I was hoping he wasn't going to say how many years we've been working together. Well, we're going to shift gears, because we've been talking a lot about sedation, and every presentation so far has mentioned delirium, and we're going to dive right into it. And a little bit of me feels like, wow, I've been saying the same thing for 25 years. And maybe that's true, because we're still learning about this, and there's some very basic things that we can do to help our patients with delirium, to help prevent it, to help manage it. And I think that we've got to be ready for more and more change, as all of that's been talked about so far, as the seas change a little, if they change, in our ICUs. Here's some disclosures that I have, that I've worked with these companies. Again, any medication that we talk about today with delirium's off-label, because nothing has an indication for delirium with the FDA. And we're going to focus on the D part of the A to F bundle, and I love this visual that we have here, because it reminds us that these things are all together. They work together, they're part of, they're very synergistic, and so we really need to remember that D is a part of this bigger puzzle, and as we change or do something in one area, it's going to cause change in another area. This was already mentioned earlier with Dr. Bose, who went into looking at the changing landscapes that we experienced during COVID, that there was a big impact, and it's had some long-term effects in our ICUs, in all of our ICUs. There's burnout, with every staff, every professional level, there's significant burnout. Staffing shortages, staffing turnovers. Many of you probably have travel, some percentage, we were in a group the other day that said, oh, in my hospital, we have 60% of our nurses are travel nurses, and then another person said, well, in our ICU, it's 80% of our nurses on any given day are travel nurses, still. So significant turnovers, significant shortages, and I was working with a group that said, we only have pandemic graduates. Every nurse working in our unit came to our unit during the pandemic, so their perspective on critical care nursing was largely shaped and molded by the pandemic, and so their practice looks very pandemic-like. So when we think of these things and these impacts, I think these all have significant impacts on the way that we view and think about delirium in our ICUs. Dr. Bose already went over this data, and I don't want to hang out there, but to highlight in our COVID-D study that we saw a significant increase in the use of benzodiazepines for a long time, continuous infusions for a week of benzodiazepines, which was not something that many of us saw in our ICUs, in fact, rarely in some of our ICUs. Maybe some of our alcohol withdrawal patients, but pre-pandemic, we didn't see that sort of use of benzodiazepines. Significant reduction in our family visitations, whether it was virtual or in-person, and the question is, maybe that was for a very specific season that had to happen, but as Dr. Bose pointed out, it keeps going, and that's where we find ourselves, and the impact of both of those highlighted features there, those variables continue to impact and put our patients at risk for developing delirium, acute brain failure, and long-term brain failure that's associated with it. So what I think, these are my big take-homes today, is we have to be in the business of re-educating why. Why does it matter? Is delirium benign? Because for that season, we said it was worth more delirium to keep our patients alive and practice during the midst of the pandemic to the best that we knew, and as data changed and we understand more, we started to readjust that, but we need to re-educate the why. We need to ensure that there's proper assessment. It's not easy, all of us. I was in something the other day that says, well, Vanderbilt's 100% perfect with the cam I see all the time. No, we're not. So we have to do that, too, right? We have to do proper education, proper making sure that everybody's doing what they're doing, they know how to do it, they're figuring out the easiest way to do it, and have a management plan. Have a plan and communicate, this is what we're doing because we want to cut down on our patients' delirium because it's got impacts. And so that's where we'll start, is re-educating the why. All of our goals for our patients is to get them home and thriving, right? That is our goal here, is if it's possible. There's a small percentage of our patients that will die in our ICU, and we want to make that the best death possible, but for the majority of our patients, the goal is home and thriving, and so we need to re-educate that delirium is associated with not going home. And that has to do with longer time on the vent, longer time in the ICU, being discharged to a rehabilitation facility, which if any of you have parents or maybe even yourself, that is such a psychological hit to go to a rehab facility, in addition to a physiological hit sometimes. And so our patients with delirium are at risk for not going home, and those that do go home are at risk of not being the same. And this association with this long-term cognitive impairment that's similar to Alzheimer's disease, that's similar to traumatic brain injury. So this is the why in one picture of why delirium is important. And so that's what we have to teach our pandemic graduates, that our ICUs right now, that all of us have to remember, it's not benign. That's exactly the same thing I said 25 years ago. It's not a benign problem. And so that's the why that we want to make sure that we're teaching. Then we've got to ensure that we have a way and we are assessing it. And right now, our two best tools for assessing delirium are the CAM-ICU and the ICD-SC. And so to the best of our abilities, I bet nearly all of you have it on a paper somewhere that you're supposed to be doing one of these. And that there's probably a portion of people in your ICU that don't even know how to do these, or they make up their own version of it. And so there needs to be a little bit of diving into, do we have one? Are we doing it? Just simple implementation science here, just looking into your practices. Are we doing it? And where's our problem? What is the reason people aren't doing it? Is it because they can't find it in the EHR? Is it because it's clumsy in the EHR? Is it because they don't really know what to do? Or that they're, again, they think it's benign, so they're not really charting it correctly? What is the why behind it? Are they doing it? Is it correct? Does your EHR support it? Chances are, if you use Cerner or Epic, you've got EHR support there, but it could be clunky. You may not know how to get it. You may not know how to wrench it in. Your view is probably different than the view of the person next to you's view, which is really challenging in those systems. I know that in the expo hall, there's a booth up front that the ICU Liberation Campaign of SCCM has created sessions on how to figure out the A to F bundle in your EHR system. And so there's folks down there that can help you figure that out. So go there, talk to them, learn how to make it work in your system if you're on either of those two systems. And then the last thing we need to do is have a management plan, that we're talking about the things that we're doing and their impacts with delirium. I was in a meeting the other day, and somebody says, well, we do all these things. We already do them. It's best practice. But are you connecting the dots with your staff that the reason that you pulled back on sedation is because you know you want to decrease the side effect of delirium? Are you making those connections? Are you teaching and talking about it to one another? And I think that's really important that you have a management plan that you all talk about, that these are things we do. And part of the reason we do them is to improve our delirium outcomes. And this is my good friend, Dr. Ely, always uses Dr. Dre. I never use Dr. Dre because I'm afraid he's going to sue me. So I am, and Wes could talk him out of it. And so I always use stop, think, and lastly, medicate. And this is the visual I want you to take home to your staff, is stop, think what you could be doing, and then lastly, go to medicate your patients. When we think of the reasons that we understand that delirium exists, it's a whole bunch of neurotransmitter imbalances. But we don't know which one's with that patient. We haven't invented that special test to say, oh, this is off for you, and this other patient, this is off. There's a lot of heterogeneity of what goes into when we see delirium. And so we don't know that yet. But when we think of this, look at how many times medications are on this list as the reason for a neurotransmitter imbalance. So that's the first step, is stop. Be doing that good medication review. Looking at the medications to say, is there anything we can stop? And by now, I hope that the number one thing you're thinking of stopping is your benzodiazepine. Can we stop it? Are they on the lowest effective dose of any of their sedatives, and especially benzodiazepines? What about other deliriogenic medications? Is there anything that they need? Is there anything that they're receiving that they don't need? Remember, what they start in the ICU, they go home on a lot of times. So ask yourself, should they be going home on this medicine? Remind yourself that it's temporary, that it's today's medicine, not every day's medicine. And then think. And this is a mnemonic that we use to help us figure out and teach our teams, and especially our teams that are very transient, what common causes for delirium are. And what I like to highlight on this is, yes, we're already thinking. I hope we're all. We're good critical care practitioners here. We're already thinking of all these toxic situations. You're looking for these. One of our neuropsychology friends who would round on patients along with the team said, I can predict sepsis one day before the rest of the team. One day. She'd been keeping tallies of it. And she's like, I can outsmart all of them, because I was looking for delirium. And they were looking for numbers to change. And I picked up on when their patients would be septic one day ahead of all of them. I was pretty good at it. And she's right. So we're looking for these, but remembering that that change in acute brain function is one of our signals, but also remembering we need to get our patients' feet on the floor. We need to get them moving. We need to get feet on the floor, mobility, as early and as much as they can tolerate. Also thinking about hearing aids, glasses. I have a weird thing going on with one of my eyes. And it's been twitching like crazy for three weeks now. And I can't see a thing when I go to read. It's been annoying, but a little bit disorienting. Like it's just I'm texting weird things to people. And it reminds me that, I mean, just that little bit of visual impairment in one eye is changing me. Imagine what I would be like in the ICU. You don't ever want me as an ICU patient. But imagine what it would be like. So making sure glasses are there, making sure that people have their hearing aids, that they are being used correctly, and that they're getting some sleep, that you're maximizing their environment to the best of our ability, that whole day-night switch, that day is day, and day can be noisy, but night is night, and that's when we sleep. And night shouldn't be noisy. We should offer earplugs, offer an eye mask, figure out ways what helps this person sleep at home. These are important parts. Moving during the day, sleeping at night, bundling our care. So these are all basic things. Bundling our care at night so that we don't go in 10 or 12 times and wake them up to have some longer periods. So when you think, think about those things. Feet on the floor, the ears, the eyes, and the Zs. And so this is in line with those PAT-IS guidelines that have been talked about already of having a multi-component non-pharm intervention strategy to help with these things. So we're doing this whole multi-component thing. We've all mentioned one, right? A big multi-component strategy is the A to F bundle. And this bundle's been shown to decrease delirium. If we do this bundle, the more we do it, maybe, is anybody in here perfect at doing this with every patient every day? Raise your hand, because we all want to meet you. Okay, so does anybody ever try a piece of this? Just one little piece of it, there you go. You're on your way. For every little piece we do, and we add a little piece, and we add a little piece, and the more of this we do, the better those outcomes in our patient. And one of those outcomes is delirium. So this is a really important thing. We want to think about all of the stuff that's been mentioned already about sedation. That's part of your delirium management. All that we think about mobility, that's part of your delirium management plan. Getting your families in there, welcoming them, having them a place to sit and be, getting rid of them when they need to take a break, that's all about delirium management. Pain control, pain management, getting off the ventilator, having awakening trials and breathing trials, that's all a part of your delirium management plan. Do medications work to treat delirium? And this is just four of the big studies that are out there looking at antipsychotics and delirium. And the big take home is there's no evidence in a widespread way that any of the antipsychotics work to treat delirium. So in the recommendation from the guidelines was against using antipsychotics. But is there ever a place to use antipsychotics? And the answer is yeah, but remember not to treat delirium. It's going to treat a behavior that you need to get a handle on. You're not using it to treat delirium. And so that's an important distinction. With that medicine, you're not going to clear up their head. You might contain that hyperactive behavior, but you're not going to clear their head. And I think that that's important to remember. And the bottom line is lowest dose, shortest effective course. Do you want them going home on this? No. So you need to stop it as soon as you can, or they will go home on it. So in summary, just take that image with you. Stop, think, get those feet on the floor, get the hearing aids in, the glasses on, have the Zs happen, and lastly, medicate. Consider talking about it with your team, using the brain roadmap that we talk about sometimes, and make sure the whole team is on board of thinking about delirium and the delirium education. Thanks a bunch.

delirium

ICU

assessment

management

non-pharmacological interventions