A Pilot Study to Evaluate the Feasibility and Effectiveness of a Multi-Component Intervention for Prevention of Delirium in Critically Ill Adults

Jan Foster, PhD, APRN, CNS, CCRN

This study was funded by Sigma Theta Tau International Honor Society for Nurses, Beta Beta Chapter

What is Delirium?

Hyperdynamic Subtype

Agitation

Combative

Hyperactive

Pure hyperdynamic is rare (5-30%)

Hypodynamic Subtype

• Decreased mental activity– Unaware of the environment– Lethargic– Apathetic– Inattention

• Decreased speech• Staring• Decreased physical activity• Psychomotor retardation

Mixed Subtype

Agitated & combative one

moment

Somnolent and

hypoactive at other times

Most cases are mixed (45%)

Waxing and Waning

Risk Factors

Delirium

Environmental

IatrogenicPatient

Characteristics

Summary of Risk Factors for Delirium

Host factors

• Advanced age (> 65 years)• Male gender• Comorbidities• Severity of illness• Cognitive impairment prior to

critical illness• Pain• Medication/drug/alcohol

withdrawal

Critical illness factors

• Hypoxemia• Hypotension• Low hematocrit• Sepsis• Inflammation/infection

Summary of Risk Factors for Delirium (cont)

Iatrogenic

• Sedatives and analgesics

• Anticholinergics• Mechanical

ventilation• Sleep disruption• Restraints

Environmental

• Day/night non-distinction

• Noise• Excessive

meaningless/deficient meaningful stimulation

Purpose of the Study

The purpose of this pilot study was to establish the proportion of delirium in the MICU and evaluate the feasibility of a multi-component intervention aimed at preventing delirium in critically ill adults

5 Part Intervention

• Daily sedation cessation• Sleep/wake cycle• Patient mobility• Meaningful sensory stimulation • Preferred music listening

Setting

• Community hospital, MICU• Delirium Team – Led by 2 CNSs– 6 frontline clinicians– MD on planning committee

Methods

• Prospective, descriptive, cohort design• Baseline data collection took place for 1-month• Education and implementation of the CAM-ICU to

assess for delirium followed• The intervention was implemented and post-

intervention data collection took place for 2 months

Daily sedation cessation

• Stopped the infusions of sedatives and opiates everyday at 0730, which has been current practice in the ICU

Sleep/wake cycle• Designated sleep period was 2200-0400 hours• Environmental modification to facilitate sleep consisted

of – dimming the overhead lights– closing the blinds– minimizing ambient noise to < 85 d– noise reduction: limiting vocal sound, television, nursing

procedures, x-rays, venipunctures, arterial sticks– cluster activities as much as possible (families, too)– Quiet Sign placed in the patient’s room, with space provided

to document each patient interruption

Quiet Time

10pm-4am• Time lights off _____• Time lights on _____• Check box for each patient

interruption:

Place patient label on back

• Time lights off _____• Time lights on _____• Check box for each patient

interruption:

Place patient label on back

Quiet Time

10pm-4am

Patient mobility

• 4 level mobility protocol was to be used (Morris, et al, 2008)

• Designed for the critically ill population and the levels determined by patient acuity

• PCAs, families, RNs, PT– PT only with provider orders

Meaningful sensory stimulation

• Visible clocks, calendars (white board)

• Opening/closing blinds during day & night

• Patients use their vision and hearing aids – Families encouraged to

provide the items • A decibel meter was used to

measure the noise level (noise = meaningless stimulation)

Preferred music listening

• Preferred music offered to each patient • Managed by patient when able, by family and/or

nurse when patient’s level of consciousness, sedation level, other condition rendered the patient unable to press buttons or make selection

• When neither patient nor family was able or available to make a selection, music was deferred (patient preference unknown)

• Music played from 1800 to 2000• OK to play at other times EXCEPT NOT during sleep

time (2200-0400)

Participants

• Inclusion criteria– >18 years – Hemodynamically stable– Hearing able

• Exclusion criteria– Hemodynamically unstable– Hearing deficit– Neurological deficits that precluded

responsiveness or physical movement

Results Pre-intervention

• 216 Assessments• Missing data for delirium status was

52/216 = 24.07% • How many of those with missing data were

positive????

Results Baseline

28%

60%

Positive

Negative

• Of the remaining 164 assessments– Positive for delirium 46/164 (28%)– Negative for delirium

98/164 (60%)– Unable to assess 20/164 (12%)

Results Post-intervention

• 32 patients consented and enrolled– 17 female, 15 male– Caucasian 30; 1 African American; 1 Hispanic

• Missing data 8/92=8.69%– Less missing data than pre-intervention

Results Post-Intervention

• Positive delirium 26 of 84 assessments (31%) • Negative 57/84 (68%)• Unable to assess 1/84 (1%)

31%

68%

Positive

Negative

Results – Sedation Cessation

10 patients mechanically

ventilated• 38 ventilator days

(42%)

• 16/38 episodes of sedation cessation (42%)

Results - Sleep

Mean sleep hours was 7.75 hours with

a mean of 5 interruptions

nightly

Results – Noise

Mean noise level was 45 decibels

Well below OSHA recommendations

< 85

Results - Mobility

Best mobility for the majority of patient observations was bed rest with passive motion only

• 30 = Level I• 28 = Level II

Results – Sensory Aids12 patients known to wear corrective lenses

20%

23%57%

Missing Data Wearing

Not Wearing

Results – Music Listening11 patients favored music playing

10%

60%

30%

Playing

Not Playing

Missing Data

Summary ResultsPatients with mechanical ventilation were 17% more likely (OR .17, 95% CI .03-.82, p.027) to have delirium

Patients receiving beta blockers were 7.2 times more likely (OR 7.2, CI 1.2-41, p.028) to have delirium

Results - Feasibility

Barriers: sleep promotion & mobility protocol adherence;

lack of support from other disciplines; patient/family consent; documentation

Facilitators: ease in environmental noise modification; family

support of sleep

Discussion and Conclusions

Barriers & promoters to implementation of the intervention AND

in data collection process

Mechanical ventilation & beta blockers increased relative risk for delirium

Sleep, noise, use of sensory aids, music had no impact on delirium

Effects of mobility on delirium prevention is

unknown

Discussion and Conclusions

People• Refinement of a multidisciplinary protocol

Process• A structured mobility program

Research

• Larger sample size• Determine effectiveness of mobility in

delirium prevention• Especially in mechanically ventilated

patients receiving BBs

• jgwfoster@comcast.net• jfoster@twu.edu