Delirium on the intensive care unit (ICU) is associated with increased mortality, hospital length of stay and cognitive impairment after hospital discharge1. Published guidelines recommend regular screening for delirium2. Furthermore, delirium screening, monitoring and management is within the top 3 research priorities of importance to patients, carers and health professionals3. This audit aimed to investigate the prevalence of delirium and compliance with delirium screening in a mixed medical and surgical ICU.
Retrospective and prospective audit during a 1-week period from 5/9/16 to 9/9/16 (inclusive) where every patient was assessed for delirium by use of the Confusion Assessment Method-ICU (CAM-ICU) screening tool. The retrospective analysis was done by checking observation charts, nursing notes and medical notes over the past 24 hours, to investigate whether or not patients had a recorded CAM-ICU score. Prospectively, a separate CAM- ICU score was determined by the audit team in those who were appropriate for testing at the time of assessment (as defined by a Richmond Agitation- Sedation Scale (RASS) score ≥ -3).
In the retrospective analysis of 52 paLents within the previous 24 hours, 23 (44%) did not have CAM-ICU scores documented. One of these patients was not suitable to be assessed (with RASS score -4 to -5). The prevalence of delirium (as defined by CAM-ICU) in those screened was 10% (3/29 CAM- ICU positive). During prospective analysis by the audit team, 8 patients (15%) were unsuitable for CAM-ICU testing as over-sedated (RASS -4 or -5). Out of the remaining 44 patients, 7 were CAM-ICU positive, with a prevalence of 16% in those tested. There was no delirium management pathway to follow for those who were CAM-ICU positive.
Delirium screening is inconsistent in this cohort, which in part may be due to over-sedation at certain time points. This makes the true incidence of delirium within this ICU difficult to determine. It is recommended that patients are screened at the time of any sedation hold and at regular intervals (in keeping with the fluctuant nature of this condition). A delirium management pathway based on published guidelines (figure) combined with appropriate staff training is suggested, which may aid the management in those who are positively identified.
1.Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluiji A, Serafim RB, Stevens RD. Outcome of delirium in critically ill patients: a systematic review and meta-analysis. BMJ 2015;350:h2538 doi: 10.1136/bmj.h2538 2.Barr J, Fraser GL, Puntillo K, Ely EW et al. Clinical pracLce guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Critical care Medicine 2013; 41(1):263-306