Cost Effective Recognition

and Management of ICU

Delirium
Johnna, Kaitlin, Jenna, Katelyn,
Paige, Morgan, Julie, Stefany, Sara

Introduction
Medical definition of delirium:
A form of acute brain injury, characterized
by an acute change or fluctuation in baseline
mental status, inattention, and either
disorganized thinking or an altered level of
consciousness.
Hsieh, S. J., Ely, E. W., & Gong, M. N. (2013). Can Intensive Care Unit Delirium Be Prevented and Reduced?. Lessons Learned and Future Directions. Annals of the American
Thoracic Society, 10(6), 648-656. doi: 10.1513/AnnalsATS.201307-232FR

ICU Statistics

Occurs in 60 to 80% of mechanically ventilated ICU patients and 20 to 50%

of non-ventilated patients.

Delirium can significantly decrease survival and worsen quality of life after
critical illness through long-term complications such as cognitive
impairment, functional impairment, and institutional placement. It is the
strongest predictor of ICU length of stay, even after adjusting for factors
such as severity of illness and age.

Intensive care unit costs were significantly higher for those with at least
one episode of delirium with an average of cost $22,346 vs. those with no
delirium, with an average of cost $13,332. This resulting in an additional
annual cost of $4-16 billion in the U.S. alone.
Hsieh, S. J., Ely, E. W., & Gong, M. N. (2013). Can Intensive Care Unit Delirium Be Prevented and Reduced?. Lessons Learned and Future Directions.
Annals of the American Thoracic Society, 10(6), 648-656. doi: 10.1513/AnnalsATS.201307-232FR

Patient Testimonials
It's been two years and I'm still trying to sort out
what was real and what wasn't.
The best way to describe it is mental
disorganization, like there is a connection
missing or a synapse not firing. It has been 10
months, and I just keep waiting for it to
straighten itself out.
For me, the reason I was in a bed, on a
ventilator, hardly able to move, was that I had
been drugged and kidnapped.
To me, it was like a slow rebooting of a
computer..
When I returned to work, the work I did before
seemed foreign and unfamiliar. I became
isolated and excluded from everyone. No one
wanted to be around me.

Vanderbilt University Medical Center (2013). ABCDEFs of Prevention and

Safety. Retrieved from http://www.icudelirium.org/index.html

Clinical Question
"In intensive care units, will the implementation
of a new delirium protocol increase the efficacy
of delirium management and decrease delirium
associated costs compared to current practice
when evaluated over 9 months?"

Summary of Current Practice

National: ABCDE Bundle
Hospitals around the country implement a common
delirium protocol.

(Balas, Burke, Gannon, Cohen, Colburn, Bevil, & Vasilevskis, 2013).

Synopsis of Current Literature

A total of eight articles were used to formulate a best practice protocol to
decrease ICU delirium. These were the significant clinical findings from each
article:
Focused Systematic Review

Early identification of patients at risk for developing delirium and of patients with delirium is imperative for effective
delivery of preventative and therapeutic interventions
Multicomponent ICU-level strategies have had better success in preventing and reducing the duration of delirium
compared with pharmacologic strategies that address only a few ICU-level risk factors

Two Prospective Cohort

The major new finding of the study was that the delirium diagnosis using CAM-ICU was predicted more accurately
in individuals with higher mortality rates as compared with ICDSC diagnosis.
Pharmacologic, non-pharmacologic, and educational interventions led to: an increase in delirium-free days out of
30, shorter length of stay in the ICU, and were less likely to be treated with benzodiazepines

Comprehensive Pre and Post Protocol Design

The mean total cost of ICU hospitalization decreased from $6212.64 (7846.86) in the preprotocol group to
$5279.90 (6263.91) in the postprotocol group (p = 0.022)

Establishing protocols for patient-driven management of sedation, analgesia, and delirium is a cost-effective
practice and allows savings of nearly $1000 per hospitalization

Synopsis of Current Literature

Prospective Before-After Mixed Methods Study

The main factors in facilitating bundle implementation were the performance of daily, interdisciplinary rounds;
engagement of key implementation leaders; and sustained and diverse educational efforts
Participants felt ABCDE bundle implementation resulted in significant practice changes that would ultimately
benefit their patients. These included more frequent interdisciplinary rounds, a decrease in the use of continuously
infused sedative, better care coordination, and more frequent and earlier mobilization.

Randomized Control Trial

The use of earplugs during the night lowered the incidence of confusion in the ICU patients studied. Also patients
developed confusion later.
After the first night, patients sleeping with earplugs reported a better nights sleep.

Retrospective Cohort

The risk factors associated with delirium were admission in multibed rooms (odds ratio, 4.03; 95% CI, 2.137.62),
older age, ICU-acquired infection, and higher Sequential Organ Failure Assessment score.
One hundred sixty-three patients (13.0%) had delirium, and the prevalence was significantly lower in patients
admitted in single-bed rooms (6.8% 15.1%; p < 0.01).

Cohort

Implementation of the bundle of interventions led to a reduction in nighttime noise, light, number of staff-patient
interaction over night, and number of times patients were woken due to staff interventions. Also, an increase in
sleep quality, and a decrease in daytime sleepiness.
The bundle led to a reduction in the incidence of delirium (33% 14%). Furthermore, a reduction in days spent
delirious (3.4 days vs. 1.2)

Strengths

Large sample size (Awissi,et al., 2012; Tomasi, et al., 2012)

Reliable tools such as RASS, CAM-ICU, ICDSC, NRS, NEECHAM

(Awissi, et al., 2012;

Tomasi, et al., 2012; Drom, et al., 2012)

Randomized (Drom, et al., 2012)

One single investigator consistently completed the scale every day (Tomasi, et al., 2011)
Took place at a teaching hospital (Awissi, et al., , 2012)
Study approved by the institutional review board & guided by framework (Balas et
al., 2013)

Compliance with the interventions was > 90% (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)
Study was approved by the Lancaster Ethics Committee and local Research
and Development Committee (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)

Limitations

Limited generalizability (Balas et al., 2013) (Caruso, P., Guardian, L., Tiengo, T., Souza, L., Medeiros, P., 2014)
Single center study results need to be confirmed by multicenter
studies including larger populations (Awissi, et al., 2012) (Tomasi, et al., 2012)
Small sample size (Drom, Elseviers, Fromont, Jorens, Rompaey, 2012)
The findings focused on the first 24 hours of admission into the ICU (Drom et al.,
2012)

Uneducated nurses floating into units (Bryczowski et al., 2014)

Population included readmitted patients (Awissi, et al., 2012)
Use of non-randomized cohorts (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)
Proposed protocol has not been tested in a critically ill population (Hsieh, et al.,
2013)

Recommendations

Protocol Implementation

Supportive Interventions
Non-pharmacological Prevention
Patients sleeping with ear plugs reported a better sleep perception (Drom et al., 2012).
The onset of cognitive disturbances were shown to be delayed in patients sleeping with ear plugs

(Drom et

al., 2012).

Patients sleeping with earplugs to reduce sound and promote sleep were shown have a 43% lower risk
of confusion in the ICU (Drom, Elseviers, Fromont, Jorens, Rompaey, 2012).

Non-pharmacological Interventions
Pain assessment and management (Numeric Rating Scale, Richmond Agitation and Sedation Scale, and
Intensive Care Delirium Screening Checklist) (Awissi et al., 2012)
Hourly pain scores and prompt action to optimise analgesia (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)
Line and drain routines should be adjusted to allow as much interrupted sleep during the night as
possible (Bryczowski et al., 2014)
Patients should be given two, 90 minute sessions of time without visitors or unessential interruptions in
the afternoon and evening (Bryczowski et al., 2014)
Orient patients regarding time, place, and date every eight hours (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)
Set appropriate sedation targets once per day based on RASS (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)
Ensure early mobilization when possible and appropriate (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)

Supportive Interventions Cont.

Pharmacological Interventions
Decreasing the use of lorazepam (benzodiazepines) with the use of propofol (anesthetic)

(Awissi,

et al., 2012; Bryczowski et al., 2014)

A statistically significant reduction in the use of each class of drug once the protocols were in
place was noted. The amount of medication used and average daily costs per patient in the
post-protocol group for the majority of targeted drugs were also significantly reduced (Awissi, et. al.,
2012)

Other Interventions

Noise reduction (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)

Close all doors
Turn monitoring equipment to night mode between 23:00 and 07:00
Reduce volumes on all telephones between 23:00 and 07:00
No non clinical discussions around patients bed space
Staff and visitors speak quietly
Light reduction (J. Patel, J. Baldwin, P. Bunting, & S. Laha, 2014)
Dim main ICU lights between 23:00 and 07:00
Use bedside lighting for patient care
Offer eyemasks to all patients with a RASS greater than -4
ICU Architecture (Caruso, P., Guardian, L., Tiengo, T., Souza, L., Medeiros, P., 2014)
Single vs. Multibed rooms for delirious patients

Overall Application and Implementation to

Nursing Practice
Goal: Education of ICU nurses and physicians
Contact ICU educator and present formal presentation
Formal presentations will occur each day for two weeks by the ICU educator
Presentations will occur twice a day at 0800 and 2000 in order to include day and night
shift
Presentations will last about 30 minutes
Semi-professional maintenance presentations will occur for six weeks by the ICU educator
Presentations will occur twice a day at 1300 and 2100 in order to include day and night
shift
Can be attended on nurses breaks or lunches
Presentations will last about 15 minutes
Costs/ Benefits:
Nurses will be paid during these presentations
The education will be done by the ICU educator at no additional cost to the implementation of
the protocol

General Timeline

Initial healthcare provider education: 2 months

Baseline data collection: 4 months

Intervention implementation: 9 months

Evaluation of the efficacy of the protocol was done during the 9

months when the interventions were implemented.

Total amount of time: 15 months

Bryczkowski, S. B., Lopreiato, M. C., Yonclas, P. P., Sacca, J. J., & Mosenthal, A. C. (2014). Delirium prevention program in the surgical intensive care unit improved the
outcomes of older adults. The Journal of Surgical Research, 190(1), 280-288. doi:10.1016/j.jss.2014.02.044 [doi]

Cost Analysis After Implementation

Low cost implementation
ICU educator will provide the education at no cost to the protocol
implementation
Minimal equipment will be necessary for the education or training

The presentations will be held during regular working hours

Awissi, D., Begin, C., Moisan, J.,Lachaine, J., Skrobik, Y. (2012). I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic
Evaluation. Critical Care Medicine Journal. doi: 10.1345/aph.1Q284. Epub 2011 Dec 27.

Cost Analysis After Implementation cont.

In a study conducted on similar implementation of delirium protocol the following results were found:

The mean total costs of an ICU hospitalization were $6212.64 per hospitalization in the preprotocol group and $5279.90 per hospitalization in the post-protocol group (p = 0.022)

The proportion of patients with NRS scores of 1 or less or RASS scores between 1 and +1
(suggesting better analgesia and less agitation or excessive sedation) increased significantly in
the post-protocol group, while costing, on average, $932.74 less per ICU hospitalization.

The use of propofol compared with lorazepam was associated with an average cost reduction
of $6378 per patient within the first 28 days after intubation.

These changes were accompanied by a reduction in hospitalization costs of approximately

15%.

Awissi, D., Begin, C., Moisan, J.,Lachaine, J., Skrobik, Y. (2012). I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the
Intensive Care Unit: An Economic Evaluation. Critical Care Medicine Journal. doi: 10.1345/aph.1Q284. Epub 2011 Dec 27.

Risk vs. Benefit

Benefits

Shorter hospital stay by 20%

Shorter length of mechanical ventilation
Decreased mortality by 10%
Prevent occurrence or development of
delirium in the ICU
Limits delirium duration
Limits long-term consequences of delirium
Increase survival
Increase quality of life after critical
illness
Can decrease costs by $4 to $16 billion
Helps with early detection

Risks
Costs regarding training the
staff
Time for implementation and
training
Compliance with staff

Evaluation
Implementation and concurrent evaluation of the bundle
protocol over a period of nine months will result in a
decrease of delirium associated costs.
After the nine months of concurrent implementation and
evaluation of the bundle protocol, the ICU team will report a
lower prevalence of delirium among patients.
ICU patients that receive care after the initiation of the
protocol will experience an average 20% shorter length of
stay compared to ICU patients that were treated prior to
protocol implementation.

 Introduction

Summary

Acute brain injury; change in mental status

Description of Issue
Ventilated patients at higher risk
Increased length of stay

Supportive Studies
Prevalent issue
Common methods of delirium care and prevention

Summary Continued:
Best Practice
Implementation of Protocol
Decreased benzodiazepines
Promoting sleep and pain control

Application to Facility
Presented protocol will be implemented

Cost Analysis
Lower costs of patients stay in the ICU
Daily hospitalization costs lowered

Questions?

Resources
Awissi, D., Begin, C., Moisan, J.,Lachaine, J., Skrobik, Y. (2012). I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols
Evaluated in the Intensive Care Unit: An Economic Evaluation. Critical Care Medicine Journal. doi: 10.1345/aph.1Q284. Epub 2011 Dec 27.
Balas, M. C., Burke, W. J., Gannon, D., Cohen, M. Z., Colburn, L., Bevil, C., . . . Vasilevskis, E. E. (2013). Implementing the awakening and
breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and
lessons learned for implementing the ICU pain, agitation, and delirium guidelines. Critical Care Medicine, 41(9 Suppl 1), S116-27.
doi:10.1097/CCM.0b013e3182a17064 [doi]
Bryczkowski, S. B., Lopreiato, M. C., Yonclas, P. P., Sacca, J. J., & Mosenthal, A. C. (2014). Delirium prevention program in the surgical
intensive care unit improved the outcomes of older adults. The Journal of Surgical Research, 190(1), 280-288. doi:10.1016/j.jss.2014.02.044
Caruso, P., Guardian, L., Tiengo, T., Souza, L., Medeiros, P. (2014). ICU architectural design affects the delirium prevalence: a comparison
between single-bed and multi-bed rooms. Critical Care Medicine Journal, 42(10), 2204-2210. doi: 10.1097/CCM.0000000000000502
Elseviers, M.M., Fromont, V., Jorens, P.G., Van Drom, W., & Van Rompaey, B. (2012). The effects of earplugs during the night on the onset of
delirium and sleep perception: a randomized controlled trial in intensive care patients. Critical Care, 16 (3). Retrieved from
http://ccforum.com/content/16/3/R73
Hsieh, S. J., Ely, E. W., & Gong, M. N. (2013). Can Intensive Care Unit Delirium Be Prevented and Reduced?. Lessons Learned and Future
Directions. Annals of the American Thoracic Society, 10(6), 648-656. doi: 10.1513/AnnalsATS.201307-232FR

Resources (cont.)
J. Patel, J. Baldwin, P. Bunting, and S. Laha. (2014).The effect of multicomponent multidisciplinary bundle of interventions on sleep and delirium
in medical and surgical intensive care patients. Anaesthesia, 69, 540-549. doi: 10.1111/anae.12638
Tomasi, C. D., Grandi, C., Salluh, J., Soares, M., Giombelli, V. R., Cascaes, S., ... & Dal Pizzol, F. (2012). Comparison of CAM-ICU and ICDSC
for the detection of delirium in critically ill patients focusing on relevant clinical outcomes. Journal of critical care, 27(2), 212-217.
Vanderbilt University Medical Center (2013). ABCDEFs of Prevention and Safety. Retrieved from http://www.icudelirium.org/index.html
Vasilevskis, E.E., Ely, E.W., Dittus, R.S. (2012). Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive
Care Unit. Agency for Healthcare Research and Quality. Retrieved from: webmm.ahrq.gov
Vemulapalli, Tejo. Delirium Prevention and Treatment Protocol in Hospitalized Patients [PowerPoint Slides]. Retrieved from:
http://www.acponline.org/about_acp/chapters/az/12mtg/12_vemulapallimeded.pdf
Zaubler, T. S., Murphy, K., Rizzuto, L., Santos, R., Skotzko, C., Giordano, J., . . . Inouye, S. K. (2013). Quality improvement and cost savings
with multicomponent delirium interventions: Replication of the hospital elder life program in a community hospital. Psychosomatics, 54(3), 219226. doi: 10.1016/j.psym.2013.01.010