Hospitals struggle to address terrifying 'ICU delirium' - Stat News

Anywhere from a third to more than 80 percent of ICU patients suffer from delirium during their hospital stay. And one-quarter of all ICU ... SkiptoMainContent Whenhisfeverspiked,hethoughtsomeonewassettinghimonfire.WhenorderliesslidhimintoanMRI,hethoughthewasbeingfedintoanoven.Frequentcatheterchangesseemedlikesexualabuse.Dialysis?Hethoughtsomeonewastakingbloodoutofadeadwoman’sbodyandinjectingitintohisveins. Thehorrifying,violenthallucinationsplaguedDavidJones,now39,duringasix-weekstayintheintensivecareunitatChicago’sNorthwesternMemorialHospital—andformonthsafterhewasdischarged.Hethoughthewasgoingcrazyandfeltveryalone. Hewasn’t. advertisement Recognizingtheprevalenceoftheproblem,doctorsandnursesacrossthecountryarenowpushinganambitiouscampaigntochangepracticesinintensivecareunitstoreducecasesof“ICUdelirium”—asuddenandintenseconfusionthatcanincludehallucinations,delusions,andparanoia. Anywherefromathirdtomorethan80percentofICUpatientssufferfromdeliriumduringtheirhospitalstay.Andone-quarterofallICUpatientssufferfrompost-traumaticstressdisorderoncetheyleave,aratethat’scomparabletoPTSDdiagnosesamongcombatveteransandrapevictims.PatientswithICUdeliriumarelesslikelytosurviveandmorelikelytosufferlong-termcognitivedamageiftheydo. advertisement “Thisisamassive,massivepublichealthproblem,”saidDr.WesEly,apulmonologistandprofessorofmedicineandcriticalcareatVanderbiltUniversityMedicalCenterinNashville,Tenn.,whowasamongthefirsttorecognizethescopeoftheproblem. Related: Raisinganalarm,doctorsfighttoyankhospitalICUsintothemodernera ElyispushinghiscolleaguesinICUsacrossthecountrytoreducetheuseofsedativesandventilatorsandpushpatientstogetontheirfeetassoonaspossible,inabidtominimizedelirium.Thetalkshegivestohighlighttheissueshowpatientstalkingandtextingwhileonventilators—amajorbreakfromthetraditionalpracticeofheavilysedatingthem.Healsoshowspatientswalkingthroughhospitalhallsdespitegrievousinjuries. The“ICULiberationCampaign,”whichElycochairs,isorganizedbytheSocietyforCriticalCareMedicine,aprofessionalgroupforICUclinicians.Ifitworks,it’llbothimprovepatientoutcomesandlowerhospitalcosts. Butit’sbeenahardsell. Despiteitsheavyclinicaltoll,ICUdeliriumisoftenignored.Intensivecareunitsaresostressful,sonoisy,andsofast-pacedthatdeliriumisoftenoverlooked. “Youmayhaveonepatientgoingintoshockwhileanotherneedstobereintubated,sopeoplegetbusy,”saidDr.MattAldrich,ananesthesiologistwhohasbeenimplementingtheICULiberationCampaignattheUniversityofCalifornia,SanFrancisco,MedicalCenter,wherehedirectsadultcriticalcare.“Deliriumhasdefinitelytakenabackseat.” It’snotthatcliniciansdon’tbelieveintheprotocols,Aldrichsaid.It’sjusthardtomaketimetoimplementthem.“Thechallengeistoslowyourselfdownanddothethingsyouneedtobedoing.It’sdailywork.It’smaintenance,”hesaid.“It’snotlettinglittlethingsslideandfallingintooldpatterns.” Keepingpatientsalive—butatacost Inaway,ICUdeliriumisaproblembornofsuccess:Today’sintensivecareunitskeepalivepatientswhowouldnothavesurvived20,10,orevenfiveyearsago.ICUshavecomesofarincurbingproblemslikesepsisandacuterespiratorydistresssyndromethatthey’vecreatedahugepopulationof“ICUsurvivors”—thosewhomakeitoutalivebutendupseverelyimpactedmentallyandpsychologically. “WeusedtocallitICUpsychosis,”saidJustinDiLibero,aclinicalnursespecialistworkingtoreduceICUdeliriumintheneuroandsurgicalICUsatBethIsraelDeaconessMedicalCenterinBoston.“Weknewitwascommonbutthoughtpatientsgotbetterwhentheygothome.Nowweknowtheycomeintothehospitalasonepersonandleaveassomeoneelse.” Familymembersareoftenthefirsttoseethattheirlovedones“aren’tthemselves.”Patientsmayactparanoid,lashoutinanger,orsimplyseemquitesilly,forexampleplanninglargegalaswhilestillintubated. WhiletheexactcausesofICUdeliriumarenotfullyunderstood,riskfactorsseemtoincludeventilation,whichcanreducetheflowofoxygentothebrain,andheavysedation,especiallywithbenzodiazepines,whichcanhaveneurotoxiceffects.Immobilityandphysicalrestraintsappeartocontributetopsychologicaldistressaswell.Thelackofsleep,noisyalarms,constantproddingbynursesanddoctors,andpatients’inabilitytokeeptheirhearingaidsandglassesonmaycontribute,too. “Theycomeintothehospitalasonepersonandleaveassomeoneelse.” JustinDiLibero,clinicalnursespecialist Theeffectscanlingerlongafterdischarge. “AssoonasIgothometherewerecognitiveissues,reallybadpanicissues,flashbacks,allverygruesome,”saidJones.“IfeltlikeI’denduredmonthsoftorture.Iwasscaredtogotosleep.I’dwakeupinacoldsweat.” Joneshadenteredthehospitalin2012withstomachpainsthatturnedouttobecausedbyacutenecrotizingpancreatitis.Hispancreaswasliterallydigestingitself;thenhisotherorgansstartedtofail.Hewasputonlifesupport:Onarespiratoranddialysis,fedthroughatube,thestockyandathleticJoneslost70ofhis260pounds.Ninedaysintohishospitalstay,doctorsgatheredhisfamilytosaygoodbye. Thankstosurgery,afloodofantibiotics,anddedicatedhospitalstaff,Jonessurvived.He’sincrediblythankfulforthecarehereceived. Buthe’salsoangry,nowthatheknowshowwidespreadICUdeliriumis,thatnotasinglepersontalkedtohimorhisfamilyaboutthementalandpsychologicalissuesthatsomanyICUpatientsface. “Ithought,‘Whyintheworldisthisnotincludedinpost-dischargeinstructions?’”JonessaidinatelephoneinterviewfromChicago,wherehehasreturnedtoworkasalegalanalyst.“Theyweresohappytheyhadsavedmylife.Butnoonetoldmetoexpectanyofthis.” Acultureof‘protecting’patientswithsedation ElyhasalwaysbeenproudoftheworkdoneathisICU.Butinthelate’90s,hestartedtonoticesomethingdeeplyunsettling:Manyofhispatientsweren’tdoingwellaftertheyleftthehospital.Somewereseverelyimpaired.Manycouldn’treturntowork. “Theycouldn’tfindtheircarsorbalancetheircheckbooks,”hesaid.“Wewondered,‘WhathappenedtothemintheICU?Whatwentwrong?’” Elywasshakenbytheencounters,butwhenhetriedtobringuptheissuewithfellowintensivecarephysicians,orcriticalcarespecialists,orevenwiththeNationalInstitutesofHealth,hegotnotraction. HiscalltoeaseuponrestrainingandsedatingpatientsbuttedupagainstwhatElysayswasadeeplyentrenched—anddeeplypaternalistic—ICUculture.“Theideahaslongbeen:‘Wewanttokeepyouunconscioussoyoudon’tsuffer.’”Elysaid.“Wethoughtwewere‘protecting’patients.” Therewerepracticalissuestoo:Heavilysedatedpatientsarefareasierfornursestoworkwiththanpatientswhoarefrightened,agitated,orinpain.Anditcanbeveryhardtodetectdeliriuminpatientswhoarelethargicandseemunaware—butmaystillbedelusionalandsuffering.“TheytoldmeIwasinacoma,”Jonessaid.“ButIwasaware.” Elyhasspentthepasttwodecadesstudyingtheissueandamassingthekindofdatathatarestartingtoconvincehiscolleagues.A 2013study,forexample,showednearly75percentofICUpatientsdevelopeddeliriumduringtheirhospitalstay.Inroughlyone-thirdofthosecases,theircognitiveproblemsweresoseverethatevenoneyearafterdischarge,theymimickedmildtraumaticbraininjury. Tominimizesuchdamage,ElydevelopedaprotocoldubbedABCDEF,withstepssuchasassessfordelirium,choosesedationwisely,andpushpatientstoearlymobility. Related: Hospitalsarethrowingoutorgansanddenyingtransplantstomeetfederalstandards Whentheproceduresareimplemented,theyseemtoworkwonders. AtBethIsraelDeaconessMedicalCenter,careteamsinthemedicalICUshavereducedthenumberofdeliriouspatientsby60percentsince2012,atacostsavingsofthousandsperpatient.Theydidthisbycarefullyassessingpatientsfordelirium,makingsuremultiplecareteammembersagreedonthoseassessments,andthenreducingsedationandparticularlybenzodiazepineusewheneverpossible. “Wediscussedeverypatienteveryday,anddeliriumwaspartofthediscussion,”saidDiLibero,thenursespecialistwhorantheproject,whichwasfundedbytheAmericanAssociationofCritical-CareNurses,whichrecentlyissuedapracticealertaboutdeliriumtoitsmembers.Whennursesweren’tsurewhattodo,DiLiberosaid,theycouldcallin“nursechampions,”whoactasmentorsandleaders. Lookingfordeliriumisespeciallyimportantinelderlypatients.Withoutacarefulassessment,elderlypatientswithdeliriummaybemisdiagnosedwithdementiaandsenttonursinghomesunnecessarily. TheprojectatBethIsraelworkedsowell,it’sbeenadoptedbyotherICUsatotherregionalhospitals.Butitwasn’teasytogetthere.DiLiberohasbeenworkingontheissuesince2010,hiscommitmentsparkedbyseeingsomanyICUpatients,includinghisowngrandmother,succumbtodelirium. “Thisisamassive,massivepublichealthproblem.” Dr.WesEly,pulmonologist “It’stakenyearsofconcertedefforttogettothispoint,”hesaid.“It’sbeenaboutchangingaculture.”Thatchangeisnowpalpableinhisunit. “WhenIstartedinICU,anyonewhowasgoingtobeintubated,they’dallbesedated,prettydeeplysedated,”DiLiberosaid.“Nowsomepatientsarecompletelyoffsedativeswhilestillonaventilator.IneverthoughtI’dseethat.” Whilethereisagreementthatit’scrucialtopreventdeliriumwheneverpossible,manyquestionsstillremainonhowbesttotreatitafteritoccurs.Vanderbiltisoneofthefewhospitalsthatoffersapost-ICUtreatmentcenter;openedin2012,itdrawspatientsfromaroundthecountry.Atthecenter,patientsaretreatedbyateamthatincludesanICUphysician,nurse,pharmacist,casemanager,andneuropsychologistwhoworktogethertohelppatientsunderstandandalleviatesymptoms. JonessaidtherapyinChicagowasagreathelptohim,andincludedrevisitinghisICUroomtobetterunderstandhishallucinations. He’salsocommittedtotalkingpubliclyabouthisexperienceinhopesotherswon’tsufferashedid.Andhealwayscarriesacarefullywordedlifedirectiveinhisbriefcasethatmakesclearthatanyintensivetreatmenthemightneedisprovidedinawaythatislesslikelytocausedelirium. “Asbadasmyillnesswas,”hesaid,“thepost-ICUwasmoretraumatic.” AbouttheAuthor Reprints UshaLeeMcFarling NationalScienceCorrespondent UshacoversthetollofCovid-19aswellaspeopleandtrendsbehindbiomedicaladvancesinthewesternU.S. [email protected] @ushamcfarling Tags hospitals ICU physician Myfiancéisgoingthroughthisverything.Thestaffisdownplayingthesituation.Thisisn’tmypartner. Theyinducedthisprocedureunnecessarily-nowtheconsequencesandcoverup.Theyshouldneverdidthis. OlderComments» Commentsareclosed. 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