In large hospitals, a program to reduce delirium in ICU patients, chiefly by reducing the amount of unneeded sedation, has cut rates of the condition in half. Soon it will be implemented in 60 more selected hospitals.
What serious hospital-acquired condition affects 25% of patients over age 70 and up to 82% of patients in the ICU?
I'll give you a few hints:
- It's not on Medicare's list of "never events," for which hospitals must forego federal reimbursement.
- It's not an infection that affects, urinary tract, or surgical sites, although patients with this condition may suffer those as well.
- It's not falls, pressure ulcers, blood clots, or mismatched transfused blood.
Still stumped?
It's delirium, which Harvard aging researcher Sharon Inouye, MD, describes as "an acute disorder of attention and cognition that is common, serious, costly, under-recognized, and often fatal," with a collective healthcare price tag of more than $164 billion a year in the U.S.
Experts say it is often missed because it's frequently subtle, manifested with quiet symptoms like extreme sleepiness, non-responsiveness, or inattention.
But it also can appear—abruptly and surprisingly—in a more alarming way, with hallucinations and agitation. It's not uncommon that patients thrash in their beds, pull out their IVs, or appear to be fighting off an attack. They may see bugs on the wall or intruders in their rooms, or think a caregiver or family member's touch is a sexual assault.
Clinicians have tended to dismiss delirium as a normal occurrence in older people that will abate in time, but it isn't, and it often does not simply go away. The best way to treat it is to prevent it.
ICU Liberation
A few new programs to prevent delirium onset for patients on general hospital wards involve concerted efforts to engage patients in movement or conversation to keep them focused, oriented, and sedative-free, if possible.
But in the ICU, such efforts are much tougher, because patients are often intubated, heavily sedated, and unable to get out of bed.
But ICU Liberation, a program launched by the Society of Critical Care Medicine (SCCM), is trying to change that. It's been used in 16 Northern California hospitals for the last four years.
The program focuses on improved management of pain, agitation and delirium, (PAD). While there are different ways to implement this safety and quality initiative, the evidence-based approach used by the ICU Liberation program is called "the ABCDEF bundle."
The bundle's chief component is to reduce the amount of unneeded sedation patients too often receive, which many believe is linked to pathological changes in the brain leading to cognitive impairment.
Other strategies include:
- Assessing and managing patients' pain, which can provoke delirium
- Avoiding certain drugs, such as benzodiazapines, in favor of safer choices with less long-lasting sedative impact
- Reducing sedation to keep patients awake and breathing on their own rather than with assistance from mechanical ventilators
- Screening for delirium and cognitive dysfunction
- Promoting movement for improved strength and attention
- Integrating families in the processes of care
The program has been so successful, that the Gordon and Betty Moore Foundation is funding a $769,000, two-year project to expand it nationally through the SCCM, says foundation program director, Marybeth Sharpe.
Soon, the SCCM will select 60 hospitals, 20 in each of three regions around the country, for specific training in the ABCDEF bundle, starting in August, says Diane Byrum RN, the SCCM's manager of Quality Implementation Programs.
"When implemented in a large hospital system, the ABCDEF bundle has been shown to reduce delirium in ICU patients by 50%, and double the likelihood that they will be mobilized," says E. Wesley Ely, MD, Professor of Medicine and Critical Care at Vanderbilt University in Nashville, where the ABCDEF bundle is used. Ely is the principal investigator of the national project.
Studies also show the bundle also increases by three the number of days that people are alive and off mechanical ventilation, Ely says. That is "as large as any other major interventions shown for critical care in the last decade."
ABCDEF also appears to improve survival compared to prior populations of ICU patients studied for whom the bundle was not implemented, although further research will be needed to validate earlier studies.
And, Ely says, "All of the data thus far indicate that how long the patient spends in delirium is a strong independent predicator of their likelihood of developing cognitive impairment that resembles dementia."
ABCDEF has been around for about a decade, and pieces of it have been used by many ICUs. But Ely, also of the VA Geriatric Research Education Clinical Center in Nashville, says "it's rare to find any institutions doing this comprehensively well with a high degree of compliance. That's why this ICU Liberation project is going to be so game-changing."
Byrum explains that many hospitals that do use some of the ABCDEF bundle, "don't do it every day, and not with every patient. What we're trying to accomplish is to get ICU teams to understand that the bundle has a synergistic effect that prevents delirium in the ICU."
Says Ely, "what we're trying to do is change the culture. That's what will lead to success." The 60 hospitals selected, he adds, "will be those on a steep portion of the learning curve, rather than hospitals that already have this down, though there aren't that many of those."
The project will not require more staffing, and may result in a decreased use of ICU labor and resources because preventing delirium can translate to reduced length of stay and less intensive care all around, experts say.
It's clear that prevention of delirium is a growing priority in hospitals. Until now, it might have been one of the industry's dirty little secrets, one rarely if ever disclosed as a possible bad outcome from what patients might consider routine care.
After all, what 70-year-old jogger with a misbehaving hip would consider anxiety-producing hallucinations and long-lasting cognitive impairment as an acceptable byproduct of her stay? She might be frightened enough to stay home and endure the hip pain.
What orthopedic surgeon would want to add the potential for delirium to what is already a long list of what should be disclosed to prospective patients?
At least there does seem to be more attention from the industry.
A February report from The Joint Commission Journal on Quality and Patient Safety focuses on delirium, saying "improving mobility is widely considered to be the most challenging part of rethinking critical care, as it involves the greatest shift in culture and daily processes… It follows reducing sedation in a natural sequence: increasing patient activity requires patients to be alert and interactive rather than sedated."
Think of the impact this could have:
There are 70,000 adult ICUs beds in the U.S., according to the American Association for the Surgery of Trauma, and they provide care to 4.4 million patients each year at an average cost of $3,500 per day.
Presuming that most of these patients are older people, that's a lot of delirium for hospitals to manage. Wouldn't it be great if delirium could be prevented? Especially if by doing so, length of stay was decreased, mortality lowered, and fewer patients were sent home with cognitive impairment?