A quality improvement project to improve the identification and management of delirium

Abstract

Efforts to reduce delirium burden through screening, identification, and prevention is considered one of the major public health priorities of the last decade. In 2017, an audit of delirium screening in our unit revealed suboptimum assessment of our patients, with compliance with the Confusion Assessment Method for the ICU (CAM-ICU) assessments highly variable and ad hoc, and sometimes not at all. A separate sedation audit also revealed that our sedation practices did not align with current critical care guidelines emphasizing light sedation strategies. The aim of this project was to develop resources to educate the unit on delirium, improve the management of sedation with a sedation algorithm, formalize the elements of delirium prevention and care into a delirium pathway, and improve the compliance with delirium screening. We developed a delirium clinical pathway and sedation algorithm, a delirium resource book, and an online educational module on the district health board (DHB) intranet. We provided extensive teaching of all these resources over delirium month. We used pre- and post-auditing of sedation practices and delirium screening compliance to inform the success of this project. Of the 140 members of staff, 85% (n=120) received delirium education. In 2018/2019, 84% of 145 patient charts reached the unit standard of four to six hourly CAM-ICU assessments compared with 45% in 2017. The sedation audit revealed a slight improvement in the trend towards lighter sedation, with Richmond Agitation Sedation Scoring (RASS) scores reflecting light sedation, increasing from a mean of 31% in 2017 to 41% in 2019 from 41 patient charts. This project provides a useful framework to enable future quality improvement work around delirium and sedation management. The clinical pathway and sedation algorithm have been a useful tool to introduce to the unit as a way of formalizing the elements of delirium care and assessment.