SCCM Resource Library-Nonpharmacologic Management and Nursing Care of Refractory ICU Delirium

Video Transcription

Good afternoon, everybody. Welcome to the 51st Critical Care Congress. My name is Michelle Ballas, and I am currently the Associate Dean of Research at the UNMC  College of Nursing in the great state of Nebraska. And I am thrilled to be here today, and I want to thank you for the opportunity to present on this topic.  But more importantly, I really do want to thank you all for the hard work and dedication you guys have provided your ICUs, your patients, and hopefully your colleagues of the last  two years. We all firmly acknowledge how devastating this period in intensive care unit history  has been, and I did want to call out, in particular, my thanks to all of you, and mention that I do keep you guys in my thoughts and my prayers daily.  And hopefully, hopefully, we can now move on to the process of getting back to some normality.  Fortunately, I do regret not having the opportunity to spend some time with you in the beautiful Puerto Rico.  I was so looking forward to going there, but hopefully we'll connect again next year. So this lecture that I'm giving today is part of a general symposium that's talking  about the management and impact of refractory ICU delirium. What we're going to do in the next 15 to 20 minutes, unfortunately we have a rather short  time to spend talking on this subject that I could talk probably years on, is really explore non-pharmacologic management and nursing care of refractory ICU delirium.  So we're going to be focusing on the non-pharm stuff in this lecture. So the first question I'm bringing to the table is, why?  Why should we consider taking a non-pharmacologic approach to delirium prevention and management?  And we're going to do that first by looking at some evidence, and then we're going to look at some pragmatic advice.  So we're going to go to our evidence in terms of delirium, we're going to look at a couple different resources.  But in particular, the information that I'm providing you today is going to be pooled from both the, I think it's 2013, I call them the BOR guidelines, but 2013 clinical practice  guidelines for the management of pain, agitation, and delirium in adult ICU patients. And then also the more recent version of the PAT-EASE guidelines.  So the SCCM's clinical practice guidelines for the prevention and management of pain, agitation, sedation, delirium, immobility, and sleep in adult ICU patients.  They're going to be heavily referenced in this. Now I went back and forth, do I put this picture of the pills up there, you know, the non-stock  images, so no copyright, no copyright things are violated. But you know, this to me, we want to talk about why we're thinking about the, why we  need to use the non-pharm over the pharm.  So I have a nice show here, polypharmacy up here, I'm a geriatric nurse, critical care nurse, geriatric critical care nurse at heart here.  So I don't like the reflection of, you know, these pills, you know, possibly having a positive role in delirium.  So it's not that, more to reflect, you know, maybe the hazards of it. Anyway, when we look back in history and we look at the 2013 pain, agitation, and delirium  guidelines, so the PAD guidelines, and we look specifically at the recommendations regarding delirium, what do we find?  So back in 2013, no recommendation was given for using a pharmacologic delirium prevention protocol.  There was also no recommendation for using either combination of the non-pharm and pharm delirium prevention protocols, because neither, there was no compelling evidence back then  showing that it reduces the incidence or duration of delirium. The 2013 guidelines also started suggesting not to use antipsychotics.  So I know Dr. Stalling is going to have a wonderful lecture on pharmacologic management of delirium.  But even back in 2013, there was suggestions that you not think about using Haldol or atypical antipsychotics to prevent delirium.  And not, and back then, there was no recommendation regarding the use of dex to prevent delirium and some other drugs up there.  They did call out, interestingly, you know, a problem that we're still obviously dealing with in everyday clinical practice, right?  And that is alcohol and other substance withdrawal in the intensive care unit. Acknowledging it back then in 2013 that, you know, patients with delirium that was unrelated  to the alcohol or benzo withdrawal, the dex, there might be some evidence showing that dex was better than the benzodiazepine.  So again, 2013, really no recommendations suggesting that there's a role of, suggesting that there's a role of, there's a role of medications in the management of ICU delirium.  And the 2018 guidelines kind of the same step in terms of suggesting not to use the typical or atypical antipsychotic statins or ketamine to prevent delirium.  Or also suggesting not to use medications in terms of treating subsedronal delirium. And also, now we're moving to the treatment and we're seeing, again, no recommendation  but the suggestion to not routinely use them, right? So don't routinely use these medications in terms of treating delirium.  So again, generally speaking, showing you the same thing that there's probably little role in terms of pharmacologic management of delirium.  Now the society will be working on some guideline updates which will may, may at some point  come back and address this pharmacologic management of delirium based on some evidence that was  not included in the last guidelines that will, that may change the, you know, the suggestions  to a recommendation against and look at a couple of other different possible pharmacologic treatments of delirium.  But to date, that's kind of where we stand in terms of the recommendation from our professional  society guidelines regarding the antipsychotics and other medications to treat delirium. In the earlier versions of the guideline, we did start to see more and more evidence  coming out and suggestions about the role that non-pharmacologic management of delirium, the role non-pharmacologic treatments might have in the management of ICU delirium, right?  So again, 2013 recommended the routine delirium monitoring. So that routine delirium assessment, really important coming, really important work from  this particular guideline was that recommendation saying, yes, we got to monitor for it. How will we know if we're doing good treating it, preventing it, if we're not following  whether or not the patient has delirium? 2013 guidelines were also the first place where it was recommended about performing early mobilization, right?  And you'll see that that's eventually how the eye got into the new PAD guideline, but the important role that early mobilization may play in terms of reducing the incidence  and duration of delirium. Now is it the early mobilization that's reducing the incidence and duration of delirium or  the fact that likely many of the medications that the patients are on have been reduced so that the patient could actually wake up and possibly participate in early mobilization,  still kind of unclear.  But again, that first recommendation coming out about the importance of early mobilization.  Interestingly, you'll see again that no recommendation for using the combined farm and non-farm, likely because the farm stuff didn't really pan out too well, right?  But the earlier version, again, focusing on one important aspect of non-farm, I consider non-farm management, is really the importance of targeting either spontaneous awakening  trials or daily sedation interruption or targeting a light level of sedation, particularly in those patients receiving mechanical ventilation.  So that role that overall sedation levels may play in the incidence and duration of delirium really coming out nicely in these 2013 guidelines.  And also the recommendation about suggesting that we take an analgesia first approach, so meaning use analgesics before considering using sedatives, particularly in mechanically  ventilated patients. In terms of the most recent 2000, I'm sorry. So again, in terms of those earlier guidelines, here comes even some more of that non-farm  suggestions, right, and recommendations. So the importance of optimizing sleep, again, followed up in the PATI's guidelines later  with the S, but the importance of promoting sleep in the ICU, optimizing patient's environments,  using strategies to attempt to control some of this really prevalent and problem, problem  of light and noise in the ICU, lights on all the time, constant noise, clustering patient care activities so that the patient has the opportunity to sleep.  So rethinking what we're doing on night shift as nurses so that at least the patients could have the opportunity to get some sustained amount of sleep while they're in the intensive  care units, decreasing that stimuli and clustering care. In the earlier guidelines, there was no recommendation in terms of the specific modes of mechanical  ventilation to promote sleep, but again, suggesting some non-farm strategies in that area might also be important.  Now let's give out a big kudos to those 2013 guidelines because they were really, I think,  so forward-thinking and forward-thinking in this recommendation about using this interdisciplinary ICU team approach, right?  That we're going to engage the entire intensive care unit team, all the professionals in terms  of providing them education, pre-printed and computerized protocols, order forms, rounds,  all of these kind of process-related things in terms of facilitating the assessment prevention and management of not only delirium, but also pain and agitation.  So that really forward-thinking approach that, again, was followed up nicely in the more recent version of the PAD ease guidelines where they did, again, specifically look at  the evidence that's out there regarding those new concepts of immobility and sleep disruption in adult intensive care unit patients, right?  If you look at the overall suggestions and recommendations in the 2018 guidelines, again, in terms of the non-farm management, there was one suggestion not to use bright light  therapy to reduce delirium in critically older adults, but again, there's another suggestion  reiterating the need for those multi-component non-farm interventions that are focused on reducing those modifiable risk factors for delirium, right?  We want to remove the factors that are associated with delirium or put the patients at greater risk of developing delirium during their ICU stay.  We want to use strategies to improve the patient's overall cognition, having them more awake,  alert, able to engage in the kind of cognitive and physical activities that we want them to engage in while they're in the intensive care units.  Again, optimizing the sleep, giving them that opportunity to mobilize, giving them basic  nursing care, and we're going to see that at the very end of this presentation, but those things that we know matter in terms of helping them interpret their really super  scary environment, the intensive care unit, but giving them their glasses and their hearing aids, things to optimize their ability to communicate.  Some of the strategies out there, particularly for patients on mechanical ventilation, though  not specifically recommendation, super important that they have ways of communicating their  needs, whether they're on mechanical ventilation or not, having them being able to communicate  their needs to ICU providers. Globally speaking, there's just not a lot of strong evidence out there supporting any  specific non-pharm intervention in the intensive care unit. Randomized control trials, which is really the design most clinical practice guidelines  require to issue recommendations and things like that, they're hard to do.  They're particularly hard to do with non-pharm interventions or what many of us would consider  what we learned in Nursing 101, so those good basic humanistic factors that all patients  should have while they're in the intensive care unit. I did reach out and looked at the state of non-pharmacologic delirium management outside  the intensive care unit to see if there's anything out there that we might be missing that might be helpful, and what is the state overall?  Do these non-pharm interventions work or not work? This most recent one, I think it was from 2021, and the citation's up there on the slide  for you to see, looked at non-pharm interventions for preventing delirium in hospitalized non-ICU  patients. They included randomized control trials that had either single or multi-component non-pharm  interventions for preventing delirium, again, outside the ICU, included 22 randomized control  trial, 5,000 patients, and looked at a variety of non-pharm interventions.  What did they find? Do these non-pharm things work? Well, the good news is indeed they do. What they found was multi-component non-pharm interventions likely reduced the incidence  of delirium compared to usual care. If you look at the smaller font up there, you can see what that risk ratio was.  Pretty significant improvement in terms of reducing the incidence of delirium when compared to usual care.  There was little to no effect on inpatient mortality, not too surprising, or on just  specifically looking at multi-component non-pharm interventions on new diagnosis of dementia.  There was some evidence showing that if you do some of these non-pharm interventions, multi-component delirium interventions, also helpful in reducing the incidence of delirium  and reducing the duration of delirium, so about a day. That's important because in the ICU, we had previous research showing that every additional  day spent with delirium was associated with a 10% increased risk of death, particularly for older patients. Dr. Pisani's work showed us that. Some benefit there.  Little difference in new care home admissions.  Interesting is the next slide, and you'll see this here. What are some of the non-pharm interventions that they looked at, or what are the other  things that might be considered non-pharm that might help patients? Well, it looks like using something, again, that we were taught very early on in our careers,  the importance of reorientation, right? Using familiar objects, but reorienting patients to their ICU, very helpful in terms of not  just preventing delirium, but if you think about the amount of not only the objects, but the personnel that's involved in ICU care, so frequent reorientation of where they are,  who they are, what they're doing, what their current situation is. Having that cognitive stimulation, it really could only happen if the patients aren't deeply  sedated in a coma, right? So again, the importance of that light levels of sedation so that they could be cognitively  stimulated, and again, that sleep hygiene being really, really important in terms of reducing that risk for incident delirium.  Also, they looked at studies that looked at nutrition and hydration, again, very kind of basic here, but important in terms of the delivery of, or humanistic models.  Medication reviews, getting them off the medications, reducing, let me just put up the next slide  so you can see kind of some of these things that they looked at, but you could see here, particularly for that reorientation, it doesn't cross that magic line there in the middle,  but the importance of the reorientation strategies and the objects.  So if you look on the left, things that have been associated with less delirium on the right, interesting, right? Look here, pain control does.  Now, it crosses the light line, so you can't say with any kind of certainty, but some of these seem to be, if you just look at this particular forest plot, the things that are  associated with increased delirium, pain control, well, pain medicines may cause delirium in  certain populations, but mobilization, well, the fact, mobilization increasing delirium, could that be that the patients, again, who are mobilized or more awake and more able  to engage with care aren't so deeply sedated so that you're just now seeing the delirium that wasn't there before? So interesting, but again, relatively nonspecific.  So they looked at some other interventions as well, things like exercise therapy, computerized  clinical decision support systems, a lot of hospitals are doing that now where they're actually putting these reminders in EMRs or trying to cut health records for delirium  protocols and things like that. Generally speaking, when you're considering both the PAD, PADIs, evidence outside the  intensive care unit, but related to delirium in terms of non-pharm interventions, overall,  there seems to be some moderate certainty regarding the benefits of multi-component non-pharm interventions for the prevention of delirium, and that the most recent evidence  says not only is it beneficial for the prevention, but there also may be some important role  for these non-pharm interventions for hospital length of stay, delirium duration, and delirium severity. So that's kind of the evidence.  So now the nurses are left, so what is a nurse to do, right? So we know that the pharmacologic interventions that we have don't really work.  There's evidence for the non-pharm interventions, particularly the ones that we talked about before, but we know it's hard, right?  We know that managing patients, particularly patients who have, that might be at a risk of hurting either themselves or the staff, we've been seeing a lot of reports of violence  against healthcare providers, heartbreaking accounts of that. So often, what is a nurse to do? We only have so much time, we only have so much resources available to us.  So in terms of my suggestions for the non-pharmacologic interventions, we, again, kind of need to  go back for the basics, protecting the patients, protecting yourself, but really focusing on  detecting what is the underlying cause of delirium. It doesn't really sound like an intervention, non-pharm intervention, but it's probably  the most important non-pharm intervention that I can offer that, in my opinion, that I think would probably be most effective, meaning really taking a close look at identifying  why it is that the patient is experiencing delirium. Once you can identify it, hopefully you could remove it, and then hopefully the patient's  cognitive trajectory will be better for that, right? So really trying to remove the causes of delirium as much as possible. Again, we know that it's important.  Are you going to get a randomized controlled trial that shows you assessing patients for delirium alone, doing nothing else, just the assessment, will improve mortality, length  of stay, event phase? Probably not. Should that even be done? Probably not, because how does the assessment part of it alone, without the follow-up of  these non-pharm interventions for the prevention and for the management of delirium, they're  the ones that will more likely have the effect on outcomes, but you can never know if these interventions that you're delivering work if you're not screening for delirium.  So really, again, reiterating the importance of assessing delirium. I just gave a lecture about how often that assessment should occur in the ICU.  My gut tells me it's probably once a shift. So again, we just did a study that looked at ICU liberation collaborative members and  found an association between more frequent pain-level arousal and delirium assessments  with increased chance of patients getting SATs and SBTs. We looked at it, but I would say at least a minimum of every shift.  And I say that because, again, when we think about that change in provider, that handover that occurs, so if your shifts are every eight hours, probably doing it every eight hours.  If they're every 12 hours, probably doing it every 12 hours. But really, for every provider, for every nurse coming on the shift to have a really  good first-thing assessment of their delirium assessment when they come on shift so that they can see if anything changes over the course of their shift.  Engaging and activating family members in the course of care. Again, COVID has wreaked havoc in our intensive care units.  One of the most devastating impacts was depriving critically ill patients of their support persons,  whether it be family or other support, not having them at the bedside, people having to say goodbye to their loved ones over video. Absolutely heartbreaking.  Engaging family members in delirium assessment prevention management is super important. They know the patient best. They know their patient's baseline.  They know patient's pain behaviors. They know them better than we will ever know them as ICU providers. That said, they can be engaged to play really important roles.  Just the talking, just the reminiscence, just the updates about what's going on at home. Those cognitively engaging activities, really important that family members could take a  part in. That skin-to-skin, that's so important, neonatal ICUs, but holding hands, bringing them back to the present moment and place in time, super important.  That said, it is very hard for family members, particularly, you know this, once the patients  are delirious, particularly if they are experiencing agitation with the delirium, that's super hard on family members as well.  They're scared, they need a lot of education, and that education normally does come from us as nurses, and that reassurance.  So letting them know that the team is taking it very seriously, they're doing everything they can to get them back to their normal state, very important.  Again, using that pragmatic, common sense, and humanistic approach. I know I've mentioned that a number of times, but it's very difficult, as we know, to document  the direct impact nurses have on patients, right? Many of the interventions that we do are not appreciated as much as they should be, but  every single non-pharma intervention that we talk about, in some way, even if it comes down to feeding a patient, you know, you might not be the person physically putting  the spoon in the person's mouth, but we know that nurses are the ones that will be making  sure that the patients are eating when they can, that they're doing it safely, that they're,  you know, not choking when we give them their liquids for the first time, obviously in collaboration  with our speech-language pathologists and all the other experts that are in the intensive care unit, but really, there is no need to, and we should actually laud, all of those  basic care activities that we're doing that are often unappreciated. So even thinking about, and you know, nobody likes to talk about it, but you know, could  the patient be displaying some of these behavioral symptoms because when was the last time they went to the bathroom, or could they be constipated?  You know, really rejoicing in the full, holistic, and humanistic approaches that nurses are taking.  That said, to make all the things necessary, mobilization, monitoring for safety, we really  do also need to be advocate, we have to advocate, and we have to call on our interprofessional  colleagues to advocate for safe RN staffing levels, and the need for additional support.  So to give the kind of care that is necessary for a human being that is experiencing delirium takes a lot of work.  It might be a different kind of work than running a CBBH machine, it might be a different kind of work than team proning a patient, it does not mean that that work is any less  important.  And to do that, we need the human capital to be able to do that. It's hard to take care of someone who is experiencing delirium.  It's hard both, again, for the patient, the family, the clinicians that are caring for them.  But to do so, and to have these interventions, particularly the non-pharmacologic interventions, implemented into everyday practice.

Video Summary

In this lecture, the speaker discusses the non-pharmacologic management and nursing care of refractory ICU delirium. They begin by highlighting the need for a non-pharmacologic approach to delirium prevention and management. They reference evidence from clinical practice guidelines, which suggest that medications have little role in the management of ICU delirium. Instead, they emphasize the importance of non-pharmacologic interventions, such as routine delirium monitoring, early mobilization, optimizing sleep, and reducing stimuli in the ICU environment. The speaker also mentions the benefits of multi-component non-pharm interventions for preventing delirium in hospitalized non-ICU patients. They stress the need for nurses to assess delirium regularly, involve family members in care, and use a pragmatic and humanistic approach. They conclude by advocating for safe RN staffing levels and greater support for nurses in providing comprehensive care to delirious patients.

Asset Subtitle

Neuroscience, 2022

Asset Caption

Delirium is common in many critically ill patients and is associated with increased duration of mechanical ventilation, duration of ICU and hospital lengths of stay, and long-term cognitive impairment. Patients may be refractory to multiple standard treatment modalities requiring alterative pharmacologic and nonpharmacologic treatment regimens. There are many research gaps in this area, and this session will help provide insight into multifaceted management strategies for refractory ICU delirium.

Meta Tag

Content Type Presentation

Knowledge Area Neuroscience

Knowledge Level Advanced

Learning Pathway Delirium and Sedation Managment

Membership Level Select

Tag Delirium

Year 2022

Keywords

non-pharmacologic management

nursing care

refractory ICU delirium

delirium prevention

non-pharmacologic interventions

routine delirium monitoring

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