Leadership Series

Delirium is an ongoing problem in hospitalized patients everywhere. But as awareness of the issue has grown, hospitals have become more proactive, taking steps to both prevent delirium and better recognize and treat it. St. Luke’s Health has been and remains at the leading edge in delirium prevention and management.

The Issue With Delirium

Delirium, a sudden confusion or acute brain failure, is widespread among older, hospitalized patients. Prevalence across hospitalized adult patients is around 23 percent, while prevalence in older patients in the ICU is as high as 80 percent. Delirium is also one of the most common reasons for acute end-organ dysfunction in these patients. Any patient can develop delirium, but those most at risk include:

• People over 65

• People with alcohol use disorder

• People with pre-existing cognitive impairment, such as dementia

As the severity of illness in the ICU increases so does the risk of delirium. Delirium, in turn, poses additional hazards for patients. Those with delirium are more likely to unintentionally remove catheters and breathing tubes, need more sedation, need longer periods of mechanical ventilation, and stay longer in the ICU. Once discharged from the ICU, these patients are less likely to be able to go home and more likely to be discharged to a nursing facility. Studies have also shown that those who experience delirium while in the ICU are more prone to long-term cognitive decline.

Delirium also increases the cost of care for hospitals, as patients need more intensive monitoring and have longer lengths of stay. 

SLH Uses Research to Improve Outcomes

While we don’t have exact statistics for SLH patients, the consensus of our care provider indicates that the prevalence of delirium is lower in our ICU patients than a decade ago. Key factors influencing the change are increased staff, better awareness of the condition and investigation into effective strategies to improve patient outcomes. Our findings were subsequently published in peer-reviewed journals:

• One study showed that use of a multidisciplinary “delirium management team,” composed of a physician, clinical pharmacist and registered nurse–delirium coordinator, reduced delirium and ICU length of stay.

• Another study demonstrated that use of a bundle of interventions reduced the odds of delirium in ICU patients by 78 percent.

• A third study found the use of exercise physiologists in the ICU resulted in earlier mobilization of patients, crucial because mobilization has been shown to reduce delirium.

Taking a Multidisciplinary Approach

SLH has since developed these research findings into a protocol and implemented them with a multidisciplinary team, as prevention and management of delirium is truly a multidisciplinary effort. We collaborate across departments with multiple health care professionals to ensure a comprehensive and integrated strategy for preventing and managing delirium.

In the ICU, nurses screen all patients for delirium using a tool called Confusion Assessment Method-ICU (CAM-ICU) that is built into our electronic medical record. We also utilize a delirium prevention bundle that includes:

• Adequate pain management

• Daily cessation of sedation

• Early mobilization using exercise physiologists

• Sensory stimulation during the day

• Sleep promotion

To improve sensory stimulation, all ICU rooms now have large windows to let in natural light. We also have liberal family visitation hours. We have found that the more time families can spend with the patient, the more the patient is likely to be reassured and reoriented, which reduces delirium.

We have also taken multiple steps to promote sleep, such as darkening ambient lights and minimizing alarms and noise at night so patients can get uninterrupted rest. In some of our units we have even implemented an afternoon quiet time from 2 to 4 p.m.

Medication Management Is Crucial

All too often, delirium can stem from medications. That’s why SLH takes steps daily to lower this risk. Both physicians and the clinical pharmacist review every patient’s medications every day to minimize the use of drugs that can worsen delirium, such as steroids, opioids and the benzodiazepine class of sedatives. 

We have also found medications can help manage hyperactive delirium in patients. One of the most useful medications is dexmedetomidine, a continuously infused sedative that reduces anxiety without suppressing respiration. Other medications we may use include haloperidol and quetiapine.

What’s Next for Delirium Prevention and Management?

At SLH, we are always working to refine our processes to provide the best patient care based on the most recent and proven medical standards. As a part of our ongoing quality improvement process, we are implementing an ICU liberation bundle supported by the Society of Critical Care Medicine (SCCM) called ABCDEF:

• A = Assess, prevent and manage pain

• B = Both spontaneous breathing trials and spontaneous awakening trials

• C = Choice of sedation and analgesia

• D = Delirium: assess, prevent and manage

• E = Early mobility and exercise

• F = Family engagement and empowerment

Studies have shown that implementation of such a bundle not only reduces delirium, but has been associated with lower hospital mortality, lower ICU readmission rates and greater likelihood of the patient going home rather than to a nursing home. 

An SLH physician served on the SCCM committee that worked with the software company Epic to help create a dashboard within a patient’s electronic medical record so staff can more easily document each aspect of the bundle. The software includes an analytic tool to track compliance with the bundle and the prevalence of delirium among patients. We piloted this dashboard in one of our ICUs and reached out to Epic for further software optimization. We hope to launch the revised dashboard in March 2024.