National Call “Learning from Delirium Collaborative”

Appel National “apprendre de la Collaboration sur le delirium”

Monday, February 25 2013 Lundi, le 25 février 2013

** All lines are muted upon entry. If you have any questions, please raise your hand or CHAT to Host **

**Toutes les lignes sont en sourdine au départ. Si vous avez des questions, s'il vous plaît levez votre main ou clavardez pour joindre l'hôte) **

Your Hosts & Planning Team Vos hôtes & l’équipe de planification et de soutien

Dr. Claudio Martin, Chair Canadian ICU Collaborative Président, Collaboration canadienne des

soins intensifs Bruce Harries, Collaborative Director and Moderator Directeur de la Collaboration et Animateur Ardis Eliason, Project Coordinator and Technical Host for today’s session Coordonatrice de projet et hôte technique Leanne Couves, Improvement Advisor Conseillère en amélioration Anne MacLaurin, Project Manager, Canadian Patient Safety Institute (CPSI) Coordonatrice de projets, ICSP

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Faculty Membres de la faculté

Chaim Bell, MD, PhD, FRCPC

Paule Bernier, Dt.P., M.Sc.

Vanda DesRoches; RN BN

Greg Duchscherer, RRT, FCSRT

Denny Laporta, MD, FRCPC

Cathy Mawdsley, RN, M.Sc.

Yoanna Skrobik, MD, FRCPC

Jennifer Turple, BSc Pharm, ACPR

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Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliser

4

Be prepared to use: - Pointer - Raise hand - CHAT - Text Tool “writing on the slide” - Shape Tools

Have you used WebEx before? Avez-vous déjà utilisé WebEx? YES / OUI NO / NON

Soyez prêts à utiliser les outils : - le pointeur - lever la main - clavardage - Outil textuel pour « écrire sur la diapo » - Outils de forme

02/12/2013

Type your message & click ‘send’

Select ‘send to’

Who’s Online? Qui est en ligne? POINTER

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What professions are represented? Quelles professions sont représentées?

Nurse/ infirmière

MD

Educator /Éducateur Quality Improvement Professional/Professionnel en amélioarion de la qualité

Infection Control\PCI

Administrator /Administrateur Senior Leader

Other/ autre

POINTER

6

Psychiatry/ psychiatrie Pharmacy/

pharmacie

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Context and Results Contexte et Résultats

Bruce Harries

Collaborative Director

Directeur de la Collaboration

Collaborative Aim Buts de la collaboration

• Improve care of the critically ill patient through implementation of standardized screening and identification of prevention and management strategies for delirium

• Améliorer les soins du patient en phase critique grâce à la mise en œuvre du dépistage standardisé et de l'identification de stratégies de prévention et de gestion du delirium

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Accreditation Canada Standard 9.8

“The team uses a delirium screening tool to assess clients for delirium. Delirium, a heightened state of agitation, contributes to increased length of stay and may cause clients to self-extubate or remove catheters. The team identifies and consistently applies a delirium screening tool.”

• “Léquipe utilise un outil de dépistage pour éaluer les pts pour delirium. Le delirium, un état avancé d’agitation, contribue à augmenter la durée du séjour et le risque d’auto-extubation ou d’enlèvement des sondes. L’équipe identifie et applique l’outil de dépistage de façon constante”

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Collaborative Principles Principes d’une Collaboration

• Everybody teaches, everybody learns

• Share generously (transparency)

• Steal shamelessly

• Acknowledge graciously

When we cooperate, everybody wins.

» W. Edwards Deming

• Tout le monde enseigne, tout le monde apprend

• Partagez généreusement (transparence)

• Volez sans honte • Reconnaîssez avec grâce Lorsque nous coopérons, tout

le monde gagne. W. Edwards Deming

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The Collaborative Approach l’approche Collaborative

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Learning Session

One (A&B)

-Jan 18 & 25-

Learning Session

Two -May 28-29-

Learning Session

Three (A&B)

-Nov 14 & 21-

Support Team Calls List Serve Document Sharing Monthly Reports

Assessments Site Visits Faculty Coaching

Planning & Pre-work a) Teams b) Topic

-July-Dec-

Action Period One Action Period Two

Distribute Findings

Dec

A

S

P

D

A

S

P

D

A

S

P

D

Action Period Three

*Based on Institute for Healthcare Improvement Breakthrough Series Collaboratives

27-Feb-13

AHS Edmonton Zone University of Alberta Hospital Grey Nuns Hospital

AHS Edmonton Zone – Sturgeon Hospital Misericordia Hospital

AHS - Calgary Zone

Saskatoon Health Region

London Health Sciences Centre

Humber River Regional Hospital Hamilton Health Sciences Centre North York General Hospital Joseph Brant Hospital

Participating Teams-Équipes particiapntes

AHS – Medicine Hat Hospital

Bluewater Health Hotel-Dieu Grace Hospital

Timmins & District Hospital

Thunder Bay Regional Health Science Centre

Horizon Health Network

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Delirium Measures in Indicateurs du delirium Patient Safety Metrics sur le portail SSPSM System (PSMS) 1. Percentage of Patients

Screened for Delirium

2. Percent of Patients Identified with Delirium

3. Percent Compliance with Non-Pharmalogical Strategies

4. Number of Unplanned Extubations per 1,000 Invasive Mechanical Ventilation Days

1. % patients ayant subi un dépistage ppour le delirium

2. % pts identifiés ayant le délerium

3. % conformité aux stratégies non pharmacologiques

4. Nombre d’extubation non planifié pae 1000 jours de ventilation effractive

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Change Concepts

• Recognize/manage/mitigate risk factors (prevention & reduction) for every patient

• Assess for Delirium every shift

• Document compliance with standardized protocol for management

• Support patients and families

• Reconnaître/gérer/diminuer les facteurs de risque (prévention et réduction) pour chaque patient

• Évaluer pour le delirium à chaque quart de travail

• Documenter la conformité au protocole standardisé pour la gestion du delirium

• Soutenir les patients et leurs familles

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Change Concepts

• Consider others to be part of same system

• Change work environment

• Standardize clinical processes

• Manage hand-offs

• Establish reliable processes

• Considérer les autres comme faisint partie du même système

• Changer l’environnement de travail

• Gérer les transitions

• Établir des processus fiables

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1.0 Percentage of Patients Screened for Delirium 1.0 Pourentage de pts faisant objet de dépistage

• Xxx of teams now have data for 2-3 key measures, standardized definitions x-Canada

• Insert run chart for those measures

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Source: SHN Patient Safety Metrics System February 2012

2.0 Percentage of Patients Identified with Delirium 2.0 Pourcentage de patients identifiés avec delirium

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Lessons Learned on the Collaborative Journey

Dr. Yoanna Skrobik

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The Agitated Patient

• Pain

• Insufficient sedation

• Delirium

Patient views on what is important in the ICU

• Painlessness

• Reassurance – Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000

– Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May

Sedation

Monitoring Sedation

• The RASS and SAS scales are valid and reliable for measuring quality and depth of sedation in adult ICU patients .

Sedation

– Depth of sedation vs. clinical outcomes: • Maintaining lighter levels of sedation in adult ICU patients is

associated improved clinical outcomes, such as a shorter duration of mechanical ventilation and a shorter ICU length of stay.

• Maintaining lighter levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia .

• The relationship between depth of sedation and psychological stress in these patients is unclear .

• sedative medications titrated to maintain light (vs. deep) levels of sedation in adult ICU patients are associated with better outcomes .

Outcomes Related to Sedation

• sedation strategies using non-benzodiazepine sedatives have better outcomes than benzodiazepine infusions in mechanically ventilated adult ICU patients.

• analgesia should be evaluated prior to sedation in adult ICU patients who are mechanically ventilated .

Delirium

Van der Mast. PhD Thesis, Delirium After Cardiac Surgery, Erasmus University, Rotterdam, 1994

Delirium and Outcomes

• Delirium is strongly associated with increased mortality and LOS in adult ICU patients.

• Delirium is moderately associated with the development of post-ICU cognitive impairment in adult ICU patients.

Delirium and Distress

Breitbart W et al. Psychosomatics 2002;43:183

CAM-ICU (Confusion Assessment Method-ICU)

Delirium Scales

ICDSC (Intensive Care Delirium Screening Checklist)

http://www.icudelirium.co.uk/ www.icudelirium.org

Delirium Nomenclature Consistency is Important

Delirium and its consequences

Delirium Prevention

• early mobilization of adult ICU patients reduces the incidence and duration of delirium.

• there are no compelling data that pharmacological delirium prevention in the ICU reduces the incidence or duration of delirium.

Protocol to address patient views on what is important in the ICU

• Painlessness

• Reassurance – Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000

– Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May

How can optimal patient care be provided?

• a multidisciplinary ICU team approach, that includes provider education, preprinted and/or computerized sedation protocols and order forms, and a quality rounds checklist, can be used to facilitate analgesia, sedation and delirium management in adult ICUs.

Impact of Using a Validated Delirium Screening Tool, With or Without a Pharmacist and Nurse-led Delirium Education Program, on the Ability of Nurses to Recognize Delirium in a

Surgical-Trauma ICU

Andrew Lin, PharmD Brittany Russell, RN, BSN, CCRN

John W. Devlin, PharmD, BCPS, FCCM, FCCP H. James Norton, PhD

Susan Evans, MD Gail Gesin, PharmD

Educational Interventions

Results: Subject Nurse Delirium Knowledge

0 1 2 3 4 5 6 7 8 9 10

Phase III

Phase II

Phase I

Average Number of Correct Answers

p=0.001

p=0.001

p=0.08

0 10 20 30 40 50 60 70 80 90 100

The ICDSC makes delirium easier to identify in my patient(s)

Delirium is challenging to assess in ICU patients

Phase I

Phase II

Phase III

% of Nurses that Agree (Moderately or Strongly)

Delirium Treatment

• There is low quality evidence that atypical antipsychotics reduce the duration of delirium in adult ICU patients .

Placebo

Quetiapine

Prop

ortio

n of

Pat

ient

s w

ith D

eliri

um

Day During Study Drug Administration

Log-Rank P = 0.001

Quetiapine added to as-needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation.

Devlin JW, et al. Crit Care Med. 2010;38:419-427.

Patients with First Resolution of Delirium

Drug Specificity: Comparative Receptor Binding Profiles

Adapted from Gareri P, et al. Clin Drug Invest. 2003;23:287-322.

Olanzapine

Risperidone

Quetiapine

Ziprasidone

Haloperidol

D1 D2 5HT2A

5HT1A

A1

A2

H1

D1 D2

5HT2A

A1 A2

H1

M

D2 D1

5HT2A

5HT1A A1 D1 D2

5HT2A

5HT1A

A1 A2 H1 D1

D2

5HT2A

5HT1A

A1

Delirium Treatment

• There is no direct evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients .

• There is low quality evidence that atypical antipsychotics reduce the duration of delirium in adult ICU patients .

• rivastigmine should not be given to reduce the duration of delirium in ICU patients.

• continuous intravenous infusions of dexmedetomidine rather than benzodiazepines should be administered for sedation of adult ICU patients with delirium, in order to reduce the duration of delirium in these patients.

My Discoveries of the Collaborative

• Awesome teams from all of Canada committed to improving patient care

• An ongoing feedback and improvement team to help make that happen based on the team’s goals

• Interest and consideration for expert opinions on the relevant topics

• A sneaky feeling good will and commitment are more important than guidelines

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In summary…

• Protocolized nursing assessments of pain, sedation and delirium are associated with improved short-term and long-term outcome.

• Protocol AND non protocol-driven medication administration result in better outcomes in the context of educated and empowered nurses, and of physician buy-in.

• These data suggests that it is individualization of care, and not protocolization of medication, which accounts for improved outcomes.

Overall management

Managing pain, agitation and delirium in the critical care setting

•Manage adult patients who need sedation and analgesia according to current standards

•Use validated scales for sedation, pain, agitation, and delirium in the assessment and to follow the management of these critically ill patients

•Assess recent clinical findings in sedation and analgesia management and incorporate them into the management of patients in the critical care setting

Thank you

A Case Study: One

Collaborative Team’s Journey

Hamilton Health Sciences Centre

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Histoire de cas: Le périple d’une équipe de la Collaboration

Next Steps/ prochaines étapes

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Next Steps/ Prochaines étapes

• Measurement Reporting System in SHN’s Patient Safety Metric System (PSMS) – Available now

Contact Central Measurement Team 416-946-3103 metrics@saferhealthcarenow.ca

• Delirium Getting Started

Kit – Available in late Spring 2013

• Système d’indicateurs de la sécurité des patients- fonctionnel maintenant – Contactez lÉquipe responsible

des mesures: 416-946-3103

– metrics@saferhealthcarenow.ca

• Trousse de départ, Delirium- disponible fin printemps 2013

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Thank You Merci

• Team Sponsors / aux Soutiens exécutifs des équipes

• Faculty 3 la Faculté

• Planning & Support Team / L’équipe de planifiation et de soutien

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Funded & Supported By Financé et appuyé par