WRHA Surgical Program Delirium Guidelines

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WRHA Surgical Program Delirium Guidelines

• Cheryl Bilawka
• April 18, 2012

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Purpose

• The WRHA Surgery Program had identified that
  there was no formal regional guidelines in place
  to identify, screen or manage postoperative
  delirium.

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Process

• A working group was created with members
  representing all the acute care sites chaired by
  Wendy Rudnick, WRHA Surgery Program Director.
• The objective of this group was to develop a
  standardized approach to delirium care for
  surgical patients in the WRHA.

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Methodology

• The group complied existing tools and protocols
  from all the acute care sites and with the
  assistance of the experts in delirium and
  surgical management, the WRHA Delirium
  Implementation Tools will be rolled out across
  the region May 14, 2012.

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Delirium Tools

• Delirium Brochure for patients and their families
• WRHA Surgery Program PREoperative Assessment
  Questionnaire
• Delirium Clinical Practice Guidelines
• Delirium Decision Tree
• Lanyard Cards
• Audit tool for evaluation
• Evidence Informed Practice Tool (coming soon)

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Opportunity for Interventions

• Preoperatively
• Postoperatively

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The Surgical Patient
Preoperatively
If patient assessed as at risk for delirium,
slating department to be notified.
Slating to identify patient at risk for delirium
on the OR slate.
All patients will be screened for delirium in PAC
If patient at risk and patient is seen, PAC will
give patient or family a Delirium brochure
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Preoperative Screening

• The WRHA Surgery Program Preoperative Assessment
  Patient Questionnaire, has been revised to have
  delirium screening criteria embedded using flags

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Example from the PREoperative Assessment Patient
Questionnaire

• The last time that you were hospitalized, did you
  experience confusion, hallucination or behaviour
  that was unusual for you?........ No Yes

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Delirium Elderly At-Risk (DEAR) Tool

• For patients greater than 65 years of age, flag
  at risk for delirium if
• ? greater than 80 years of age
• ? benzodiazepines and/or alcohol
  greater than 3 x/week
• ? glasses and/or hearing aides
• ? Mini Mental Status Exam less than
  24 or previous delirium
• ? assistance with any activities of daily
  living
• Delirium Risk Flags
• _____________/5
• Delirium Risk if greater than 2 flags.
  Implement facility protocol.
• ? N/A patient less than 65 years of age

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Communication of Delirium Risk

• Each hospital will develop a process so that the
  delirium risk will be identified on the OR slate.
• Inpatient postoperative units will have access to
  the delirium risk information.

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Delirium Brochure
DELIRIUM A Medical Emergency
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Delirium Decision Tree
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Delirium Decision Tree

• WHAT ARE THE RISK FACTORS?
• Severe Illness
• Sensory Impairment (hearing/vision)
• Age (age 65 years and over)
• Cognitive Impairment (dementia)
• Dehydration
• Multiple Medications (Sedatives/Hypnotics/Narcoti
  cs/Anticholinergics/ Psychotropics)
• ETOH/Substance abuse
• Previous Delirium
• Infection
• RECOVERY FROM SURGERY
• Impairment of Activities of Daily Living
  (bathing/dressing/toileting/grooming/feeding)
• Pain

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The Surgical Patient

• Postoperatively

Administer CAM within the 1st 8 hours of
admission.
Positive CAM Assess using CAM Q shift and prn
Negative CAM Assess Q 24 hours and prn (with any
cognitive and/or functional changes)
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Delirium Decision Tree
Search for reversible causes and treat ,/ CXR
,/ EKG ,/ CBC ,/ Electrolytes ,/ BUN/CR ,/
TSH/B12 ,/ Urinalysis ,/ Medication
Review Nurses Assess ,/ Vital Signs/02 sat ,/
Assess/treat pain / Fluid balance ,/ Blood
Sugar ,/ Elimination
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Delirium Decision Tree
INTERVENTIONS Environmental Clocks/Calendars
Cognitive Frequent orientation Communication
Simple short sentences Safety Fall
prevention/Safe environment Psychological
Don't dispute delusions reassurance
Pharmacology Avoid Polypharmacy Avoid
Benzodiazepines For agitated delirium please
consider an antipsychotic Function Balance,
rest, activity
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Delirium Decision Tree
CONFUSION ASSESSMENT METHOD (CAM) Need
presence of (1) (2) and either (3) or (4) 1.
Abrupt change? 2. Inattention, can't focus? 3.
Disorganized thinking? Incoherent,
rambling, illogical? 4. Altered level of
consciousness? (Hyper-alert to stupor?)
Trigger Questions 1. Acute changes in
behavior? 2. Changes in function? 3. Changes
in cognition? MMSE 4. Changes in medications?
5. Physiologically stable?
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Lanyard Card of CAM
CONFUSION ASSESSMENT METHOD (CAM) Answer these
four questions 1) Was the onset acute and does
behaviour fluctuate? AND 2) Is there
evidence of inattention? (difficulty
focusing attention, shifting and keeping track)
AND EITHER 3) Is there evidence of
disorganized thinking? (Incoherent, rambling,
illogical flow of ideas) OR 4) Is there
evidence of disorganized thinking? (i.e. any
state other than alert) (Alterations include
hyperalert, lethargic, stuporous and
comatose) FEATURES 1 AND 2, AND EITHER 3 OR 4
ARE REQUIRED FOR A DIAGNOSIS OF DELIRIUM
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Delirium Clinical Practice Guideline
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Goals of Implementation

• Awareness of postoperative delirium
• Screen for delirium and communicate risk
• Routine utilization of the CAM as the standard
  method for detecting delirium
• Use of the CAM tool when communicating with other
  Health Care Professionals
• Proactive interventions

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Audit Tool

• Screened for delirium in PAC
• Delirium Risk on Slate
• CAM done within 8 hours postop
• If CAM positive, are interventions and plan
  documented in IPN
• Physician notified
• If CAM positive, is CAM reassessed 8 hours later
• If CAM is negative, is CAM reassessed q 24 hours.

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Metrics

• Length of stay
• Constant Care Use
• Falls Reduction

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Future Opportunity?

• Pose the question
• What if the patient is flagged as high risk for
  delirium, yet does not actually go on to
  experience a delirium?
• Examination looking for evidence of proactive
  care planning
• Early Mobilization
• Adequate Pain Management

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Delirium Working Group Members and Contributors

• Wendy Rudnick
• Karen Murphy
• Michele Lepp
• Lisa Anthony
• Graciana Mederios
• Ann Reichert
• Cheryl Bilawka
• Christine Johnson
• Leslie Dryburgh

• Rayan Horswill-Tees
• Valerie Hiebert
• Vera Duncan
• Karen Gutknecht
• Carol Knudson
• Bruce Anderson
• Claire Dionne
• The PAC Working Group