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.
 

[Click here to toggle visibility of the answers]

College answer

  1. Elements of QI project are:

    1. Identify local motivation, support and change champions and establish a multi-disciplinary team

    Review evidence for strategies and interventions to minimise delirium

    Environment:

    • 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.

    Unit practices:

    • 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

    1. Prioritise interventions and implement with staff education and training as needed

    2. Evaluate outcomes

      • 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.

Discussion

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

  • Key stakeholders form a multidisciplinary working party .
  • A multidisciplinary approach is called for which involves consumers
  • The working part appoints a Team Leader (or, one if appointed from the top down)
  • Timeframes are identified, as to how long it should take to create the policy, and the mandatory review period (for the next time this policy needs to be updated)
  • A schedule of meetings is drawn up, with key dates for completion of policy drafts and other important time intervals in the process.

Perform research to answer the question, "how to decrease the incidence of delirium in our unit"

  • Evidence selection criteria are developed
  • A literature search is performed with the abovementioned criteria. If possible, a systematic literature review should be undertaken.
  • The evidence is reviewed and critically appraised
  • Data relevant to the guideline is extracted and presented for the working party to assess
  • The working part develops a series of recommendations according the the presented data
  • Other similar policies and guidelines from other institutions are explored and useful material is borrowed or adapted
  • A cost analysis is performed and the cost of the new policy is compared to that of existing practice
  • Possible barriers to implementation  are considered
  • A draft of the guideline is generated

Interventions which could form a part of this review would include:

  • Anaesthesia guidelines for booked post-op ICU admissions
  • Routine nursing interventions:
    • Early mobilisation
    • Screening for bowel and bladder dysfunction
    • Sleep enhancement strategies (eg. "lights out" time)
    • Therapeutic cognitive activities and orientation
    • Vision and hearing protocols
  • Routine medical interventions
    • Geriatric consultation
    • Medication revoew
    • Analgesia protocols
  • Environmental changes
  • Visitor policy
  • Mobility policy
  • Education for staff
  • Education for families
  • Delirium screening

    (this is all from Reston & Schoells (2013), who summarised the elements of successful delirium prevention programs)

Recursive improvement

  • The draft is widely circulated
  • Key personnel outside the working panel are nominated to critique the draft
  • Consideration is given to suggestions and commends on the draft, and by recursive improvement a final draft is created which is approved by all key stakeholders.
  • The final draft is then framed in a pre-defined publication format for thematic consistency with other existing guidelines
  • The final product is submitted for approval by the department manager.

Implementation

  • Roll-out occurs on a previously specified date, of which all key audiences are made aware well in advance.
  • The final policy is then widely circulated. Alternatively, the guidelines may be piloted in pre-specified locations or scenarios before wirder circulation.
  • Internal and external education sessions are held to update staff on the new practice
  • Guideline documents are made accessible
  • Contact is made with educators, to act as ‘champions’  to promote the guideline
  • Experts are made available for contact and questions

Audit and quality assurance

  • Repeated data analysis and collection should be carried out after the guidelines are disseminated and implemented.
  • Guideline dissemination efficacy, uptake and adherence by practitioners, consumer satisfaction and health outcomes are possible data to be collected for audit.
  • Auditors are nominated from departments to implement this policy monitoring processes
  • The auditing team creates short-term and long-term frameworks for evaluation and identifies who will conduct the studies.
  • Regular meetings are scheduled by the auditors to monitor compliance and to feed back on the implementation process

Revision

  • A multidisciplinary group not unlike the one which developed the guidelines should meet regularly to determine whether new evidence needs to be incorporated.
  • The group should review research strategies of the original group, and improve on the process where possible
  • Outcomes and recommendations arising from audit activity should be incorporated into the revision process

References

References

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.