Sherry Simone, and I'm the Advanced Practice Provider Manager for Pediatric Clinical Care at the University of Maryland Medical Center and a professor in the Doctor of Nursing Practice Program at the University of Maryland School of Nursing. I would like to thank the Congress Planning Committee for the opportunity to present how to implement delirium screening in the PICU and what to do with your results. I have no conflicts of interest, but we did receive an interprofessional collaboration education grant for interdisciplinary student and trainee delirium education with our initial QI project. So my objectives are to highlight our PICU delirium QI efforts at the University of Maryland Medical Center and then to discuss key delirium screening implementation strategies to promote successful implementation and sustainability. So our delirium assessment prevention and management QI project began in 2013. We were not screening for delirium and recognition was based on clinical suspicion and a psychiatry evaluation. So our initial aim was to examine the impact of interprofessional collaboration to improve detection prevention and management that included not only PICU team members, but also pharmacy and psychiatry. So we assembled a task force in the fall of 2013 that included pediatric psychiatry, pharmacy, PICU intensivists, and myself. Our goals were to utilize interdisciplinary expertise to improve staff and training delirium education and then to develop a delirium protocol to implement universal screening, enhance early and systematic detection, develop prevention strategies, and standardized delirium treatment. So we developed an evidence-based delirium clinical protocol based on the limited evidence at that time. This protocol included universal pain sedation screening along with delirium screening using a validated tool. We chose the Cornell assessment of pediatric delirium or the CAPD tool based on its ease of use, especially mechanically ventilated children. This is a condensed picture of our four-page algorithm, which includes assessment prevention measures and with positive delirium screen and acronym for identifying potential etiologies and non-pharmacologic and pharmacologic treatment and monitoring parameters when antipsychotic treatment is prescribed. So our intervention was to implement an evidence-based delirium protocol for assessment prevention and treatment, and our data measurements included screening compliance, delirium prevalence, a demographic and clinical data of delirium cases, and then staff training pre, post knowledge attitudes and skills survey. So one important interdisciplinary education forum was the creation of a Brain Rounds monthly conference. This was a well-attended conference by the PICU multidisciplinary staff, which include intensivists, advanced practice providers, fellows, residents, nurses, and pharmacy and psychiatry and students. The conference was led by me with psychiatry, pharmacy, and PICU participation. We presented in-depth review of delirium cases, especially complex cases, and then we would review screening, prevention, diagnosis, and management strategies and modify our treatment and algorithm as needed. We also created this booklet, a pediatric team, which stood for training, education, assessment, and management of delirium and included information on delirium criteria, subtypes, on the pathophysiology, risk factors, screening tool, and our algorithm. So although our original QI project was to implement delirium screening, you can see here that our timeframe extended from 2013 to 2015. And this was mainly due to performing multiple of QI PDSA cycles with evolving adult evidence of bundled strategies to not only decrease delirium, but also liberate critically ill patients from mechanical ventilation in the ICU. So at the top in December, 2013, we rolled out comprehensive education to the multidisciplinary staff and then began delirium screening and initiation of the delirium protocol, and then conducted daily monitoring of the screening adherence. We also did a pre-assessment survey of delirium knowledge and attitudes of the staff. And then in February, 2014, we initiated the Brain Rounds monthly conference and also around that time received an interprofessional educational seed grant for student and trainee delirium education and over the next year created multiple educational activities. And this grant was really instrumental in driving intensive and structured education as well as maintaining interdisciplinary commitment. In March, 2014, the CAPD tool had been revised and we re-educated the staff and continued daily monitoring of screening adherence. And again, as there was increase in evidence of bundled strategies and adults to decrease delirium, we phased in these bundled strategies by adding core teams to create the bundles and then to roll out education and implementation. We screened 1875 patients over 22 months with a phased in implementation of the three protocols, the delirium sedation, early mobilization protocols, and we standardized delirium assessment using the CAPD tool and implemented prevention and treatment strategies. We also created multiple resources to provide comprehensive education to multidisciplinary staff and interdisciplinary students. And as you can see here, our delirium prevalence decreased from 28% to approximately 12% over this time frame, which was a remarkable success for our team. And then we published this work in Pediatric Critical Care Medicine 2017. There are several key implementation strategies that influence the success of our delirium QI project that I hope are helpful to those of you beginning this process or struggling with implementation. First, creating an interdisciplinary QI team with the right individuals is critical. In addition to having multidisciplinary PICU team members, psychiatry and pharmacy expertise was critical to influence key PICU stakeholders and drive change, especially as delirium research was limited in critically ill children at the time of our implementation. And having a shared commitment with project lead and interdisciplinary champions, I was the project lead but was fortunate to have a psychiatrist, clinical pharmacist, intensivist, APPs, and nurse champions that were highly engaged. They assisted with education on nights and weekends with discussions and multidisciplinary rounds, huddles, and early consults. This also assisted with achieving buy-in from PICU leadership, which is necessary to support process change and culture change. And our monthly brain rounds conference helped, especially as it had consistent interdisciplinary representation and assisted with consensus on the process, management, and outcomes. You must choose a validated pediatric delirium screening tool. There are three recommended in the new PANDEM guidelines. The first is the pediatric confusion assessment method for the ICU, also known as the PCAM ICU, which assesses children five years of age and older, and the preschool version, which assesses children under five years of age. This is a point-in-time assessment with interactive and observational components. The third tool is the Cornell assessment of pediatric delirium, also known as the CAPD tool. This is an observational assessment that is performed over several hours of the shift and is validated in children zero to 18 years of age. Another key implementation strategy is identifying and addressing barriers to screening. Understanding the ICU context is really critical and requires a deep dive assessment of your unit culture, resources, leadership commitment, competing projects that are going on, unit priorities, and readiness to change. We obviously implemented our project well before COVID, and we're not faced with some of the challenges that we are seeing now, including staffing shortages. Also assessing the staff knowledge and attitudes and beliefs pre-implementation can be really helpful in understanding barriers to expect. And then typically, pilot implementation involves paper documentation, but limiting redundancies in documentation is important and can greatly affect adherence. We did screen using paper tools for the entire 22 months, so it's not impossible, but we enlisted unit secretaries to distribute and collect tools at night, and they had a very clear responsibility and ownership of this. And having frontline ownership with nurses, APPs, physicians, the clinical pharmacist, and the unit secretary also greatly assisted with overcoming barriers and creating solutions. And Costa and colleagues in 2017 performed a systematic review and identified 107 barriers to the A2F bundle implementation, and really many of these are the same as I've described, but they identified four themes, patient-related, such as safety concerns, hemodynamic instability, clinical-related, such as staff lack of knowledge or workload, protocol-related, not having a protocol, and ICU context. So using a multifaceted or multimodal approach to train clinicians in delirium screening is really important. Startup education must be comprehensive and rolled out to all multidisciplinary staff through the use of in-services, train-the-trainer sessions with frontline staff. We also created nursing competency training with case-based scenarios and performed co-assessments to evaluate for accuracy of screening assessments, especially with hypoactive and mixed delirium cases. We also added education to the nursing orientation in our monthly resident education. We created web-based resources and other educational materials, such as our booklet. You can also develop pocket cards. We had posters, PowerPoint presentations readily available, and our algorithm is easily accessible on our PICU internet page. And then, of course, just-in-time education by delirium staff champions must be ongoing. So what data should be collected and what should you do with your results? Assessing staff knowledge pre- and post-implementation provides great insight on barriers and facilitators for implementation and also sustainability and was very helpful to us. The primary process outcome is screening adherence. You can see in this graph in the upper right-hand corner that ours was high throughout, and this was because of unit nursing and the unit secretary champions ensuring screening and also that the paper forms were readily available. Clinical outcomes should include the delirium prevalence, your patient demographic, and clinical characteristics of delirium cases. And the success of your data collection is going to be dependent upon who's collecting the data, what databases are available, and what can be extracted from the electronic medical record. If you have limited resources, I would consider using some creative resources such as the interdisciplinary students. When we first started, we had psychiatry and pharmacy students that assisted with this data collection. That was extremely helpful. And then, disseminating the data and using the impact of the implementation to sustain practice, the practice change is key. We presented our screening compliance, and we were able to get a lot of data collected. We presented our screening compliance and prevalence throughout our project in our monthly case conference and in our PICU quality review meetings, which was really helpful for momentum and also commitment to the project. It's also important to monitor throughout so you can quickly address such as a dip in compliance and retrain and reassess new barriers. Your results can then be used to demonstrate the need to standardize practice. Delirium screening must be incorporated into the nursing workflow, and ideally, embed all delirium documentation into the electronic medical record. This is really a key strategy for sustainability. We discussed screens and multidisciplinary rounds. And here, you can see our ICU checklist, which includes the delirium assessment. And then also, we have incorporated the delirium assessment into the nursing flow sheet. So, you want to make it all easy to do and not easy to forget. Continuing to improve, monitor, and disseminate results are critical for sustainability. Use a QI method for implementation, such as a plan-do-study-act cycles, which are easy to do and should be incremental and continuous. Having at least one team member with QI expertise is also really helpful. Our initial aim, again, was not to create multiple bundled strategies, but our successful implementation of delirium screening really created momentum and led to further improvements. Having a stepwise approach was really successful for us. Doing too much at once can be overwhelming for busy clinicians. And also, celebrating successes and disseminating internally frequently is really important. We presented at multiple pediatric nursing APP Grand Rounds. This really helped to spread the effort. And since we have assisted pediatric inpatient units and our NICU with delirium screening and management. So, screening is the first major step in delirium prevention treatment, but the other bundled strategies were also necessary for preventing delirium. This was our statistical process control chart, which demonstrates the impact of the three ICU bundle process changes that we implemented over the course of 22 months. Initially, as you can see, our delirium prevalence increased with screening, as it should have. But over the course of the bundle implementation, there was a nice stepwise decrease in prevalence, which we were extremely excited about. So, what do we continue to do with our results? We have since implemented five of the six ICU liberation A to F bundle strategies. We have incorporated strategies to improve family engagement empowerment. Our PICU Connect program here in the middle includes the use of Zoom during multidisciplinary rounds and therapies when parents are unable to be at the patient's bedside. These pictures are pre-COVID, but you can see the mothers zoomed in for rounds. And laying the groundwork with delirium screening has really facilitated further QI efforts to improve our practices related to these A to F bundle strategies. We have also modified our delirium pharmacologic management and shared our work. So, I hope sharing our delirium QI project and strategies we found to be key for successful implementation and sustainability are helpful for those who are planning to implement delirium screening. Thank you, and I look forward to questions.

delirium screening

Pediatric Intensive Care Unit

University of Maryland Medical Center

Cornell assessment of pediatric delirium

evidence-based delirium protocol