All right, so hopefully you're in the right session. This is Give Hugs, Not Drugs, Managing Pediatric Delirium. And I'm really excited, Stacy and Pete and I were on the PANDEM guidelines together, so it's really nice to be in person together, and they're going to be speaking along with me. I'm going to do the first brief session, though, but overall, our goals today are to talk about methods for identifying pediatric delirium, and then we want to talk about non-pharmacologic strategies for prevention and managing delirium, and then also pharmacologic strategies for prevention and management. So first, for a brief 15-minute whirlwind, I'm going to walk you guys through on how we identify delirium in pediatric patients. So briefly, I'm a pediatric intensivist at Vanderbilt University Medical Center. I was on the PANDEM guidelines with these smart people, and I'm also on the IC Liberation Committee, and so this is really in the heart of things that I think are super important for patient care. My only disclosure is I have a small amount of salary support on an NIH grant, and then to the meat of it. So today, in my brief 15 minutes, I want to review why diagnosing pediatric delirium is important and convince you that we should be testing all of our patients for it. And then I want to review the tools for diagnosing delirium and get a little bit nitty-gritty in how to use those tools, and then provide some tips for implementation success. So why do we care? Pediatric delirium is extremely prevalent. Depending on which study you look at, a child in the ICU, 15 to 60% of children in the ICU will have delirium at some point during their ICU stay. We know that it has short-term negative consequences. Many, many studies have seen associations with things like increased mechanical ventilation, increased ICU length of stay, increased hospital length of stay, increased hospital costs, and even mortality has been associated with the presence of delirium for pediatric patients. And we think that it likely has long-term negative consequences. This data is starting to emerge. The CAPD group, the Cornell group, recently published a study in preschoolers showing that preschoolers, when compared to preschoolers in the ICU who didn't have delirium, those with delirium had developmental consequences later down the line, several months out when they talked to parents. So when I think of delirium, I like to think of the risk factors in two different groups. Predisposing risk factors are things that we as intensivists or we as clinicians in the ICU cannot control. Our patients come in with those risk factors. But precipitating risk factors are things that we may be able to mitigate. So predisposing risk factors, some of the big ones for delirium are younger age, developmental delay, poor nutritional status, and cyanotic heart disease. Some of the big precipitating risk factors that you may be able to change in your ICU are the need for mechanical ventilation, prolonged cardiopulmonary bypass, deep or coma sedation states, and benzodiazepine exposure. Why is it important to screen with validated tools? Because if you aren't looking, you may miss it. The cardinal features of delirium seem very obvious when you're reading about them. So an acute change or fluctuation in your mental status, inattention, altered level of consciousness, and disorganized thinking systems. But it gets a little complicated for our patients in the PICU, especially those that are receiving sedation. So the three delirium subtypes are hypoactive, hyperactive, and mixed. And hypoactive is actually the most common subtype of delirium in children. The hyperactive patients, I think we tend to pick up more, right? Those are the patients, especially when they're intubated, that are a safety issue. Those are the patients that we're worried they're going to pull out their endotracheal tube or their central line. But the hypoactive patients, unfortunately, are the ones we miss because they're the ones that we're not worried about their safety. They're the good patients, unfortunately, the ones that aren't needing a lot of sedation. So those are the children with the deep sedation states that are not secondary to sedation. And then mixed is clearly a mixture of those two, which is very common. And even the same child can move between these subtypes and be in the mixed subtype. So when we talk about diagnosing delirium in the PICU population, I wish that we could have a pediatric psychiatrist round every day on every patient in the PICU. But those of us that work in the PICU know that that's not feasible. We don't have the resources for that, and that's why these tools were created. So our recommendation is to use validated, sensitive, and specific tools, and screen for the entirety of the PICU stay. The other thing I want to make a point about is that there's not a specific time point in a children's ICU stay where they're at risk for delirium. There isn't a situation where it's like, if your child doesn't develop delirium in the first 48 hours, they're not going to. No, children can develop delirium at any point during their ICU stay, and actually, after they leave the ICU. So that's important to know as well. In the adult population, they're starting to screen patients outside the ICU with modified tools, and actually, Stacy recently implemented delirium screening in our cardiac step-down unit at Vanderbilt Children's. But for the point of this talk, we're going to talk about in the PICU, and you need to assess them throughout the duration of their stay. And you want to assess frequently, because it's a waxing and waning mental status, so at least two times a day. And when I work through the tools, you'll see that they were both intended for use at least two times a day. So when the PANDEM Guidelines group met, there were five published pediatric delirium tools. We assessed those tools for sensitivity, specificity, and reliability. And in the end, the two that were the most sensitive, specific, and reliable for the PICU population were the PCAM, PSCAM, and the CAPD. So that's where those recommendations came from in the PANDEM Guidelines. If you want to get a little bit more details about that, if you go to the supplemental digital content in the PANDEM publication, you can see all the tools that we assess. But for the purposes of this talk today, I'm going to focus on the ones that we recommended. So these tools are similar, but also different. And so the PCAM, PSCAM is a point-in-time assessment. What do I mean by that? You can walk in the room and do it. You don't have to have an observational period of time before you do it. It has an observational and interactive component, though. You are going to have to interact with the patient, and we'll talk more about that. The CAPD is an observational tool. It's a passive assessment, so it does require an observational period. And it was intended, really, for nursing staff to use at least halfway through their shift, so after about six hours of observation. I want to point out, at the bottom of this slide, I have a website here. This is actually the Cib Center website, which Dr. Wes Ely created, and he has generously given us space to put pediatric content on that. And on that website, there's some information for healthcare providers about both of these tools and some downloads and things that can help you with implementation. So first I'm going to talk about the Pediatric and Preschool Confusion Assessment Method. So this was based on the CAM-ICU, which is the adult delirium tool, and it was modified for developmental indications for our patient population. And it's validated from birth to age 18, and again, it was really envisioned that you would be using it at least Q12, if not more frequently, in screening your patients for delirium. It's been translated in several different languages, and you can see the performance statistics here are really good. The picture here is the cards that we use for this tool. And so if you go to that website I had on the last slide, you can actually download these and print them out and laminate them. So we have these cards laminated in every patient room in our ICU, and I'll talk a little bit more about how we use those. The first step of either tools for pediatric delirium is doing an arousal assessment. So you have to kind of see where your patient's at to determine if they can even be assessed yet. And so they must have a RAS score of greater than or equal to minus 3, or an SBS score of greater than or equal to minus 1. And so here we use the RAS, and I put that up here, but I know many of you probably use the SBS. If for some reason your patient is too sedated and they don't meet this criteria, then you can lessen your sedation and come back and do the assessment. You can also try, we often find that doing a little bit of gentle tactile stimulation for 15 seconds can often wake up a patient enough that they can participate. So I'm going to go, this looks busy, but this is the true assessment. And this is on that slide deck of those cards that you divide, this is in it. So it's a four-feature assessment, but you don't always have to do all four parts on your patient. So I'm going to walk you through it. So bear with me a little bit on this. So feature one is looking at acute change or fluctuating course of mental status. The first question you ask is, is this patient having acute change from their mental status baseline? And if they do, then you have to go to feature two, no matter what. If they don't, you ask the second question, have they had fluctuation in their mental status in the last 24 hours? If the answer is no, you stop the assessment there. Your patient is not delirious. So it's as simple as that. If the answer is yes for either of these questions, you have to go to feature two. Feature two is inattention. So how do we do that in a baby or a child under the age of five? The PS CAM is for ages zero to five. That's when the picture cards come into place. You could also use a familiar object or toy, but those picture cards are nice if you laminate them and have them in every room. So there's 10 pictures or mirrors and you place those in front of your patient's face and you see if they have attention to the pictures. If they lack eye contact for three or more pictures, you have to go on to feature three. If they have eye contact to eight or more pictures of the 10, then you ask the question, did they have sustained eye opening for at least half of the assessment? So if they did, then you stop there and your patient is not delirious. If not, then you go on to the next feature. So altered level of consciousness is the next one. And for the PS CAM, you ask, is your patient altered right now? Are they anything other than alert and calm? If yes, then they're delirious and you can stop there. If no, if they appear alert and calm, then you need to go on to feature four and assess their thinking and see if they have a disorganized brain function. It's a little challenging in younger children. And so the way this tool does it is by looking at sleep-wake cycle disturbances and then unawareness and inconsolability. So asking in the recent time, has the patient ever been unaware and inconsolable? And I think we all have seen that in our patients who are really delirious, where they don't know what's going on in their surroundings, they're not focusing on their parents, and they're just completely inconsolable no matter what you do. And so if they have any of those features, then they are delirious. Otherwise, you stop there and delirium is absent. The PCAM is intended for children that are ages five and above. And I'm not going to go through all of this again. The only things that are different in the PCAM are feature two and feature four. And those are more in line with the ICU CAM, the adult assessment. So for feature two, you actually can do a hand squeezing assessment where you say a phrase of letters and you ask the patient to squeeze your hand every time you say an A. And the phrase we use here is a bad, bad day, misspelled with an extra A. But if they have three or more errors, then you go on to feature three. And then for disorganized thinking, because these children are a little bit older and have more cognitive skills, you ask them some questions that are easy. Is sugar sweet? Do birds fly? Is ice cream hot? So there's some alternate questions there, too, as well. So you ask the patient those questions, and then you ask them to follow a two-step command with holding up their hand and giving two fingers. So if they struggle with that, then they are delirious. So those are the big changes in the older kids. I'm going to switch gears a little bit and talk about the Cornell Assessment for Pediatric Delirium, which I don't use currently, but I used that in my fellowship program. So I have used it. It's also a great screening. It's a great tool. And this was adapted from the Pediatric Anesthesia Emergence Delirium Scale. What it added to the Pediatric Emergence Delirium Scale was looking for hypoactive delirium because that was really focused on hyperactive. It's been translated to even more languages and has great performance statistics. This is the form that you use for the CAPD, and these are the questions you ask. So again, you have to do an assessment of your patient's arousal level, similar to the PCAM and PSCAM. They must have a RAS greater than or equal to minus 3 and an SBS greater than or equal to minus 1. And then you total up their score, and if they have a score of 9 or more, that's consistent with delirium. The CAPD authors also have created these developmental anchor points for the youngest patients that I think are really, really helpful. So this goes up from newborn to age 2 for those younger kids and questions. I would be remiss to give this talk without bringing up the Vedic. And so this is really a tool that was meant for a psychiatrist, and it's all based on the DSM criteria, and it added pediatric-specific modifiers to make a standardized assessment for delirium. And so if you have a psychiatrist that you work with in your institution, I welcome you to share this with them. I think it makes their assessments a lot easier, and especially with trainees when they're trying to focus on developmental-appropriate questions. So special considerations when using these tools. We talked about the developmental anchor points for the CAPD for younger children or children who are developmentally delayed. And then for the PSCAM and the PCAM, you need to ask the family. If the patient has developmental delay, it's helpful to ask the caregivers, what level do they function at? So if I have a 10-year-old, but developmentally they're at the level of a 4-year-old, I'm going to use the PSCAM. And it's been interesting. We actually, on the adult side at Vanderbilt, and cognitively delayed adults, they've been using the PCAM on those patients. So I'm going to wrap up here with just a brief bit about implementation, because these things are hard. It's hard to implement these things. Even at Vanderbilt, where these tools existed before I even joined faculty, we are always trying to increase our sustainability and efficiency in doing these things. So if you're going to be starting out implementing this from scratch, I encourage you to engage key stakeholders from the start so that you have buy-in. And then you need champions. Champions are so key, especially for delirium tools. You really need, you need pharmacy, you need nursing staff. They're at the front line. They're the ones who are usually doing these assessments on our patients. I think it's important when you're increasing workload, you know, you're asking your nurses to do more work than they already do. They're already super busy. You need to educate them on the importance of delirium and share stories. Share patient stories about how delirium affected a patient's outcomes. And then when you get going and you have a success story, share that. Show them how they're changing patient care. I think that making it personal really helps staff, especially when you're adding work to them. And then I would encourage you to create systems that facilitate the workflow and ways that you can, you need to grab your data and kind of see how you're doing over time. And I bring this up because in the beginning of 2020, we noticed we had gone to a new EMR. We had a lot of nursing turnover and our delirium assessments weren't being done. They just, they weren't being done at the frequency that they were supposed to be. We're not sure the barriers were that the flow sheets changed when we switched over to Epic. And so Stacy actually spearheaded an effort to do a full QI project on improving our assessments. And so part of that was multimodal education, but I think the biggest part of it was we completely revamped our flow sheets. And so this is our, we use Epic, this is our delirium charting flow sheet. And we built out row information, we built out each feature, and basically you can walk through this and it will teach you how to do the assessment on your patient. And what's even better is it will auto-calculate. So if you answer no to both of feature one's questions, it stops them there and says delirium is absent. You don't need to keep going. So it increased efficiency. And so the nurses weren't having to do all four features on patients that didn't need it. So I'm just going to share this. We published this in Peds Quality and Safety last year. And so you can see we have this big ramp up. We did virtual platform education, and then we did educational handouts that we emailed out, and then we did our EMR changes. And then we came back a year later and the gains persisted. And I really, really think that is because of the EMR build, because we're still having high levels of nursing turnover and a lot of new staff in our unit. So I think building that education into the EMR was integral for sustaining our changes.

pediatric delirium

importance of identifying

managing pediatric delirium

risk factors for delirium

screening tools for delirium