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Synopsis

“Attitudes of Health care workers, towards Delirium in Critically ill

Patients of PIMS.”

DR SAIM ALI SOOMRO.MSC. Critical Care Medicine, (trainee.PG)

QPGMC, PIMS, Islamabad.

SUPERVISOR:

DR. RUBINA AMAAN.MBBS, MRCP, INCHARGE, MICU.

PAKISTAN INSTITUTE OF MEDICAL SCIENCES, ISLAMABAD.

2010.

To,

The Honorable Dean,

QPGMC, PIMS, ISLAMABAD

R/MADAM

Kindly find enclosed with this the synopsis/ research proposal of the regarding “ Attitudes of Health care workers towards delirium in critically ill patients”. Same as title.

DATE OF JOINING JULY 2009.

AS PREREQUISITE OF M.Sc. CRITICAL CARE MEDICINE.

NAME OF SUPERVISOR DR RUBINA AMAN.MBBS,MRCP, INCHARGE MICU.

HEAD OF DEPTT. DR MOHAMMAD IQBAL MEMON.MBBS,MCPS,FCPS.HEAD OF ICU & ANESTHESIOLGY,PIMS.

TRAINING & RESEARCH INSTITUTE QPGMC,PIMS,ISLAMABAD.

Following synopsis is being submitted for your kind approval.

Sincerely,

DR SAIM ALI SOOMRO.PG. Trainnie. M.Sc Critical care Medicine.

QPGMC, PIMS , ISLAMABAD Dated: 15. 12. 2010

INTRODUCTION:

Delirium is one of the commonest disorders among ICU patients. All

patients regardless of age & sex but Old patients and mechanically ventilated

patients being especially at risk (1). Main risk factors being older age, critical

illness, multi system involvement, co-morbidities, medications,multiple medical

interventions, catheters , restraints & ICU atmosphere which disturbs sleep wake

cycle.(2). Incidence can be up to 89% in ICU admitted patients. In the ICU,

delirium negatively effects patient's long term survival, weaning from ventilators,

it also contributes to Nosocomial pneumonias, increased length of stay and higher

cost of management. (3,4, 5).

Delirium in critical care is classically characterized by acutely changing and

fluctuating mental status, disorganized thinking, inattention & altered level of

consciousness. Patients with delirium are mostly described as hyperactive

(agitated or combative) but current epidemiological evidence suggests that more

than Two third suffer from hypo-active (Psycho motor slowing) or with mixed

pattern Delirium (6). Delirium is most unrecognized and overlooked complication

among ICU population universally, its prevalence is universal in critically ill

patients, its ironically very easily recognized and ruled out if validating tools are

applied and Health care workers are trained to use (3). Recent guidelines of

Intensive Care Societies mandates daily and repeated screenings of Delirium in all

patients admitted in Critical care units, by using validated scales, early diagnosis

will lead to prompt intervention and treatment. (7,8, 9)

Despite all the work going on international circuit ,delirium is still

underestimated in the developing countries. I have chosen this topic not only to

start a research and debate in commonly overlooked but very important

complication of ICU stay and among critically ill. Nowadays there is increasing

interest in Critical care management and increasing number of specialists in the

field of critical care. We have to address among other issues the very important

issue of delirium in ICU according to international emphasis to improve the care

and outcome in our units. I have selected this topic because I think this will

increase awareness among the health care providers not only in intensive care

settings but also outside. This is also first step in research of Delirium in critical

care units of Pakistan.

Aims & Objects:

“Assessment of attitudes of health care workers towards Delirium, in critically ill

patients at ICUs of PIMS.”

OPERATIONAL DEFINITIONS:

1. HEALTH CARE WORKER: Denotes Doctors and Nurses working in

Critical Care units, who are actively involved in treatment, monitoring and

decision making in the care of critically Ill.

2. DELIRIUM: Is an acute cognitive impairment syndrome, called as organic

brain failure, as included in DSM IV (R) & ICD 10. Its characteristic waxing and

waning phenomenon and recovery to full senses makes it distinct.(7,8,9)

3. DEMENTIA: Chronic progressive decline in cognitive function due to some identifiable cause. Its irreversible and due to some identifiable cause.(8)

4. CONFUSION: State of clouding of conscious, under the effect of drug,

disease or psychological conditions. Patient is rousable to consciousness but with

draws again.

5.CAM-ICU: Vanderbilt University (USA) is heading research programs in

Delirium, they have made extensive research in the field, they devised a tool to

diagnose the Delirium in ICU, called “Confusion assessment Method” popularly

known as CAM-ICU, its popular all over the globe for diagnosing or assessing

Delirium even in patients on ventilators. It was patented in 2002 and revised again

in 2005. (7,8,9)

6. DELIRIUM TREMENS: A life threatening condition due to with drawl of

Alcohol.(8,9)

7. Other popular scales for assessing Delirium (6,7,8,9,10)

a. R-SAS: Riker Sedation-Agitation Scale.(SAS)

b. RASS: Richmond Agitation and Sedation scale. Popularly used to asses Delirium and sedation. (7, 8) .

c. ICDSC: Intensive Care delirium checklist.

MATERIALS AND METHODS:

*STUDY DESIGN:QUASI EXPERIMENTAL ( Survey Type).

*SETTINGS:

CRITICAL CARE UNITS OF PAKISTAN INSTITUTE OF MEDICAL SCIENCES.

*DURATION OF STUDY:

Six months after approval of study.SAMPLE SIZE:

100 PHYSICIANS AND WORKING IN VARIOUS ICUs OF PIMS, WILL BE INCLUDED IN STUDY/SURVEY.

SAMPLE TECHNIQUE:NON PROBABILITY.

SAMPLE SELECTION:

*INCLUSION CRITERIA1. Drs and working in critical areas with minimum 01yr experience in Critical care.2. Drs who has past exposure of ICU for more than or at least a year.

*EXCLUSION CRITERIA .

i) DRs with less than one year Experience in Critical areas.ii) Drs working in areas other than Critical care.iii) Drs having no exposure in Critical Care will be excluded.

DATA COLLECTION PROCEDURE:

A detailed questionnaire is prepared to assess and evaluate the attitudes of

health care workers in critical care units of PIMS, they include Doctors of various

ICUs of PIMS. Prepared questionnaire will be given to health care workers of

ICUs, time for completion will be given and data collected and analyzed.

DATA ANALYSIS:

Data will be analyzed on SPSS. Chi square test will be applied to explore

difference between various answers. p value less than 0.5 will be considered

statistically significant.

REFERENCES:

1. Marget A Pisani,Katty LB Aroujo,Peter H Van Ness, Ying Zhang, E Wesly Ely, Sharon K

inouye, A reasearch algorithm to improve detection of Delirium in the intensive care

unit.,Crit Care. Aug.2006,

2. May L.,Truman B, Speroff T, Gautam S, Margolin R.,et al. Delirium in mechanically

ventilated patients: validity and reliability of confusion assessment method for intensive

care unit (CAM-ICU) JAMA.2001;286:2703-2710.

3. Ely,E.w.,Siegle,M.D.,Inouye,S.K Delirium in intensive care unit An under recognized

Syndrome of organ dysfunction. Seminar Respir Crit Care Med; 22:115-126,2001.

4. Ely,E.W.,Stephans.R.,K,C., Thomson,J.W,Truman,B.,Gordon, S., Dittus,

R. ,S.,Bernard,G.,R.,Current opinions regarding the importance, diagnosis, and management of

delirium in the intensive care unit: a survey of 912 healthcare professionals.Crit Care Med.2004

Jan;32(1):295-6.

5. Ely,E.w.,Truman B, Speroff T, Gautam S, Margolin R., Dittus,R.,S.,Bernard,R.,

Inouye,S.K. The impact of delirium on hospital length of stay. Intensiv care Med.2001;27; 1892-

1900.

6. Cadogan FL, Reikerk B,Vreeswijk R, rommes JH, Toornvliet Ac, Honing ML, Spronk

PE, current awareness of delirium in the intensive care unit: a Postal survey in the Netherlands.

Nether J Med.2009 Jul-Aug;67(7):296-300.

7. Ely E,W, Brenda,T, The Confusion Assessment Method for the ICU(CAM-ICU),Training

Manual,copy right 2002,Vanderbilt University Medical Center for Health Services Research6th

Floor MCE, 6109Nashville, TN 37232. USA.(updated 2005).

8. Camilla L. Wong, Jayna Holroyd-Leduc, David L. Simel, and Sharon E. Straus, Does This

Patient Have Delirium?: Value of Bedside Instruments JAMA. 2010;304 (7):779-786.

9. www.icudelirium.org, official web site for education and research on delirium.

10. www.wikipedia.org\ delirium.

http://www.wikipedia.org/

http://www.icudelirium.org/

QUESTIONNAIRE

Date: Serial #: /

A Profile: Name: Age: Sex:

Level of Experience:

Type of ICU: No. of beds:

Monthly/ Annual number of patients Admitted:

*Delirium*

A. Part I. Definitions & associated factors

Click the correct option in your opinion:

1. Delirium is disorganized, thinking, inattention and waxing and waning of consciousness. is it correct?

Yes NO I don’t know

2. Delirium has been confined to only agitated OLD age patients in ICUs in past .


3. 64% Patients have hypo active or Psycho motor slowing type de4lirium.


4. Older patients are more on the risk of Delirium.


5. Multiple medical procedures also put Patients on Risk of Delirium.


6. Long term sedation specially in infusion forms without interval in drug administration is likely to cause Delirium.


7. Delirium is easily confused with Dementia.


8. Long term mechanical ventilation is also a valid risk factor of Delirium.


9. Mutliple diseases, co morbidities are not among causative factors of delirium.


10. Delirium is among one of most important research and discussion topic

in Intensive Care world over.


B. Part II: Assessment & Diagnosis.

1. Delirium is very easily over looked by Drs and nurses in ICUs world over.

yes No I dont Know

2. Specially trained to use validated scales its only a job of less than a minute.


3. CAM-ICU Scale is being used world over, is one of most popular scales to diagnose & evaluate Delirium.


4. Monitoring constantly is key to easily diagnose the patients in Delirium.


5. Richmond agitation and sedation scale, Pain and sedation scale

and international critical care delirium and sedation scales are other valid tools.


C. PART III . C omplications and Treatment

1. Delirium is instrumental in delayed weaning from ventilators.


2. Delirium is associated with short and long term Mortality among ICU population.


3. Delirium is also associated with Morbidity, increase cost of treatment and multiple complications in ICU.


4. Haloperidol and other Psycho active drugs are first line of treatment.


5. Physio therapy, Psycho therapy, music and counseling is among the mainstay of treatments.


6. Do you think Delirium diagnosis & treatment is mandatory for Health care workers in ICUs.


7. Do you think Drs & Nurses working in various ICUs should be trained for using various scales to diagnose Delirium in PIMS.


SAIM.

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