as the

standard method for detecting deliriumstandard method for detecting delirium Use of the CAM tool when Use of the CAM tool when

communicating with other Health Care communicating with other Health Care ProfessionalsProfessionals

Proactive interventionsProactive interventions

Audit ToolAudit Tool

Screened for delirium in PACScreened for delirium in PAC Delirium Risk on SlateDelirium Risk on Slate CAM done within 8 hours postopCAM done within 8 hours postop If CAM positive, are interventions and plan If CAM positive, are interventions and plan

documented in IPNdocumented in IPN Physician notifiedPhysician notified If CAM positive, is CAM reassessed 8 hours If CAM positive, is CAM reassessed 8 hours

laterlater If CAM is negative, is CAM reassessed q 24 If CAM is negative, is CAM reassessed q 24

hours.hours.

MetricsMetrics

Length of stayLength of stay Constant Care UseConstant Care Use Falls ReductionFalls Reduction

Future Opportunity?Future Opportunity?

Pose the question:Pose the question: ““What if the patient is flagged as high What if the patient is flagged as high

risk for delirium, yet does not actually risk for delirium, yet does not actually go on to experience a delirium?”go on to experience a delirium?”

Examination looking for evidence of Examination looking for evidence of proactive care planningproactive care planning Early MobilizationEarly Mobilization Adequate Pain ManagementAdequate Pain Management

Delirium Working Group Delirium Working Group Members and ContributorsMembers and Contributors

Wendy RudnickWendy Rudnick

Karen Murphy Karen Murphy

Michele LeppMichele Lepp

Lisa AnthonyLisa Anthony

Graciana MederiosGraciana Mederios

Ann ReichertAnn Reichert

Cheryl BilawkaCheryl Bilawka

Christine JohnsonChristine Johnson

Leslie DryburghLeslie Dryburgh

Rayan Horswill-TeesRayan Horswill-Tees

Valerie HiebertValerie Hiebert

Vera DuncanVera Duncan

Karen GutknechtKaren Gutknecht

Carol KnudsonCarol Knudson

Bruce AndersonBruce Anderson

Claire DionneClaire Dionne

The PAC Working The PAC Working GroupGroup