SMH Delirium Study in Orthopedic Patients Suggests Lower than Anticipated Rates
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Transcript of SMH Delirium Study in Orthopedic Patients Suggests Lower than Anticipated Rates
Kim Macfarlane
Clinical Nurse Specialist, Critical Care
Lisa Ying
Post-operative delirium in orthopedic surgery:
incidence, risk factors, and mitigation
Disclosure
• The authors have none to declare
•Dareena Malli
•Christine Donald
•Susann Camus
•Parm Panesar
•Pawan Sindhar
Acknowledgements
•Delirium is an ACUTE BRAIN FAILURE
• Patients who become delirious are unable to think clearly and can’t make sense of what is going on around him
• Commonly, they have hallucinations that are particularly frightening
•Delirium significantly increases morbidity and mortality and as such is a MEDICAL EMERGENCY requiring the same expert attention and intervention as any other acute organ failure
What is delirium?
• The incidence of delirium is high amongst hospitalized older adults being about 50% in the general population, and 60% in the orthopedic population
• However, in 40% of cases, delirium is preventable
• The biggest misunderstandings about delirium are that it is inevitable and inconsequential
• As a hospital-acquired condition, it far exceeds the rates of other care-sensitive adverse events such as SSIs, UTIs and pneumonia
• Delirium causes significant patient/family suffering, increases morbidity and mortality, and financially burdens the healthcare system
What are the consequences of delirium?
•Many patients never return to their pre-hospital mental or functional status:
• Some will develop posttraumatic stress disorder, which is characterized by re-experiencing the traumatic event via flashbacks or nightmares
•Mortality at 1 year may be as high as 20%
•The length of stay rises by 60%
•The rate of nursing home placement increases 5 fold
What are the consequences of delirium?
•A study of delirium risk factors, incidence and mitigation factors in a Surrey Memorial Hospital’s Orthopedic Unit:
• Estimate baseline delirium risk factor prevalence
• Estimate incidence of postoperative delirium
•Audit nursing assessments and interventions for delirium
Aims of our study
Methods
• Literature review to explore common causes, risk factors, assessments and interventions for delirium
• Patients (n=24) scheduled for orthopedic surgery were assessed for delirium between June and August of 2015
• Collected medical, functional, and social information from medical records completed upon admission
• Noted nursing delirium assessments and interventions on patient chart audits
• Patients individually evaluated postoperatively through Confusion Assessment Method, and review of 24-hour nursing record
•Sample Size: n=24
•Incidence of Delirium: 12.5% determined by positive Confusion Assessment Method (CAM) scores
What were the key finding ?
ASA levels of orthopedic patients undergoing surgery
0
2
4
6
8
10
12
14
16
1 2 3
Nu
mb
er
of
pati
en
ts
ASA level
Predisposing risk factors
0 10 20 30 40 50 60 70 80 90 100
Age > 65
Gender (male)
Dementia
Depression
Bipolar
Anxiety
Stress
Aggression
Hypertension
GERD
Hyperlipidemia
Hypothyroidism
Arthritis
Gout
Headaches
Renal insufficiency
Nephrectomy
Anemia
BMI > 30 kg/m^2
Myocardial infarction
Cerebral Vascular Accident (Stroke)
Peripheral Vascular Disease
Pacemaker
Diabetes Mellitus
Brain tumour
Deep Vein Thrombosis
Obstructive sleep apnea
Visual impairment
Hearing impairment
Proportion of patients (%)
Pre
dis
po
sin
g f
acto
rs
Delirious patients
Control patients
All patients
Precipitating risk factors
0 20 40 60 80 100
Polypharmacy (>5 drugs)
General anaesthesia
Spinal anaesthesia
Infection
Sleep disturbances
Alcohol or drug withdrawal
Nutritional deficiencies
Electrolyte Imbalances
Hypotension or shock
Immobility
Nursing home
Language barrier
Physical restraints
Proportion of Patients (%)
Pre
cip
itati
ng
facto
rs Delirious
patients
Control patients
Drug therapy
0 20 40 60 80 100 120
Amitryptiline
Dilaudid
Dimenhydrinate
Fentanyl
Meperidine
Propofol
Stemetil
Proportion of patients treated (%)
Dru
g n
am
e
Delirious patients
Control patients
All patients
0
1
2
3
4
5
6
7
8
9
10
28-Jul 29-Jul 30-Jul 31-Jul
Pain
scale
(0
-10)
Date
Patient A
Patient B
Patient C
Patient D
Other patients
Spikes in pain management over 4 days
Mitigating Factors Enhancing Factors Reorienting patients Administration of delirium culprit
medications (e.g. meperidine, dimenhydrinate)
Alcohol withdrawal protocol initiated when needed
Inadequate pain management
Encouraging visits from family and friends
Movement of patients within wards/rooms
Checking for mood and psychosocial well-being of patients
Medical and nursing interventions during sleeping periods
Ensuring patient nutrition and adequate fluid intake
Use of physical restraint on patients
Keeping track of bowel movements
Early ambulation
Looking for and treating infections
Alarm call bell within reach
Factors affecting delirium development
•Substantial reduction in the use of Dimenhydrinate
•Redesign of nursing flowsheet to support CAM assessments
•Review of pain management practices
•Second study with 60 patients using the same methodology completed
What have we improved on?