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Interventions help reduce delirium incidence in ICU

Thursday February 28, 2013
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A team of physicians, nurses, psychologists and pharmacists in the medical intensive care unit at The Johns Hopkins Hospital in Baltimore implemented a project to reduce delirium and improve patient perceptions about the quality of their sleep.

Biren Kamdar, MD, MBA, MHS, a Johns Hopkins pulmonary and critical care fellow who led the initiative, said the interventions improved "a patientís odds of being free of delirium in the ICU by 54%, even after taking into account the diagnosis, need for mechanical ventilation, age and other factors."

"Many patients said that the ICU was quiet and comfortable enough for them to get a good nightís sleep," Kamdar added in a news release.

Three sets of interventions were introduced in stages. The first was a 10-item environmental checklist that included turning off televisions, room and hallway lights and safely consolidating the number of staff visits to patient rooms overnight for drawing blood and giving medications. The goal was to reduce interruptions and overhead pages and minimize unnecessary equipment alarms.

In the second stage, patients also were offered eye masks, ear plugs and tranquil music. In the final stage, a medication guideline was introduced that discouraged giving patients certain commonly prescribed drugs for sleep, such as benzodiazepines, that are known to cause delirium.

Before the interventions had been instituted, the researchers did a baseline assessment of 122 patients in the ICU over an eight-week period. After the measures were in place, another 178 patients were evaluated.

Kamdar said each patient was evaluated twice a day for delirium with a widely-used screening tool, the Confusion Assessment Method for the ICU. "After 13 weeks during which all of the interventions had been in place, we saw a substantial reduction in patient delirium compared to the baseline group."

The researchers also measured perception of sleep quality with a questionnaire given to each patient by MICU nurses every morning. Although there were positive findings in that measure, the improvement overall was not statistically significant.

"This is a unique study in terms of the number of patients involved and the three stages of interventions," Dale M. Needham, MD, PhD, the studyís senior author and an associate professor of pulmonary and critical care medicine at Johns Hopkins, said in the news release.

"Delirium is a syndrome of confused thinking and lack of attention. It typically comes on quickly with illness, and itís a marker for the health of the brain. We put together a common-sense approach to change how care is provided to see if by improving sleep, we could reduce patientsí confused thinking, and it was effective."

Needham also noted that physical rehabilitation is important for the recovery of ICU patients, and if they are sleepy or delirious during the day, they cannot appropriately participate in their therapy.

Up to 80% of ICU patients might experience delirium during their stay, Needham said. "The longer they have it, the higher their risk of long-lasting problems with memory and other cognitive functions. With advances in medicine and technology, many ICU patients can now recover and go home, so reducing their risk of delirium in the hospital is very important."

The study will appear in the March issue of the journal Critical Care Medicine. The study abstract is available at http://bit.ly/134wQ61.


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