Ashley Cundiff, MSN, RN, keeps a close eye on patients in her 32-bed intensive care unit (ICU) at Chippenham Hospital in Richmond, Virginia. She’s watching for more than changes to their vital signs. She’s looking for what they may not be able to communicate. She’s trying to keep them from slipping into delirium.
“We call it the matrix,” says Cundiff, director of the medical/surgical trauma ICU at Chippenham. “They look like they are asleep, but they’re just in a whole other realm.”
Cundiff knows that no matter how vigilant she and her nursing team are, some of her patients will descend into this delusionary state. Her mission is to pull them out before they plunge too deeply into it.
“These patients are sick enough already, and we never want to bring anything else on them,” Cundiff says. “We’re constantly asking ourselves what we can do to prevent them from going into the matrix, so when they get better, they’re not suffering lifelong consequences.”
Marked by sudden and intense periods of confusion, hallucinations and paranoia, ICU delirium has become an alarmingly common experience for patients in critical care units. Patients who succumb to it have longer hospital stays, poorer outcomes and higher mortality rates. Even after leaving the hospital, some are left with night terrors and cognitive repercussions equivalent to a blow to the head or early Alzheimer’s disease, according to a 2013 study in the New England Journal of Medicine. A growing number of hospitals are becoming aware of the dangers of ICU delirium and searching for ways to free patients from its grip.
As Essential as Your ABCs
These are the elements of the ABCDEF care bundle:
A: Assess, Prevent & Manage Pain
B: Both Spontaneous Awakening Trials & Spontaneous Breathing Trials
C: Choice of Analgesia & Sedation
D: Delirium: Assess, Prevent & Manage
E: Early Mobility & Exercise F: Family Engagement & Empowerment
The dilemma has even commanded the attention of the Society of Critical Care Medicine (SCCM), which launched an ICU Liberation initiative in 2015 to rescue patients from the harmful effects of pain, agitation and delirium in the ICU. The organization is working with hospitals nationwide to implement new research-based guidelines for the Management of Pain, Agitation and Delirium (PAD). SCCM has also partnered with critical care innovators at the Vanderbilt School of Medicine, the University of Chicago and other institutions to promote what’s called the “ABCDEF care bundle,” which includes protocols for assessing and managing pain, minimizing the use of sedatives and ventilators, getting patients up and moving and encouraging family engagement. (See box left.)
“We create some of our own problems,” says Laura Reed, MSN, RN, associate chief nursing officer at Chippenham Hospital, which has implemented the ABCDEF bundle across its critical care departments. “The first thing we used to do when a patient started showing signs of delirium was medicate them, but that just exacerbated the issue. Then you had to restrain them, which often led to more problems. If we can prevent delirium from the beginning, we can limit their stay in the ICU and improve their outcome.”
The Delirium Spiral
When Reed started working in the ICU nearly 30 years ago, nurses were urged to wean patients off ventilators as quickly as possible, but over the years the pendulum swung toward sedating them for days while they recovered.
“We used to think if we kept patients sedated and calm, we could leave the life-saving tubes and devices in them until they got better,” agreed Beverly Shields, DNP, MSN, RN, CCRN, director of critical care and medical surgical services for Franklin, Tennessee-based Community Health Systems (CHS).
While drugs such as benzodiazepines and other anti-anxiety medications do make patients calmer and less combative in the short term, they ultimately fuel the cycle of delirium, and patients are often confused and delirious when they wake up, says Seenu Reddy, M.D., director of cardiac surgery outreach for Nashville, Tennessee-based TriStar Cardiovascular Surgery and chair of HealthTrust’s Physician Advisor Surgery Council. Older patients who are already experiencing cognitive decline or taking a lot of medication are even more susceptible.
“Combine that scenario with an unfamiliar environment full of alarms, beeps and buzzers going off at all hours, strangers coming in and out of your room, fluorescent lights and a complete inversion of your days and nights, and it’s basically set up to cause delirium in the susceptible patient,” Reddy adds.
“We’re in their rooms all the time,” Reed says. “We wake them up at all hours, and there aren’t consistent times for allowing patients to sleep.”
The lack of rest, combined with hours of lying in the same position in cramped rooms with little, if any, natural light, can agitate patients even more. Though delirium is typically associated with hyper, belligerent patients who try to climb out of bed or rip out tubes and monitors, many delirious patients act just the opposite.
Reed notes, “They may be looking at you and answering questions, but not really understanding anything you’re saying or what’s happening around them.”
Because delirium can develop within a day or two and fluctuate in its severity, catching it early is vital for elimination without resorting to antipsychotic medication, which can cause adverse effects. While going along with what a delirious patient is saying or doing may seem more convenient in the hustle and bustle of the ICU, overlooking delirium can trigger a cascade of consequences for patients that can prolong their ICU stay and follow them home.
“As nurses, we pat ourselves on the back for saving people and getting them out of the hospital,” Reed says. “But when they return home, some of these patients never get back to their previous level of functioning. So it’s important to be thinking longer term.”
Pushing Patients Out of the Cocoon
For ICU nurses at Chippenham Hospital, protecting patients from the ravages of delirium starts with keeping them as awake and alert as possible and being more mindful in helping them manage pain.
“If we can keep patients less sedated, they’re usually able to reason better and understand when we say, ‘Don’t pull this tube out,’ ” Cundiff says. “You can explain things to them, and they tend to work with you because they’re not on so many mind-altering substances.”
Scaling back the amount of sedation patients receive and time spent on ventilators required critical care teams at Chippenham to change their way of thinking. However, seeing how well patients responded brought everyone around.
“The most successful transition for us was recognizing that, while we were trying to help our patients, what we were doing for them was often making them worse,” Reed says.
Managing patient expectations about pain with surgery can also help, Reddy adds. “For decades, there was an expectation that patients should be treated so aggressively with medications that they wouldn’t experience any pain after surgery—but that’s changing,” he says. “Now we’re better at explaining preoperatively that patients will have discomfort with surgery, but we’re going to try to minimize it.”
Combining fewer opioids with milder pain relievers is another alternative many ICUs are using for postoperative pain management, along with strategies as simple as changing how a patient is positioned in bed.
“You don’t always have to bring out the big guns to bring relief from pain,” Cundiff notes. “Sometimes Tylenol is enough.”
As part of the ABCDEF bundle, many care teams perform spontaneous awakening and breathing trials every morning to rouse patients and evaluate their ability to follow commands and breathe on their own. “If they start getting anxious from breathing on their own, you can try putting their sedation back on by half,” Cundiff says.
There is also a growing number of quick, bedside assessments available to measure pain, agitation and delirium in patients, including the Behavioral Pain Scale (BPS), the Richmond Agitation-Sedation Scale (RASS) and the Confusion and Assessment Method for the ICU (CAM-ICU).
Nurses at Chippenham use these assessments daily to monitor patients for delirium. Tools like these keep delirium on nurses’ radar and prompt them to think critically about how to handle it, Reed says. “If something is off scale, that’s a cue for our teams to intervene.”
Getting patients moving helps, too. Nurses at Chippenham work closely with physical therapists to encourage patients to sit up, stand and walk—even while on a ventilator. Not only does mobility reduce their risk of pneumonia, blood clots and bedsores, but it also helps regulate their circadian clock and puts them in the present moment.
“We try to mimic the routine they have at home and help them maintain their muscle strength,” Cundiff adds.
Family Support & Human Connection
Delirium is often hardest on the families of patients who rarely see it coming and struggle to understand why their loved one is acting so out of character. While they may wonder if their loved one will ever be the same, their support is the best lifeline for helping patients break free of delirium.
“We are doing a much better job of involving families and having open visitation, so they can be there to reorient patients,” Reed says.
Having family and friends at the bedside gives patients familiar faces among the rotating ICU staff and keeps them grounded. Hospitals can help by educating family caregivers on how they can create more normalcy for patients, from decorating their room with family photos to bringing in their glasses, hearing aids or favorite music. Families can also engage loved ones by talking or reading to them or doing activities with them they enjoy such as crossword puzzles or checkers.
Including families in bedside reports and giving them a chance to ask questions helps caregivers and patients feel like they have a voice in their care. So does explaining what you are doing to patients and asking about their lives.
“Even if patients are in a delirious state, you never know what they may be comprehending,” Cundiff says.
Helping patients set goals for what they want to accomplish day-to-day also gives them back a sense of control and motivates them to look ahead.
“Critical care nurses are very list-driven,” Cundiff adds. “We love to go in and say, ‘This is what I’m going to do for you today.’ But we need to be asking, ‘What’s your goal for today? If I could do anything to help you, what would it be?’ ”
Changing the Culture
Delirium used to be viewed as an inevitable consequence of an ICU stay for some patients, Reddy says. But with research and awareness about delirium growing, more clinicians are understanding how they perpetuate it—and, more important, how they can help combat it.
“Nurses and physicians are more attuned to it now,” Reddy says. “We’re catching it earlier than we ever have before, and we’re creating interventions to minimize it.”
CHS is working to help its hospitals change the culture around delirium by providing ICU staff with easy-to-use, evidence-based tools to help them recognize symptoms and tackle it early.
“We developed a gap analysis for our hospitals using guidelines condensed from the American Association of Critical-Care Nurses, so clinicians can see what they are doing well and where they need to improve,” Shields says.
Those efforts are paying off. Now patients who used to sleep all day are “up walking around in the unit and maintaining their strength and energy,” Shields notes. “We get patients out of the hospital a lot faster, and they are much better in the long run.”
At Chippenham, ventilator days—the measurement they use to track their success with the bundle—are down by at least a day for most patients, and ICU nurses are seeing the positive impact of their interventions.
“We like to think we know what our patients experience and that we’re always doing what’s best for them,” Cundiff says. “But we’re starting to see that our patients are capable of more than we necessarily believed. Until you give them that chance, you never know.”
For more information, visit the Society of Critical Care Medicine’s ICU Liberation website, or the American Association of Critical-Care Nurses’ website.