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Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium
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Learning from Delirium Collaborative / apprendre de la Collaboration sur le delirium

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Shared learnings and results from the Delirium Med Rec Collaborative

Shared learnings and results from the Delirium Med Rec Collaborative

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  • 1. National Call “Learning from Delirium Collaborative” Appel National “apprendre de la Collaboration sur le delirium” Monday, February 25 2013 Lundi, le 25 février 2013 ** All lines are muted upon entry. If you have any questions, please raise your hand or CHAT to Host ****Toutes les lignes sont en sourdine au départ. Si vous avez des questions, sil vous plaît levez votre main ou clavardez pour joindre lhôte) **
  • 2. Your Hosts & Planning Team Vos hôtes & l’équipe de planification et de soutien Dr. Claudio Martin, Chair Canadian ICU Collaborative Président, Collaboration canadienne des soins intensifs Bruce Harries, Collaborative Director and Moderator Directeur de la Collaboration et Animateur Ardis Eliason, Project Coordinator and Technical Host for today’s session Coordonatrice de projet et hôte technique Leanne Couves, Improvement Advisor Conseillère en amélioration Anne MacLaurin, Project Manager, Canadian Patient Safety Institute (CPSI) Coordonatrice de projets, ICSP27-Feb-13 Delirium and Med Rec Collaborative 2
  • 3. Faculty Membres de la faculté Chaim Bell, MD, PhD, FRCPC Denny Laporta, MD, FRCPC Paule Bernier, Dt.P., M.Sc. Cathy Mawdsley, RN, M.Sc. Vanda DesRoches; RN BN Yoanna Skrobik, MD, FRCPC Greg Duchscherer, RRT, FCSRT Jennifer Turple, BSc Pharm, ACPR27-Feb-13 Delirium and Med Rec Collaborative 3
  • 4. Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliserHave you used WebEx before?Avez-vous déjà utilisé WebEx?  YES / OUI NO / NON  Soyez prêts àBe prepared to use: utiliser les outils : - Pointer - le pointeur - Raise hand - lever la main - CHAT - clavardage - Text Tool - Outil textuel pour Type your“writing on the slide” « écrire sur la diapo » Select message & - Shape Tools - Outils de forme ‘send to’ click ‘send’ 02/12/2013 4
  • 5. POINTER Who’s Online? Qui est en ligne?27-Feb-13 Delirium and Med Rec Collaborative 5
  • 6. POINTER What professions are represented? Quelles professions sont représentées?Nurse/ MD Infectioninfirmière ControlPCI Administrator /Administrateur Educator /Éducateur Senior Leader Quality Improvement Professional/Professionn el en amélioarion de la qualité Other/ Psychiatry/ autre Pharmacy/ psychiatrie pharmacie27-Feb-13 Delirium and Med Rec Collaborative 6
  • 7. Context and ResultsContexte et Résultats Bruce Harries Collaborative DirectorDirecteur de la Collaboration
  • 8. Collaborative Aim Buts de la collaboration • Improve care of the • Améliorer les soins du critically ill patient patient en phase through critique grâce à la mise implementation of en œuvre du dépistage standardized screening standardisé et de and identification of lidentification de prevention and stratégies de prévention management strategies et de gestion du for delirium delirium27-Feb-13 Delirium and Med Rec Collaborative 8
  • 9. Accreditation Canada Standard 9.8 “The team uses a delirium • “Léquipe utilise un outil de screening tool to assess clients dépistage pour éaluer les for delirium. Delirium, a pts pour delirium. Le heightened state of agitation, delirium, un état avancé contributes to increased length d’agitation, contribue à of stay and may cause clients augmenter la durée du to self-extubate or remove séjour et le risque d’auto- catheters. The team identifies extubation ou d’enlèvement and consistently applies a des sondes. L’équipe delirium screening tool.” identifie et applique l’outil de dépistage de façon constante”27-Feb-13 Delirium and Med Rec Collaborative 9
  • 10. Collaborative Principles Principes d’une Collaboration • Everybody teaches, • Tout le monde enseigne, everybody learns tout le monde apprend • Share generously • Partagez généreusement (transparency) (transparence) • Volez sans honte • Steal shamelessly • Reconnaîssez avec grâce • Acknowledge graciously When we cooperate, Lorsque nous coopérons, tout everybody wins. le monde gagne. » W. Edwards Deming W. Edwards Deming27-Feb-13 Delirium and Med Rec Collaborative 10
  • 11. The Collaborative Approach l’approche Collaborative Action Period One Action Period Two Action Period Three A P A P A P S D S D S D Planning & Learning Learning Pre-work Session Learning Session One Three Distribute a) Teams Session (A&B) (A&B) Findings b) Topic -Jan 18 & Two -Nov 14 & Dec 25- -May 28-29- 21- -July-Dec- Support Team Calls List Serve Document Sharing Monthly Reports Assessments Site Visits Faculty Coaching*Based on Institute for Healthcare Improvement Breakthrough Series Collaboratives27-Feb-13 Delirium and Med Rec Collaborative 11
  • 12. Participating Teams-Équipes particiapntes AHS Edmonton Zone University of Alberta Hospital Grey Nuns Hospital AHS Edmonton Zone – Sturgeon Hospital Misericordia Hospital AHS - Calgary Zone Saskatoon Health Region Horizon Health Network Timmins & District Hospital AHS – Medicine Hat Hospital Humber River Regional Hospital Hamilton Health Sciences Centre Thunder Bay Regional Health Science Centre North York General Hospital Joseph Brant Hospital Bluewater Health Hotel-Dieu Grace Hospital London Health Sciences Centre27-Feb-13 Delirium and Med Rec Collaborative 12
  • 13. Delirium Measures in Indicateurs du delirium Patient Safety Metrics sur le portail SSPSM System (PSMS) 1. Percentage of Patients 1. % patients ayant subi un Screened for Delirium dépistage ppour le 2. Percent of Patients delirium Identified with Delirium 2. % pts identifiés ayant le 3. Percent Compliance with délerium Non-Pharmalogical 3. % conformité aux Strategies stratégies non 4. Number of Unplanned pharmacologiques Extubations per 1,000 4. Nombre d’extubation non Invasive Mechanical planifié pae 1000 jours de Ventilation Days ventilation effractive2/27/2013 Delirium and Med Rec Collaborative 13
  • 14. Change Concepts • Recognize/manage/mitigate • Reconnaître/gérer/diminuer risk factors (prevention & les facteurs de risque reduction) for every patient (prévention et réduction) • Assess for Delirium every pour chaque patient shift • Évaluer pour le delirium à • Document compliance with chaque quart de travail standardized protocol for • Documenter la conformité management au protocole standardisé • Support patients and pour la gestion du delirium families • Soutenir les patients et leurs familles27-Feb-13 Delirium and Med Rec Collaborative 14
  • 15. Change Concepts • Consider others to be part • Considérer les autres of same system comme faisint partie du • Change work environment même système • Standardize clinical • Changer l’environnement de processes travail • Manage hand-offs • Gérer les transitions • Establish reliable processes • Établir des processus fiables27-Feb-13 Delirium and Med Rec Collaborative 15
  • 16. 1.0 Percentage of Patients Screened for Delirium 1.0 Pourentage de pts faisant objet de dépistage • Xxx of teams now have data for 2-3 key measures, standardized definitions x-Canada • Insert run chart for those measures Source: SHN Patient Safety Metrics System February 201227-Feb-13 Delirium and Med Rec Collaborative 16
  • 17. 2.0 Percentage of Patients Identified with Delirium 2.0 Pourcentage de patients identifiés avec delirium27-Feb-13 Delirium and Med Rec Collaborative 17
  • 18. Lessons Learned on the Collaborative Journey Dr. Yoanna Skrobik27-Feb-13 Delirium and Med Rec Collaborative 18
  • 19. The Agitated Patient• Pain• Insufficient sedation• Delirium
  • 20. Patient views on what is important in the ICU• Painlessness• Reassurance – Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000 – Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May
  • 21. Sedation
  • 22. Monitoring Sedation• The RASS and SAS scales are valid and reliable for measuring quality and depth of sedation in adult ICU patients .
  • 23. Sedation– Depth of sedation vs. clinical outcomes: • Maintaining lighter levels of sedation in adult ICU patients is associated improved clinical outcomes, such as a shorter duration of mechanical ventilation and a shorter ICU length of stay. • Maintaining lighter levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia . • The relationship between depth of sedation and psychological stress in these patients is unclear . • sedative medications titrated to maintain light (vs. deep) levels of sedation in adult ICU patients are associated with better outcomes .
  • 24. Outcomes Related to Sedation• sedation strategies using non-benzodiazepine sedatives have better outcomes than benzodiazepine infusions in mechanically ventilated adult ICU patients.• analgesia should be evaluated prior to sedation in adult ICU patients who are mechanically ventilated .
  • 25. DeliriumVan der Mast. PhD Thesis, Delirium After Cardiac Surgery, Erasmus University, Rotterdam,1994
  • 26. Delirium and Outcomes• Delirium is strongly associated with increased mortality and LOS in adult ICU patients.• Delirium is moderately associated with the development of post- ICU cognitive impairment in adult ICU patients.
  • 27. Delirium and DistressBreitbart W et al. Psychosomatics 2002;43:183
  • 28. Delirium ScalesICDSC CAM-ICU(Intensive Care Delirium Screening (Confusion Assessment Method-ICU)Checklist) http://www.icudelirium.co.uk/ www.icudelirium.org
  • 29. Delirium Nomenclature Consistency is Important Delirium and its consequences
  • 30. Delirium Prevention• early mobilization of adult ICU patients reduces the incidence and duration of delirium.• there are no compelling data that pharmacological delirium prevention in the ICU reduces the incidence or duration of delirium.
  • 31. Protocol to address patient views on what is important in the ICU• Painlessness• Reassurance – Feeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000 – Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May
  • 32. How can optimal patient care be provided?• a multidisciplinary ICU team approach, that includes provider education, preprinted and/or computerized sedation protocols and order forms, and a quality rounds checklist, can be used to facilitate analgesia, sedation and delirium management in adult ICUs.
  • 33. Impact of Using a Validated Delirium Screening Tool, Withor Without a Pharmacist and Nurse-led Delirium EducationProgram, on the Ability of Nurses to Recognize Delirium in a Surgical-Trauma ICU Andrew Lin, PharmD Brittany Russell, RN, BSN, CCRN John W. Devlin, PharmD, BCPS, FCCM, FCCP H. James Norton, PhD Susan Evans, MD Gail Gesin, PharmD
  • 34. Educational Interventions
  • 35. Results: Subject Nurse Delirium Knowledge Average Number of Correct Answers Phase I p=0.08 p=0.001 Phase II p=0.001 Phase III 0 1 2 3 4 5 6 7 8 9 10
  • 36. Delirium is challenging to assess in ICU patients Phase I Phase II Phase IIIThe ICDSC makes delirium easier to identify in my patient(s) 0 10 20 30 40 50 60 70 80 90 100 % of Nurses that Agree (Moderately or Strongly)
  • 37. Delirium Treatment• There is low quality evidence that atypical antipsychotics reduce the duration of delirium in adult ICU patients .
  • 38. Patients with First Resolution of Delirium Log-Rank Proportion of Patients with Delirium P = 0.001 Placebo Quetiapine Day During Study Drug Administration Quetiapine added to as-needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation.Devlin JW, et al. Crit Care Med. 2010;38:419-427.
  • 39. Drug Specificity: Comparative Receptor Binding Profiles Quetiapine Olanzapine D1D2 D1 D2 5HT2A 5HT1A 5HT2A M H1 A1 A1 A2 A2 H1 Ziprasido Risperidone Haloperidol ne D1 D2 A1 D2 D1 A2 H1 D1 5HT1A A1 A1 5HT1A 5HT1A 5HT2A 5HT2A D2 5HT2AAdapted from Gareri P, et al. Clin Drug Invest. 2003;23:287-322.
  • 40. Delirium Treatment• There is no direct evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients .• There is low quality evidence that atypical antipsychotics reduce the duration of delirium in adult ICU patients .• rivastigmine should not be given to reduce the duration of delirium in ICU patients.• continuous intravenous infusions of dexmedetomidine rather than benzodiazepines should be administered for sedation of adult ICU patients with delirium, in order to reduce the duration of delirium in these patients.
  • 41. My Discoveries of the Collaborative • Awesome teams from all of Canada committed to improving patient care • An ongoing feedback and improvement team to help make that happen based on the team’s goals • Interest and consideration for expert opinions on the relevant topics • A sneaky feeling good will and commitment are more important than guidelines 27-Feb-13 Delirium and Med Rec Collaborative 42
  • 42. In summary…
  • 43. Overall management• Protocolized nursing assessments of pain, sedation and delirium are associated with improved short-term and long-term outcome.• Protocol AND non protocol-driven medication administration result in better outcomes in the context of educated and empowered nurses, and of physician buy-in.• These data suggests that it is individualization of care, and not protocolization of medication, which accounts for improved outcomes.
  • 44. Managing pain, agitation and delirium in the critical care setting•Manage adult patients who need sedation and analgesia according tocurrent standards•Use validated scales for sedation, pain, agitation, and delirium in theassessment and to follow the management of these critically ill patients•Assess recent clinical findings in sedation and analgesia managementand incorporate them into the management of patients in the critical caresetting
  • 45. Thank you
  • 46. A Case Study: Histoire de cas: One Le périple d’une Collaborative équipe de la Team’s Journey Collaboration Hamilton Health Sciences Centre27-Feb-13 Delirium and Med Rec Collaborative 47
  • 47. Next Steps/ prochaines étapes27-Feb-13 Delirium and Med Rec Collaborative 48
  • 48. Next Steps/ Prochaines étapes • Measurement Reporting • Système d’indicateurs System in SHN’s Patient Safety Metric System de la sécurité des (PSMS) – Available now patients- fonctionnel Contact Central Measurement maintenant Team 416-946-3103 – Contactez lÉquipe responsible metrics@saferhealthcarenow. des mesures: 416-946-3103 ca – metrics@saferhealthcarenow.ca • Delirium Getting Started Kit – Available in late • Trousse de départ, Spring 2013 Delirium- disponible fin printemps 201327-Feb-13 Delirium and Med Rec Collaborative 49
  • 49. Thank You Merci • Team Sponsors / aux Soutiens exécutifs des équipes • Faculty 3 la Faculté • Planning & Support Team / L’équipe de planifiation et de soutien27-Feb-13 Delirium and Med Rec Collaborative 50
  • 50. Funded & Supported By Financé et appuyé par

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