Contributed by Heidi Lindroth, RN, PhD, T32 Postdoctoral Fellow, Indiana University School of Medicine, Division of Pulmonary and Critical Care Medicine.
Covid-19 has substantially changed the environment for patient care due to dramatically increasing patient volumes, personal protective equipment (PPE) shortages, stringent isolation and infection control activities, and severe restrictions on visitors and contact between patients, providers, and families. The extreme physical and emotional isolation, added to the severity of Covid-19 infections among hospitalized patients, puts nearly all potential risks for delirium into play.
Even when we need every bed the most, prevention of delirium should also be our goal with Covid-19 patients. Critically ill patients with delirium have an increased number of days on the ventilator compared to those without delirium (1-4), and as such, delirium prevention may be part of our ventilator stewardship programs. If we can reduce the incidence of delirium, we reduce the future prevalence of Post-Intensive Care Syndrome, and potentially improve post-acute resource needs.
Every day we prevent delirium makes a difference.
In the Covid-19 era, simple, evidence-based tools such as the following can be adapted for use in any setting:
- Music can be played from a portable computer workstation, and YouTube pairs nature scenes or colorful paintings with classical music. This reduces delirium and anxiety as well as pain (5-11).
- Earplugs at night reduce delirium by improving sleep. A meta-analysis showed a reduction in delirium with an overall relative risk ratio of 0.59 (95%CI: 0.44, 0.48)(12).
- Connection with family can be maintained, even with visiting restrictions. Video conference calls (like Zoom or Google Hangouts) can help maintain social support and family connection, or, provide reorientation and encouragement to do exercises to maintain strength and work towards early mobility.
- Reorientation and reassurance reduce delirium. Pre-recorded messages can be made by family or volunteers. This idea is based on a pilot randomized control trial completed by Dr. Cindy Munro et al. (2017). Family can be encouraged to make these recordings and personalize them for the patient (19).
The ABCDEF bundle is specific to the ICU setting. While the complete bundle may be challenging to implement, completing portions of the bundle also reduce delirium. As more components are implemented, less delirium results! In a study of 15,000+ patients, complete bundle performance resulted in an adjusted odds ratio of delirium (AOR 0.60, CI: 0.49, 0.72) and next-day mechanical ventilation (AOR 0.28, CI: 0.22-0.36). These outcomes are dose-dependent (p<.002); the more components completed, the larger the decrease in delirium and next-day mechanical ventilation (20-24).
Consider these actions with hospitalized patients:
- Assess, prevent and manage pain.
- Do spontaneous awakening and breathing trials to minimize sedation and ventilator days.
- Review the choice of analgesics and sedatives. Are there other drugs that may work better for this specific patient?
- Assess and monitor delirium. Are the interventions reducing delirium? If not, want else can be done?
- Mobilize the patient. Complete passive or active range of motion in bed if mobilizing to chair or ambulation is not possible. Mobilization is especially challenging during COVID-19 yet is critical to reduce delirium, ICU-acquired weakness, and ventilator days.
- Connect the patient with their family through video conferencing, FaceTime, or recorded messages when possible.
As you’re rapidly innovating and adapting evidence-based solutions to prevent and reduce delirium, see the following resources for guidance.
The HELP Program has created a COVID-19 delirium prevention toolkit offering proven effective solutions to prevent delirium in non-ICU patients(13-18). Check it out & download here: https://www.hospitalelderlifeprogram.org/for-clinicians/covid19-resources
The website www.icudelirium.org has a wealth of resources specific to ICU-delirium and the ABCDEF bundle.
While COVID-19 is creating a number of barriers for optimal care delivery, it is more important than ever to help patients recover faster by using proven tools and strategies to mitigate harm and prevent longer lengths of stay, increased ventilator days, or post-traumatic stress disorder.
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- Yamamoto T, Mizobata Y, Kawazoe Y, Miyamoto K, Ohta Y, Morimoto T, Yamamura H. Incidence, risk factors, and outcomes for sepsis-associated delirium in patients with mechanical ventilation: A sub-analysis of a multicenter randomized controlled trial. J Crit Care 2020; 56: 140-144.
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