The findings of your departmental mortality and morbidity meeting suggest that delirium is an increasing problem in the patient population in your ICU.
Describe how you would design a quality improvement (QI) project to minimise delirium in your unit, including in your answer a list of potential strategies and interventions.
Elements of QI project are:
Identify local motivation, support and change champions and establish a multi-disciplinary team
Review evidence for strategies and interventions to minimise delirium
Excessive noise and insufficient light associated with delirium
Ideal design allows patient exposure to daylight, space to facilitate early mobilisation, space for family and visitors to be involved in care. Access to outdoor spaces for long stay patients.
Monitoring equipment quiet, audible alarms adjusted to accepted physiologic parameters.
Use of valid screening tool for delirium e.g. Confusion Assessment Method for the ICU (CAM-ICU)
Sedation – minimise sedation, titrated to sedation target e.g. Richmond Agitation and Sedation Score. Avoidance of benzodiazepines.
Early mobilisation – physical environment, equipment, allied health staff
Cues for orientation – easy to read clocks, whiteboards or similar with day plan
Day/ night maintenance - low lights and quiet overnight, promotion of sleep, minimising interventions at night, grouping cares
Staff awareness and education – identification of high-risk patients, routine monitoring for delirium, seek staff input to quality initiative
Family involvement in care
Prioritise interventions and implement with staff education and training as needed
Ongoing monitoring and data collection
Benchmarking with previous results and other comparable units
An acceptable answer addressed a breadth of initiatives including departmental design, processes and individual patient care. Details of treatment and management of delirium not relevant to the question.
Your ICU is in the grip of an epidemic of delirium. Confused patients are smearing faeces on the all the walls. How will you manage this bedlam? Obviously, by identifying change champions and establishing a multi-disciplinary team. It is clear that the objectives of this SAQ were to determine whether the exam candidate is familiar with the appropriate administrative buzzwords. Actual management of delirium is discussed elsewhere.
In summary, "departmental design" of this intitiative should follow the following process outline, where the appropriate mark-scoring corporatespeak is italicised.
Compose the guidelines panel
Perform research to answer the question, "how to decrease the incidence of delirium in our unit"
Interventions which could form a part of this review would include:
Audit and quality assurance
Moulding, Nicole Therese, C. A. Silagy, and D. P. Weller. "A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines." Quality in Health Care 8.3 (1999): 177-183.
Schünemann, Holger J., Atle Fretheim, and Andrew D. Oxman. "Improving the use of research evidence in guideline development: 1. Guidelines for guidelines." Health Research Policy and Systems 4.1 (2006): 1.
Silagy, C., et al. "A guide to the development, implementation and evaluation of clinical practice guidelines." National Health and Medical Research Council, Canberra, Commonwealth of Australia (1998): 1-79.
Reston, James T., and Karen M. Schoelles. "In-facility delirium prevention programs as a patient safety strategy: a systematic review." Annals of internal medicine 158.5_Part_2 (2013): 375-380.