THINK delirium in intensive care | NICE

In November 2018 Warrington Intensive Care Unit (ICU), a 20 bedded unit, organised a multi-professional delirium study action day on Warrington ICU. Sharedlearningdatabase   Organisation: WarringtonandHaltonNHSHospitalsFoundationTrust Publisheddate: March2020 NICECG103Delirium:prevention,diagnosisandmanagement2010addressesthediagnosisandtreatmentofdelirium.NICEQS63Deliriuminadults,2014provides5qualitystatements. InNovember2018WarringtonIntensiveCareUnit(ICU),a20beddedunit,organisedamulti-professionaldeliriumstudyactiondayonWarringtonICU. TheoutcomewasourTHINKDeliriumStrategy:TrainingprogrammeontheDeliriumCAMICUTool(PP),multicomponentinterventionpackageandourowninnovation,aT.H.I.N.Kalphabetchecklistfordelirium. Ouroutcomesincludeda20%to60%increaseincompliancewithNICEguidelineswithin6monthsofintroduction.ICUICNARCSMRreducedfrom0.99to0.89overtheperiodourTHINKdeliriumstrategywasintroduced. ACQCreportfromAugust2019recognisedoureffortsasatrustwith outstandingpractice.“Theunithadreceivedalargeamountofcharitablefundsandtoinvolvestaffindecidinghowtospendthemoneytheyhelda‘DragonsDen’eventwherestaffwereableto‘pitch’fortheirideaonhowthemoneyshouldbespent”. Guidancethesharedlearningrelatesto: Delirium:prevention,diagnosisandmanagement (CG103) Deliriuminadults (QS63) Viewthesupportingmaterial DoestheexamplerelatetoageneralimplementationofallNICEguidance? No DoestheexamplerelatetoaspecificimplementationofaspecificpieceofNICEguidance? Yes Example Aimsandobjectives Reasonsforimplementingyourproject Howdidyouimplementtheproject Keyfindings Keylearningpoints Aimsandobjectives Aim: ToimplementNICECG103Delirium:prevention,diagnosisandmanagement,2010andNICEQS63Deliriuminadults2014intoacriticalcareICU. Objectives: ToorganiseanICUDeliriumStudyDayinvolvingallstaffdevelopadeliriumStrategy:THINKDelirium ToassesspatientsonadmissiontoICUfordeliriumusinganewdeliriumtrainingtoolCAM-ICU TointroduceatailoredmulticomponentinterventiondeliriumpackageasrecommendedbyNICE NewdeliriumchecklistbasedonNICEQS63's5statementstoensurewearecompliant. Reasonsforimplementingyourproject Wearea600-bed,largedistrictgeneralhospital.OurICUisageneral20-beddedunitopenedin2010.Wehavearound900admissions/yeartotheICU. Deliriumisasyndrome,anacuteconfusedstate,potentiallyreversible.Whatdefinesitisthecardinalsign-inattention(lossofconcentration). TheDSM-5definitiondescribes4domains:disturbanceinattention,awareness,cognitionanddevelopsacutelyandfluctuates.Thereare3types,hyperactive(agitation)hypoactive(lowerGCS)andmixed.Thediagnosisisclinical,therearenodiagnostictests. Differentialdiagnosis:depression,dementia,acutepsychosis.Trigger:lookforchangeinbehaviour.NICElists15changese.g.:confusion,slowresponse,hallucinations,restless,sleep,withdrawn.NICEguidelineshighlight4riskareas:age65,dementia,#NOFandcriticalillness. InWarringtonICUwecareforthemostcriticallyillpatientsinthehospital.Wewantedtoensurethatourpatientsareassessed,treatedfordeliriuminlinewiththeNICEclinicalguidelinesandqualitystandards. NICECG103Delirium:prevention,diagnosisandmanagement2010addressesthediagnosisandtreatmentofdelirium. NICEQS63Deliriuminadults2014provides5QualityStatementsforDelirium: QS1:AssessingRecentChangesinBehaviour:Adultsnewlyadmittedtohospitalorlong-termcarewhoareatriskofdeliriumareassessedforrecentchangesinbehaviour,includingcognition,perception,physicalfunctionandsocialbehaviour. QS2:InterventionstoPreventDelirium:Adultsnewlyadmittedtohospitalorlong-termcarewhoareatriskofdeliriumreceivearangeoftailoredinterventionstopreventdelirium QS3:UseofAntipsychoticMedication:Adultswithdeliriuminhospitalorlong-termcarewhoaredistressedorarearisktothemselvesorothersarenotprescribedantipsychoticmedicationunlessde-escalationtechniquesareineffectiveorinappropriate QS4:InformationandSupport:Adultswithdeliriuminhospitalorlong-termcare,andtheirfamilymembersandcarers,aregiveninformationthatexplainstheconditionanddescribesotherpeople'sexperiencesofdelirium. QS5:CommunicationofDiagnosis:AdultswithcurrentorresolveddeliriumwhoaredischargedfromhospitalhavetheirdiagnosisofdeliriumcommunicatedtotheirGP. Howdidyouimplementtheproject InNovember2018weorganisedamulti-professionalDeliriumStudyActionDayonWarringtonICU.Theagendaincludedpresentationson:TheevidencebasefordeliriumonICU,neweducationandtrainingproject,NICEguidelinesandqualitystandardsondelirium.WealsopresentedthefindingsfromourbaselinedeliriumauditwhichhadbeencompletedinAugust2018. ThedayconcludedwithanopeninteractivediscussionandthedevelopmentofourStrategyfordeliriumfor2019. WecalledourNewStrategy:THINKDELIRIUM Goals: CommunicateourstrategytoallICUStaff CompleteatrainingprogrammeontheDeliriumCAMICUTool(PP). Allpatientstobeassessedonadmissionandtwicedaily Introduceamulticomponentinterventionpackage:clocks,lights,calendar,orientation,games,familyandfriends DevelopanewT.H.I.N.KalphabetchecklistfordeliriumfromtheNICEQSstandards 5auditactivitybasedontheQSstandards Followingourdeliriumday,asummarywasforwardedtoallstaff.ByJanuary2019thetrainingprogrammeondeliriumassessmentCAM-ICUhadbeencompletedforallICUstaff.Therewasalargenumberofstaffthatneededtrainingapprox.50inthisproject.Staffturnoverisquitehighandsoconsistencyisdifficult. Wedevelopedanauditwhichwasdesignedtoincludethefivequalitystandardstatements.Wepurchased19calendarclockstoenhancepatientorientationtodateandtimeandaSoundEarsystemtomonitorandalertstafftonoiselevelsaboveacceptablelevel.TheSoundEarcost£2567fortwounits andthe19clockscost£2007intotal.Otherthanthis,thecosttoimplementwasminimal.Althoughwehavenofigurestodatethecostsavingswillbeindecreasedlengthofstay. TheICUbookletwasgiventorelativesofallnewcasesofdelirium.OurICUGPdischargesummaryincludedasectionwhichalertediftheirpatienthaddevelopeddelirium.InNovember2019weintroducedadailywardroundchecklisttopromptpatientassessmentThroughout2019wegraduallyintroducedanumberofmeasurestoimprovethequalityofpreventionandmanagementofdelirium.Thishelpedustocontinuethemomentumfromourstudyday,raisingawarenessandrepeatingthemantra:THINKDelirium. Keyfindings Wecarriedout3auditstoplotimprovementwiththenewprocess. Audit1).August2018.Apre-audit.20PatientsrandomlyselectedontheICUwhohadtestedCAMPositivewerereviewed. Ourfindings:CAMassessmentwasincompleteonmanypatients’notes.Nopreventionguidelineswereinplacebeforeorduringthisaudit.Themanagementwasalmostentirelyconfinedtodrugtreatment.Therewasinconsistencywitholanzapineusedinhalfofcasesandhaloperidolintheotherhalf.Therewasnoclearguidanceontheuseofanti-psychoticsorescalationwithtreatmentfailure.Therewasincreasedefficacywitholanzapinecomparedwithhaloperidol.Thepercentagetreatedsuccessfullywas25%. Audit2).November-March2019Patientdatawascollectedfrom19thNovember2018to8thMarch2019(14weeksintotal).Welookedat2areas:79newadmissionsonICUwereusedtoassessfordailyCAM-ICUassessmentinthefirst48hoursand30CAMpositivepatientsusedtoassessforcommensalonolanzapine Ourfindings:TheresultsshowincreasedCAMassessmentfollowingthedeliriumdayandfollowingthenursetraining.Thereissomevariationthroughoutthe14-weekstudyperiodbutoveralltherewasanincreasefrom20%to65%inthenumberofpatientsCAMassessedonadmission30ofthenewCAMpositive60%werestartedonolanzapine.Notallpatientsneededolanzapinebuttheresultsshowaconsistencyintreatmentwithourrecommendeddrugwhereaspreviouslyotheragentswereused. Audit3):September2019.A9-weekauditfromJulytoSeptember2019lookingatcompliancewithdeliriumguidelines.29newadmissionstoICUwereassessed.Outcome:50%compliance,aslightdrop-off. Ouroutcomes:20%to60%IncreaseincompliancewithNICEguidelineswithin6monthsofintroduction.MortalityICNARCIntensiveCareSMR(mortality)reducedfrom0.99to0.89overtheperiodourTHINKdeliriumwasintroduced. Keylearningpoints Westartedourprojectwithadeliriumstudyday.Thiswasamulti-professionalapproachtoinvolveasmanyICUstaffaspossible.AninteractivesessiononthedeliriumdayallowedustodevelopajointstrategyandthiswasthencommunicatedtothewholeICUTeam. Keytosuccess: ThedeliriummanagementchecklistandaudittoolwereorganisedaroundtheNICEfivequalitystandardstatementsgivingusaframeworktomeasureimprovement. Educationandtrainingforallstaff. Periodicallyintroducingnewmeasuresandre-auditingtoenergisethemessage:THINKDelirium. Contactdetails Name: JeromeMcCann Job: ConsultantIntensivist Organisation: WarringtonandHaltonNHSHospitalsFoundationTrust Email: [email protected] Sector: Secondarycare Istheexampleindustry-sponsoredinanyway? No