So I'm going to be speaking on the state of nursing literature in delirium. We found so many articles on delirium that I have a couple extra studies to present on this one. So I have no relevant disclosures. We're going to discuss briefly the clinical significance of delirium and why this is such an important topic for us, and then we'll give evidence on some articles that decrease the occurrence and duration of delirium. We have some exciting new information on predicting mortality with changing our screening process, and then translating that into actual clinical implications. So delirium, we know that we can't treat it at this time. I mean, it would be great if I had like the panacea, this is how we treat it, but no research has given us definitive treatment. So instead, prevention is where we need to focus. Delirium is an acute organ failure of the brain, and it has significant direct and indirect impacts on our patient population. We know that it occurs in up to 87% of ICU admissions, and it costs between $4 and $16 billion per year in just the United States. That's an increase of almost $4,000 in ICU costs per patient, as well as almost $6,000 in all hospital costs for that admission for a patient diagnosed with delirium. Some of the direct impacts include hemodynamic and respiratory instability, causing a functional decline in these patients, longer ICU stays, longer dependence on mechanical ventilation, higher morbidity and mortality rates for these people, and now our post-intensive care syndrome that we know can take months to years for these patients to overcome. So the indirect impacts include hospital-acquired conditions, partially from the extended stay, partially from their deconditioned state, falls, pressure injuries, additional infections, the psychological effects, the loss of income from extended stays, decreased quality of life, including at discharge, where they are 2.5, two and a half times more likely to be discharged to a skilled facility instead of home. So we definitely, as health care bedside people, this is where we need to focus for these patients. So I have an article from Neurosurgery that found the neurologic examination frequency and time to delirium after traumatic brain injury was dramatic. In fact, it turns out that Q1 hour neuro exams are an independent risk factor for developing delirium, which means, I mean, sometimes we have to do Q1 hours, but as soon as we are able to, transitioning from that. This study was a retrospective review of patients with neuro exams ordered Q1 hours compared to those ordered Q2 and Q4 hours, right? So waking these patients up, disturbing their normal pattern of sleep, obviously, we know that leads to delirium, but this is definitive evidence. So the study included 1,552 patients, 620 ended up with the Q2 hours, and 932 were the every two to four hour neuro checks. As you can see from the graph on the right-hand side, that's our hazard ratio. That bottom line, that dark line, demonstrates how quickly we ended up with patients that were experiencing delirium in the ICU with those Q1 hour neuro checks, and that dramatic decrease there, the y-axis is time before delirium, right, or days without delirium, and then the bottom line is our timeline. So almost immediately, you're seeing within two days, these people are developing delirium from being woken up and having these every single hour neuro checks. So the difference between the two groups, the Q2 hours instead of Q1, hazard ratio was 0.44, so almost half, and then with the Q4 hours, we were at 0.48, so a dramatic change between the two groups. Our next study, the effect of music on delirium pain, sedation, and anxiety in patients receiving mechanical ventilation in the intensive care unit. In this group, we had a single blind RCT of three groups, and they were divided into music, noise reduction, and standard of care. The music group received 10 hours of music each day for 10 days with over-the-ear headphones. The noise reduction group received earplugs for that 10 hours a day for 10 days. And then the standard of care, which everyone received and was the control group with no other noise interventions, were on dextamidine for agitation and anxiety, and acetaminophen and tramadol. All right, so in this case, our music group across the board had a significant reduction in delirium severity, pain severity, anxiety, and level of sedation that was required to keep them comfortable. So it demonstrates that using that music with the over-the-ear was better than noise reduction, which I know we've all heard how important noise reduction is, but apparently music is even larger. So the study considered the people that it was small. Only 36 were indicated in the final analysis. 48% of treatments were completed, and 36% of the patients were lost to follow-up. So a little bit more work to be done in that area, but definitely exciting implications for this patient population. Now the effects of non-pharmacological interventions on sleep improvement and delirium prevention in critically ill patients was a systematic review and meta-analysis, with a systematic review of 118 studies and a meta-analysis of 100 of those studies. So in this case, they broke up the interventions into three groups, interdisciplinary, which was mostly implemented protocols, environmental, where we adjusted their physical environment in some way, and active interventions, where we were doing something with the patients to alter that. So this is the outcomes of those studies. Decreasing delirium was significant for those that provided exercise. It decreased delirium duration and delirium incidence. Implementing our famous ABCDF multi-interventional approach, it decreased delirium and incidence. Family participation reduced incidence, as did information giving, a delirium prevention protocol that was specific to the facility that published on it. Some early detection protocol, and then combined interventions, which was not clearly defined by the authors. They didn't state what the combined interventions truly were in those studies. And then noise and light blocking was also shown to decrease our delirium incidence, along with improving sleep quality. So some things that are a little new, it kind of demonstrates that even if you can't do the full protocol, any implementation is advantageous to our patients. And then this one's a slight departure. This is predicting hospital mortality and length of stay. It was a prospective cohort study that compared the use of the intensive care delirium screening checklist, the ICDSC, compared to the confusion assessment method for the intensive care unit, the CAM ICU, which is pretty much the standard in most facilities right now. So what this demonstrated in our six medical ICUs in Taiwan over the span of about a year and a half had a population of 384 that were screened, 97 participated. The study had nurses administering both tools within 15 minutes of each other, and determining the number of positive by the ICDSC compared to the positive for CAM ICU. And these patients were followed for their entire length of stay to determine in-hospital mortality and length of stay. So some of them were followed up to a year for their extended stays. The ICDSC was more sensitive. We found it had identified 67 out of the 97 participants as having some level of delirium. The CAM ICU detected 49 of that same 97 population. And the significance comes with there was a dramatic change in in-hospital mortality for the ICDSC positive compared to the CAM ICU, with almost five-fold compared to the CAM ICU, which had the 2.79. And then a longer hospital stays, which the ICDSC predicted with their positivity of 17.59 days a longer stay compared to the 8.5. There was no significant difference in time to administer these two tests. And the predictive ability were both negatively impacted by a RAS less than 0, which probably surprises none of us, because how are you going to get them to respond to some of these questions if they're sedated, right? So what does this mean for potential benefit practice changes, right? That's why we care about these studies at this point. Obviously, avoiding the Q1 neurochecks as much as possible. There are patients that are going to need them. That is not an arguable statement. But sometimes they don't get discontinued as soon as they could either. So if you're still waking up your patient when they're not indicated anymore, it's something to look at. Providing structured music therapy with the 10 hours, and that was a standard MP3 player. That study had lost some people from not liking the music, another area that we can look into. But actually providing something to distract, not just blocking noise, but distracting them from what was going on. Although blocking noxious noise was shown, especially when it was allowing rest, to improve patient quality of sleep, and delirium occurrence. So keeping on that diurnal schedule. Then providing exercise, family participation, information giving, cognitive stimulation, daytime bright light therapy. These are all things we knew, but they continue to demonstrate a positive effect on this delirium occurrence and severity. Then implementing our bundles and protocols. And then this intriguing idea of utilizing the ICD-SC over the CAM-ICU, especially if our RAS is zero or higher, to help us predict mortality and length of stay, and address the needs of this specific patient population from the beginning. All right, and I will turn it back over. Thank you.

delirium

ICU

non-pharmacological interventions

ICDSC

prevention strategies