a pilot study to evaluate the feasibility and effectiveness of a multi-component intervention for...
DESCRIPTION
Hyperdynamic Subtype AgitationCombativeHyperactive Pure hyperdynamic is rare (5-30%)TRANSCRIPT
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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
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What is Delirium?
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Hyperdynamic Subtype
Agitation
Combative
Hyperactive
Pure hyperdynamic is rare (5-30%)
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Hypodynamic Subtype
• Decreased mental activity– Unaware of the environment– Lethargic– Apathetic– Inattention
• Decreased speech• Staring• Decreased physical activity• Psychomotor retardation
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Mixed Subtype
Agitated & combative one
moment
Somnolent and
hypoactive at other times
Most cases are mixed (45%)
Waxing and Waning
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Risk Factors
Delirium
Environmental
IatrogenicPatient
Characteristics
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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
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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
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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
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5 Part Intervention
• Daily sedation cessation• Sleep/wake cycle• Patient mobility• Meaningful sensory stimulation • Preferred music listening
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Setting
• Community hospital, MICU• Delirium Team – Led by 2 CNSs– 6 frontline clinicians– MD on planning committee
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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
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Daily sedation cessation
• Stopped the infusions of sedatives and opiates everyday at 0730, which has been current practice in the ICU
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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
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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
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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
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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)
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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)
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Participants
• Inclusion criteria– >18 years – Hemodynamically stable– Hearing able
• Exclusion criteria– Hemodynamically unstable– Hearing deficit– Neurological deficits that precluded
responsiveness or physical movement
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Results Pre-intervention
• 216 Assessments• Missing data for delirium status was
52/216 = 24.07% • How many of those with missing data were
positive????
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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%)
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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
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Results Post-Intervention
• Positive delirium 26 of 84 assessments (31%) • Negative 57/84 (68%)• Unable to assess 1/84 (1%)
31%
68%
Positive
Negative
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Results – Sedation Cessation
10 patients mechanically
ventilated• 38 ventilator days
(42%)
• 16/38 episodes of sedation cessation (42%)
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Results - Sleep
Mean sleep hours was 7.75 hours with
a mean of 5 interruptions
nightly
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Results – Noise
Mean noise level was 45 decibels
Well below OSHA recommendations
< 85
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Results - Mobility
Best mobility for the majority of patient observations was bed rest with passive motion only
• 30 = Level I• 28 = Level II
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Results – Sensory Aids12 patients known to wear corrective lenses
20%
23%57%
Missing Data Wearing
Not Wearing
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Results – Music Listening11 patients favored music playing
10%
60%
30%
Playing
Not Playing
Missing Data
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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
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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
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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
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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