Preventing Delirium During Covid-19 with Evidence-Based Tools

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.

References

  1. Vasilevskis EE, Chandrasekhar R, Holtze CH, Graves J, Speroff T, Girard TD, Patel MB, Hughes CG, Cao A, Pandharipande PP, Ely EW. The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient. Med Care 2018; 56: 890-897.
  2. 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.
  3. Jeon K, Jeong BH, Ko MG, Nam J, Yoo H, Chung CR, Suh GY. Impact of delirium on weaning from mechanical ventilation in medical patients. Respirology 2016; 21: 313-320.
  4. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr., Inouye SK, Bernard GR, Dittus RS. Caring for the critically ill patient. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA: Journal of the American Medical Association 2004; 291: 1753-1762.
  5. Sharda N, Mattoon E, Matters L, Prewitt J, McDonald S, Sloane R, Cassas C, White H. Bach to the Basics: Implementation and Impact of a Postoperative, Inpatient Personalized Music Program for Older Adults. Journal of PeriAnesthesia Nursing 2019; 34: 347-353.
  6. Khan SH, Xu C, Purpura R, Durrani S, Lindroth H, Wang S, Gao S, Heiderscheit A, Chlan L, Boustani M, Khan BA. Decreasing Delirium Through Music: A Randomized Pilot Trial. American journal of critical care : an official publication, American Association of Critical-Care Nurses 2020; 29: e31-e38.
  7. Khan SH, Kitsis M, Golovyan D, Wang S, Chlan LL, Boustani M, Khan BA. Effects of music intervention on inflammatory markers in critically ill and post-operative patients: A systematic review of the literature. Heart & lung : the journal of critical care 2018; 47: 489-496.
  8. Chlan LL, Weinert CR, Heiderscheit A, Tracy MF, Skaar DJ, Guttormson JL, Savik K. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial. Jama 2013; 309: 2335-2344.
  9. Stamenkovic DM, Rancic NK, Latas MB, Neskovic V, Rondovic GM, Wu JD, Cattano D. Preoperative anxiety and implications on postoperative recovery: what can we do to change our history. Minerva anestesiologica 2018; 84: 1307-1317.
  10. Ames N, Shuford R, Yang L, Moriyama B, Frey M, Wilson F, Sundaramurthi T, Gori D, Mannes A, Ranucci A, Koziol D, Wallen GR. Music Listening Among Postoperative Patients in the Intensive Care Unit: A Randomized Controlled Trial with Mixed-Methods Analysis. Integrative medicine insights 2017; 12: 1178633717716455.
  11. Rivosecchi RM, Kane-Gill SL, Svec S, Campbell S, Smithburger PL. The implementation of a nonpharmacologic protocol to prevent intensive care delirium. J Crit Care 2016; 31: 206-211.
  12. Litton E, Carnegie V, Elliott R, Webb SAR. The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis. Critical care medicine 2016.
  13. Program HEL. Hospital Elder Life Program (HELP) for Prevention of Delirium. The Hospital Elder Life Program; 2018.
  14. Hshieh TT, Inouye SK, Oh ES. Delirium in the Elderly. The Psychiatric clinics of North America 2018; 41: 1-17.
  15. Hare M, Wynaden D, McGowan S, Landsborough I, Speed G. A questionnaire to determine nurses’ knowledge of delirium and its risk factors. Contemporary Nurse 2008; 29: 23-31.
  16. Wang YY, Yue JR, Xie DM, Carter P, Li QL, Gartaganis SL, Chen J, Inouye SK. Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial. JAMA internal medicine 2019.
  17. Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, Inouye SK. Effectiveness of Multicomponent Nonpharmacological Delirium Interventions: A Meta-analysis. JAMA internal medicine; 2015.
  18. Inouye SK, Bogardus ST, Jr., Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM, Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal Of Medicine 1999; 340: 669-676.
  19. Munro CL, Cairns P, Ji M, Calero K, Anderson WM, Liang Z. Delirium prevention in critically ill adults through an automated reorientation intervention – A pilot randomized controlled trial. Heart & lung : the journal of critical care 2017; 46: 234-238.
  20. Stollings JL, Devlin JW, Lin JC, Pun BT, Byrum D, Barr J. Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle. Crit Care Med 2019.
  21. Balas MC, Pun BT, Pasero C, Engel HJ, Perme C, Esbrook CL, Kelly T, Hargett KD, Posa PJ, Barr J, Devlin JW, Morse A, Barnes-Daly MA, Puntillo KA, Aldrich JM, Schweickert WD, Harmon L, Byrum DG, Carson SS, Ely EW, Stollings JL. Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience. Crit Care Nurse 2019; 39: 46-60.
  22. Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, Byrum D, Carson SS, Devlin JW, Engel HJ, Esbrook CL, Hargett KD, Harmon L, Hielsberg C, Jackson JC, Kelly TL, Kumar V, Millner L, Morse A, Perme CS, Posa PJ, Puntillo KA, Schweickert WD, Stollings JL, Tan A, D’Agostino McGowan L, Ely EW. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Crit Care Med 2019; 47: 3-14.
  23. Stollings JL, Devlin JW, Pun BT, Puntillo KA, Kelly T, Hargett KD, Morse A, Esbrook CL, Engel HJ, Perme C, Barnes-Daly MA, Posa PJ, Aldrich JM, Barr J, Carson SS, Schweickert WD, Byrum DG, Harmon L, Ely EW, Balas MC. Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative. Crit Care Nurse 2019; 39: 36-45.
  24. Barnes-Daly MA, Pun BT, Harmon LA, Byrum DG, Kumar VK, Devlin JW, Stollings JL, Puntillo KA, Engel HJ, Posa PJ, Barr J, Schweickert WD, Esbrook CL, Hargett KD, Carson SS, Aldrich JM, Ely EW, Balas MC. Improving Health Care for Critically Ill Patients Using an Evidence-Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation. Worldviews Evid Based Nurs 2018; 15: 206-216.
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