Culture Change Needed to Combat ICU Delirium

Nancy A. Melville

March 27, 2014

LAS VEGAS — Patients who receive benzodiazepine, opioid, and/or other sedative infusions in the intensive care unit (ICU) are nearly 5 times more likely to transition to delirium during their stay than those who don't, new research shows.

This finding is "entirely consistent with our suspicions and findings from other delirium researchers," said investigator Karin Neufeld, MD, director of general hospital psychiatry at Johns Hopkins Hospital in Baltimore.

However, the high odds underscore the extent to which sedatives could be pushing patients toward delirium, she told Medscape Medical News.

What was surprising to the researchers was the lack of association between sleep quality and delirium.

"There is compelling literature suggesting that sleep deprivation can be a cause of delirium, so we expected that sleep quality would be related to delirium transition," said Dr. Neufeld.

In fact, the study presented here at Hospital Medicine 2014 was designed to analyze the role of sleep quality in ICU delirium.

All 131 patients evaluated had at least 1 night of sleep between 2 consecutive days of delirium assessment. In the medical ICU, 31 (24%) of these patients transitioned to delirium.

Patients rated their perception of sleep quality daily with the validated Richards-Campbell Sleep Questionnaire.

There were no significant differences in median ratings of perceived overnight sleep quality between those who did and those who did not transition to delirium (60 vs 57; P = .64).

The questionnaire itself could be an issue, noted Dr. Neufeld. It evaluates the way "the patient and the nurse thought the patient slept. This might have been why we did not see a relationship."

"The best way to measure sleep quality is with EEG monitoring all night long in the form of a polysomnograph," she explained. "Our ability to gauge our own sleep quality is not very good when you compare it with polysomnographic evidence of actual sleep wave morphology," she explained.

Of note, the patients who reported using sleep aids at home were less likely to transition to delirium when they were in the ICU (odds ratio, 0.21, 95% confidence interval, 0.06 - 0.74).

It is very interesting that "the self-reported use of sleep aids appears to be protective for delirium," said another study investigator, Timothy Niessen, MD, who is also from Johns Hopkins University.

He reported that some of the research team was involved in a previous study of ICU patients (Crit Care Med. 2013;41:800-809). It demonstrated that delirium can be reduced by improving the ICU environment, leading to a better quality of sleep.

However, we don't want people to conclude from the current findings "that sleep quality is not an important factor for delirium," he stressed.

ICU Culture Change Necessary

A look at the key factors associated with a transition to delirium underscores how important clinicians' decisions are in preventing delirium, Dr. Neufeld said.

But despite the strong evidence, taking measures to prevent in-hospital delirium is easier said than done.

 
There is an old notion that sedating patients is the kind thing to do.
 

"There is an old notion that sedating patients is the kind thing to do. It's a struggle for providers to learn to manage patients who are critically ill and awake and alert," said Dr. Neufeld.

She acknowledged that "change is happening," but emphasized that the culture needs to shift in each ICU and hospital ward.

"Important strategies for reducing delirium in the ICU, and in the hospital in general, include improving sleep environments, decreasing sedation as soon as possible, and getting patients up and mobilized as soon as possible — even if they are intubated and mechanically ventilated," Dr. Neufeld said.

By keeping very ill patients alert and awake, "we can improve their outcomes significantly; they die less often and get out of the ICU and the hospital more quickly," she explained.

Assertive efforts are necessary to bring about the changes needed to prevent delirium, said Malaz Boustani, MD, associate professor of medicine and adjunct associate professor in public health at Indiana University Health in Indianapolis.

"As in any human network, introducing change is a challenge that requires special skills in organizational psychology and behavioral change," he told Medscape Medical News.

"My main concerns about ICU care are over-reacting and the overuse of psychotropic medications," he added.

At Indiana University Health, "the focus is precisely on identifying innovative healthcare solutions and working on implementing such solutions in a rapid and scalable way," explained Dr. Boustani, who is chief of the office of innovation and implementation.

One of the key changes that office is implementing in all of the system's ICUs is the ABCDE bundle, which is designed to reduce oversedation, immobility, and the development of delirium.

With up to 80% of patients on mechanical ventilation developing delirium, such interventions are important, said Dr. Niessen.

"Delirium in the ICU is very common. If you don't actively look for it, you will miss it in 3 of 4 cases," he added.

Dr. Neufeld is president of the American Delirium Society. Dr. Neufeld, Dr. Niessen, and Dr. Boustani have disclosed no relevant financial relationships.

Hospital Medicine 2014. Presented March 25, 2014.

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