Medicine Hat Regional Hospital

ICU Delirium Collaborative

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Background

• 10 bed critical care unit in Medicine Hat Regional Hospital

• Supports a catchment population of 110,000 people, SE AB & SW Saskatchewan

• Team comprised of Registered Nurses (16.19fte’s), supported by Internal Medicine Specialists & an interdisciplinary team of HCP

• AHS/MHRH has adopted the use of the intensive care delirium screening tool (ICDSC)

• MHRH ICU introduced the ICDSC screening tool & trained staff July 2011 on the application of the ICDSC

• The practice/process has not been consistently followed since being introduced

Background

• Rationale for non-adherence to delirium screening– Staff state if the patient is not presenting with S&S of

delirium or changes to behaviour they simply forget to administer the delirium screening tool

– lack of education, – timing bad for rollout (summer), – prompt/flag not on care plan or admission assessment, – screening tool instructions & scoring located on the back

of the graphic record.

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Aim

Problem Statement Current screening practices/process for delirium detection, prevention &management not consistently being adhered to in MHRH ICUGoal StatementAHS expectation is that within 6months 100% of patients admitted to ICU be screened,using the ICDSC tool & standard care guidelines be implemented, to detect, prevent &manage Delirium

AIM– To improve the care of critically ill patients at risk for delirium through the implementation of

standards for screening and identification of preventative and management strategies.Objectives

– To determine the baseline incidence/prevalence of delirium within 3-6 months– Implement a process to screen 100% of ICU patients within 6 months– Develop education resources and support for staff to assist with screening, prevention and

management of delirium in the ICU within next 6 months– Implement standardized prevention interventions within the next 12 months– Implement standardized management interventions within next 12 months– Implement strategies to support families within the next 18 months

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Team Members

• Team Lead/Sponsor, Brenda Ashman Director Critical Care and Medicine • ICU Manager, Rickie Pomreinke• Clinical Quality Improvement Consultant, Jill Forsyth• Transformational Team Leads

– Environmental Lead, Melissa Hill RN– Mobility Lead, Stephen Yuen Team Lead Physical Therapy– Sedation/Vacation Lead, Catherine Johansen Manager Respiratory Therapy

• Pharmacist Joyce Nishi• Occupational Therapy Shayne• Clinical Educator Jamie Fauth• Psychiatrist Dr. Patel• Social Worker Dan Stevens (to be invited to participate)

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Results

Results

ICDSC audit

25

100

81

57

85

78

0

10

20

30

40

50

60

70

80

90

100

4-Jun 11-Jun 18-Jun 25-Jun 27-Jul 27-Aug

Perc

ent o

f doc

umen

ted

scor

e on

ICD

SC

ICU Delirium MHRH ICDSC Scoring Compliance Rate

Data 1

Median

40% staff attended inservice

57% staff attended inservice

66% staff received education

76% staff received education

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Changes Tested

• Education of all ICU staff, excluding physicians, including allied health

• “All about me” posters utilized & posted• Initiation of interdisciplinary daily Rapid Rounds • Establishment of day & night routines• Documentation of # of hours of sleep• Delirium awareness posters in each room• Patient brochure provided to patient/family• Vented patient PROM & mobilization plan documented

Lessons Learned

Keys to success• Interdisciplinary transformational team, including frontline-

care providers• Support/feedback from ICU Collaborative, networking, CoPLessons Learned• Small steps/tests, one at a time, prioritize areas to improve• Communication Key! Develop a formal plan, Make it visible• At onset establish responsibility, accountability for

progression/completion of project

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Lessons Learned

• Once again summer months created delay in roll-out• Changes to ICU Manger, Clinical Educator &

Respiratory Therapist Manager hampered momentum, buy-in, sustainability

• Education alone does not change practice• Front-line staff engagement in all stages of

improvement initiative imperative for adoption of changes to practice. Change management plan required

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Next Steps

• Continue chart audits for compliance with ICDSC• Perform root cause analysis for non-compliance to assessing

& documenting ICDSC score per shift on every patient • Engage staff in brainstorming sol’ns for maintaining

compliance with environmental, mobility, ICDSC assessment for Delirium. Develop PDSA’s to test sol’ns

• Engage ICU physicians in supporting/developing plan for awake & breathing trials, (sedation vacations)

• Monitor incidence/prevalence of delirium diagnosis in ICU• Assess effectiveness of Rapid Rounds• Establish accountability for monitoring & sustaining

improvements