Hi, my name is Debbie Long, and I'm from Australia. My background is PQ nursing, and I've done that for about 30 years. In the last few years, I've just moved into academia. And I'm delighted to talk to you today about delirium and how we've been implementing our assessment, management, and prevention in our unit. No. So just to let you know before I start, there's quite a few videos in this. And all the photos and videos have permission of the families, parents, and children were able. But really, what Gerry has pointed out to us today already is that delirium is avoidable and also treatable if we do get it. And there's very good evidence now in the adult literature that regular screening, assessment, and prevention can minimize delirium significantly. So we've now got some new emerging pediatric literature that's shining more light on this concerning problem. So for children, the assessment of delirium and the diagnosis of delirium is essentially similar to adults. We still see the three subtypes of delirium being hyperactive, hypoactive, and mixed. The difference is that in children, approximately 50% of those are hypoactive. And another 40% to 50%, again, are mixed. And we don't tend to see so much of the hyperactive symptoms. And in terms of pediatrics, some of the considerations that we need to take on board is their ability to communicate, whether it's their age or their level of cognition, whether they have an ETT in or a mask on their face, the typical stranger danger, or their developmental stage where they may not want to communicate or express any concerns with anyone else other than a trusted parent. And the other thing that we need to take into consideration is different developmental stages and whether the child has developmental delay as well. And I really, at this point, want to point out a survey done by Sapna's group looking at several cardiac PICUs over 13 countries. And they found that a lot of the time, and I said that hypoactive symptoms were actually the most common symptoms that we see or subtype that we see in pediatrics. But these are, unfortunately, also the most commonly missed. And so we've heard people talk already today about validated screening assessments and standardized tools and standardized protocols. And you're going to continue to hear that from each one of us and talking the same language. And it's only by implementing screening assessment tools that we can start to pick up on these hypoactive symptoms. There was little routine rounding done around delirium. And again, this is about sharing the same language and having the communication link between the nurses and the doctors and the medical staff understanding what tools are being used. 75% of units did not routinely screen. And only a very small percentage always screened. And in this survey, most of the attendings were the ones that did any sort of screening. And as Sapna has pointed out, that actually, the people who are with the patient all the time are the nurses and the parents. And so they're your biggest ally. So as I mentioned, validated screening tools. There are quite a few now that we have the luxury of accessing. And in the PANDEM guidelines, specifically the CAM ICU suite, so that's the pediatric and the preschool confusion assessment method in ICU, and then also the CAPD. We do have the SOSPD, but the PANDEM is recommending the CAM ICUs and the CAPDs, both well-validated and used frequently across a lot of the units now, as Sapna has showed you with what's happening at the moment. However, one of the limitations that we've found is that in the literature, we know that there's evidence for these screening tools, but they were developed by highly trained individuals, which is great. And also, all of the literature that was coming out about the reliability and the validity of these tools was from the actual units where they were developed. And so a question I often get asked by people is, well, what tool should we use? And there isn't a right answer or one answer for everyone. You have to look at those tools and how you could implement them in your unit and what your makeup of your staff is and the culture. And so we did exactly that. We took both of the CAM ICUs for pediatrics and preschool and also the CAPD and implemented them in our unit. The nurses loved me for it. And we had them assessed against the gold standard DSM-5. And we had a psychologist doing that, not psychiatry. And the reason is that our psychiatry consultant liaison team said, well, you know more about delirium than we do. And they weren't as engaged in the ICU. They were more sort of outpatient care. So fortunately, we had a very actively engaged psychology team, which turned out to be great. Because in talking to and touring around a lot of other units that are really great at implementing delirium assessment and treatment and prevention, psychology just brings a different perspective to it. So we were able to draw from the psychiatry work that's been done. And Christina did present some of that the other day. But psychology really brought in that family, child, parent, child, dyad, and child neurodevelopment perspective to the delirium piece, which has been really great. So you can look up the results of what we found. But this applied to our unit. But in actual fact, we used two different delirium screening tools in our unit. Our default that everyone uses, at least twice a shift done by the nurses, is the CAPD. And then if there's any concern or query or I'm not sure, then we've got a significant number of other people within the unit that can talk them through that and either confirm or as a second check, use the CAMs as well. One of the other things that we found with this study is that the discordance. So where we had disagreement with the gold standard was related to, and this is really not surprising, or shouldn't be surprising for people, is a younger age. So we had more disagreement when the child was the youngest age, when they were on sedation, and when there were symptoms of subsyndromal delirium. So when they were either just tipping into delirium or just tipping out. And so we were able to use that evidence from our own unit in our own study to say, OK, these are our trigger points where we really need to focus our education is around the most youngest child. And obviously, Sutton's pointed out that most of our children are under two years of age. And they are really tricky. So we've really leaned in heavily on the developmental matrix that Connie and her team have developed to go along with the CAPTI and integrated that into our medical information system. Sadly, we don't have EPIC-CERNA. We have a different one, just to be a little bit more challenging, but we've integrated that in there. And that has been a bit of a game changer for us. So instead of the nurses reading the standard default CAPTI, they will actually read the ones with the proper developmental milestones in them. So some of these assessments that we've practiced, and we use these videos as education for our staff as well. You'll see us doing some, it's usually me doing the assessments on some of these children. So as I'm talking, I'm not going to necessarily talk about the videos. See if you can pick up some of the features that the kids are displaying. And so in terms of the prevalence that we understand, and again, Christina and Stacey and even Peter covered quite an extensive bit of information on this the other day. We see a wide variation in the prevalence of delirium that's reported in pediatrics. And sometimes that's likely to be because people are just reporting on observation of clinical symptoms. So you see the really low prevalence, and it's likely that they're missing those hypoactive symptoms. It will often also depend on the type of unit that you're seeing. So there's strong evidence to show that there's a higher incidence or prevalence of delirium in cardiac units, in particular, surgical in this case. And then there's been a more recent systematic review, which has actually pulled all those prevalence papers together to show us a pooled prevalence of around 35%. So again, we do have a long way to go to minimize that. Certainly, there are some risk factors that have been identified within pediatric cases. And all of these are really useful to educate your staff on who they should be targeting. In our unit, we don't do delirium assessments on certain patients. It's every patient. I know people started to try and tell me in the beginning, oh, we only do it on ventilated patients. But there are other risk factors. And when we started seeing delirium in non-ventilated patients, the staff got the message and the picture. So obviously, I said that the younger children are at risk. Those with a developmental delay are also at risk. And when we think about the other end of the age spectrum, we've got our elderly patients and the dementia. And that's also a risk factor as well. So if we think about older age, younger age, dementia, developmental delay, they seem to be the concerning areas and other comorbidities. There are some emerging illness-related factors. But we can't modify some of those things. So the areas that we can really pay attention to are the areas where there's the modifiable risk factors. And so we've heard already Christina talk about benzodiazepines. But it's not just the only drug. There are other drugs. We've heard about pain control. And again, we've already heard today how you can't look at delirium in isolation. You need to look at it factored in against all the other elements of the bundle. And it's not until you can get that synergy with all of those bundles that you really start to see the impact. And as Gerry pointed out from the adult paper, and hopefully we'll see in the pediatric paper soon, is that dose response. So every little bit more that you can do in terms of each individual bundle and the elements within those, the more impact that you are going to have. And I know Christina talked the other day about, or maybe it was Stacey, about the brain maps. There are actually tools that we can use to help think through what might be causing this delirium. I get lost in things like brain maps. I don't know, maybe I'm a bit simple. And I often just think of the three overlapping areas of what does the illness or the injury that's actually going on with the child? Is there sepsis, inflammation? Are they an oncology patient? What are the treatment factors that come along with that? Are we giving them sedation? Are they having chemotherapy? Are they having steroids? And then finally, what environment are they in? And obviously, the ICU is noisy and bright. And so a lot of the things that we talk about are those environmental factors that are modifiable that we can address. Just, you know, I know this is more about implementation. But I think having and educating our staff, particularly about the mortality and the cost of delirium. We know that delirium is a strong and independent predictor of mortality, stronger in one particular study than our PIM. We often look at our PIM or our prism or our risk of mortality. And this has been shown in one study to be a stronger predictor. And we know that about 85% increase in PICU costs, even when adjusting for severity of illness and length of stay, those sorts of things, that every day a child has delirium, the cost of care goes up incrementally. So there's huge evidence here why we should be minimizing it. But to me, the evidence of why we should be minimizing it, yes, the cost is important to understand. And obviously, mortality is important to understand. It's the burden on the child that survives and also on the parents. Because we can't look at children and parents in isolation. We have to look at the family unit. So there's mixed evidence about neurodevelopmental outcomes after experiencing delirium for children. So there was one particular study that found no association with cognition and behavior and delirium. But there have been other studies done here in the States that have seen a strong association with a decrease in cognitive status. But that was measured with the PCPC. In the previous study I mentioned, there were quite comprehensive, validated, face-to-face neurodevelopmental assessment tools. There is definitely evidence about a reduction in the quality of health-related quality of life. And then some work that we've done in our own unit has looked at child outcomes out to six months. And within that, it's not published yet, but we're working on it. We're seeing a trend towards a higher intensity of post-traumatic stress symptoms, particularly in children older than seven years, whether that's cognition and memories of being delirious. Because children do remember some of their thoughts and processes while they have been delirious. It's not all a blur. And they often need help putting those pieces back together, but in the right order. And not correcting them, but sort of restructuring and almost re-scrapbooking their time that they're in ICU. And we've also found a significantly poorer quality of life. We've also done some work with our parents. And this is the interesting component, is that with parents, even at two weeks, had higher anxiety symptoms. Total depression tended to be higher. There was no difference in the groups, those that were delirious and those that weren't, in terms of stress or PTSS. But with the post-traumatic stress symptoms, they had a higher severity. And they definitely had poor coping and adjustment as well. But all of those differences disappeared by six months. So we know that it's definitely impacting both the children and the families, at least out until six months. So in terms of the treatment, we've talked about brain maps or Dr. Dre. There's so many acronyms and the three circles. And essentially, what that's acknowledging is that it's a multifaceted problem. You go to some of the delirium conferences and they put up the big pathway pictures of 10 million bits and pieces all contributing. I can't work with that. But to know that there are multiple causes. And because of that, you need to take a multifaceted approach. There's not just one thing that you can do. Similar to the bundle elements, you should be layering them all on top. And so what we tend to see, again, is that focus on the non-pharmacological, modifiable features, particularly around the environment. There's not really any evidence, again, for pharmacological treatment. And again, the PANDEM guidelines state this quite clearly. There are some small studies with some off-label antipsychotic use. And the biggest thing about using the first line or the atypical antipsychotics is consideration of adverse events. And typically, the recommendation is not to consider pharmacological agents in terms of the antipsychotics unless you have protracted distressing delirium. So for us in our unit, we rarely see it used. And everyone is pulling out all stops to look at the non-pharmacological methods first. And essentially, prevention is the same as treatment. There's not two different sets of rules. But in essence, it is early recognition. And you can only do that with a validated assessment tool that has been validated for the PICU. So what I'm getting at here is that there are some other validated pediatric delirium assessment tools. But for example, the post-anesthetic tools have really focused in on that hyperactive symptomatology. So the recognition with PICU being predominantly hypoactive, those tools have been developed to capture those symptoms. And the recommendation is at least once per shift. In our unit, we do it twice. Obviously, we're in a liberation session. So it would be remiss of me not to say the bundled approach is the way to go. I actually started trying to implement delirium screening 2012, I think, very early on, and maybe 2013. And I just tried to do delirium alone. And I had just tried to do sedation alone. And it wasn't until the liberation initiative here started rolling out that we started looking at it and thinking, OK, this is why it's not sticking and not working and it's not hanging in people's heads is because it wasn't all fitting together. And so we didn't have our aha moment, thanks, Oprah, until we started looking at it all together. We had to. For me as one person, I thought I can't roll out all these individual elements. But then once I found key leaders in each of the other areas and we rolled it out all at the same time was when we really started to see the gains. And the nice thing is that there are some little quality improvement studies. And I know for the people who publish these papers, they weren't that little, but that show that we can implement simple rounding checklists at the bedside. We can implement noise reduction strategies, looking at delirium, sedation, and pain alone. So not necessarily all elements of the bundle. People have significantly reduced the incidence of delirium in their units by little quality improvement activities. The other thing is sedation stewardship. Again, we've already heard several times about setting daily goals and making sure that we're all talking on the same page. In our unit, and I mean, I know we've already talked about sedation, but you can't do delirium without talking about sedation. We have a default. The default is your sedation score is zero. We use the RAS. And unless someone else says, your aiming and your goal is zero. But that goal is discussed and set every morning with the ward round. And then we have a liberation round in the afternoon where we look to see how people are meeting their goals. Obviously, we have other goal setting as well. We have early mobility goal setting. And we check in with the staff and the family at the bedside to see how they're reaching those goals, if they've swayed from them, if they've exceeded them, and how we can help them reach them or move to the next level. And then, obviously, there are other things outside of liberation like music and games. And this is all about being a child, getting back to basics, massage, and reading. I've talked about education, and I can't emphasize this enough. And not just for the staff, but for the parents. Educating the parents about what delirium is, what it looks like. And they are actually the first person that might pick up on something. This is not my child. It's commonly something that we hear from the parents. So to engage them very early in the piece, about delirium and what that is, is extremely important. And we find the CAPD tool a really great place to start in terms of what their normal behaviour and arousal and awareness is like at home. But we know that delirium is an area where there's a huge amount of variability. We know that there are units that are still not implementing it. And we know that there are still deficits in our knowledge from a clinician's point of view. So we've got more work to do. But as I said before, our bedside nurses are the most ideally placed to do our preventative work and also our screening. So we do need to, as a first step, take home message from my session is, if you are not screening, you need to start doing that. And obviously, there's one thing to say you're screening, but to do it reliably, is a really important piece. So we, like I said, I've implemented delirium almost 10 years ago now. But not a six month has gone by where I've not had to go back into the unit and keep training and educating the staff. Because we have staff turnover, things change, the world changes, people get distracted with other initiatives and tend to fall back into old habits. So we need to constantly be educating and updating people. And of course, new evidence rolls in all the time. In terms of implementation, this is drawing on my experience, there's no in particular evidence, is understanding the unique barriers to your unit. So talking to your staff about what are their concerns and fears. And this is not just implementation of delirium, this is in general. So I'm sure some of the next speakers will mention this. Acknowledging and rewarding the early adopters. People say, you know, you just need one leader. I say, you just need one follower to really get this stuff going. And we've found great success in highlighting patient and family narratives. So we have a weekly newsletter. And we are constantly putting in information about achievements that staff have made in terms of liberation and also families as well. And we also appeal to our staff as the ideal clinician. And we have found specifically, and we've done all the organizational surveys and things like that, that participating and providing PICU liberation is providing meaning making for our staff. We choose one bed and we work outwards. So we focused on one bed and having all the elements, and obviously for delirium, exactly how we wanted it to according to our protocols in one bed. And then we moved out and out and out. So we always knew that bed 10 was the liberation bed. And we provide extensive support and training and education. And important to that is feedback, constant, timely feedback to your staff. We've all finished on slides that talk about resources. And I'm going to add to that. So if you want to take a photo. So we've got the PANDEM guidelines. We've got the up-to-date literature. We've got the SCCM web page. These are all fantastic places to go. There are other delirium web pages. And we've had podcasts, which are a great source of information. The other thing is reach out to people. There are numerous people in this room and beyond who even just for me in Down Under where people tend to forget where we are. They have been a huge source of information and support in trying to implement these sorts of things. So reach out. Ask people. Thank you very much.

Debbie Long

Australian nurse

pediatrics

delirium assessment

delirium management

delirium prevention