The American Delirium Society (ADS) invites you to attend its 8th Annual Meeting. The Conference Planning Committee endeavored to identify a stellar panel of internationally-recognized, multidisciplinary experts to advance your knowledge regarding the recognition, prevention and treatment of delirium across the entire lifespan and in all practice settings. At this meeting, scientific investigators from more than 10 countries will be presenting cutting-edge research in 30 podium presentations and in a large poster session.

Also consider attending the pre-conference session on Sunday June 10th to learn from top experts in the field on how to optimize your practice.

Enjoy San Francisco (a top travel destination), interact with colleagues from around the world, and gain valuable knowledge and skills to effect change when you return home.

“Late-Breaking Research” Poster Abstract Proposal Invitation

For each submission, please visit the online submission portal via the link below and complete the form.

May 14, 2018 (10pm PST): Deadline for late-breaking research poster presentation abstracts

idelirium #WDAD2018

On March 14th, the iDelirium Consortium held its 2nd Annual World Delirium Awareness Social Media Campaign. The goal was to raise awareness and inspire action among healthcare workers and the community to prevent, detect, and care for people with delirium.

In our inaugural year (2017) we were very pleased to have engaged over 7 million people. This year, we set a lofty goal of tripling our previous reach.

To achieve this, we introduced two new elements. The “best meme” competition and two live Tweetchats that were co-led by Heidi Lindroth (USA) and Alishya Burrell (Canada).

Using Brackify.com, we opened up the voting for the best delirium meme to the international audience. This year’s competition was filled with incredibly creative content. We are pleased to announce the winner of the #WDAD2018 #bestmeme content is Christopher Gabor (@DeliriumCare; Canada).

So did we reach our goal?

We…. came very close. Tracking tweets throughout the course of the week, we reached over 20 million people via Twitter alone.

We had tremendous activity that was significantly augmented by the live tweetchats held in Australia and in Europe.

This year, the Twitter Cup Award went to Roberta Castro (Brazil) for the absolutely tremendous effort undertaken before and during #WDAD2018.

The Twitter Cup will be formally presented to Roberta by Jim Rudolph and Alasdair McLullich at the #ADS2018 in San Francisco this June.

Practical Use of the AWOL Delirium RIsk Score

Vanja Douglas, MD, University of California, San Francisco School of Medicine

Multicomponent non-pharmacologic delirium prevention is recommended in several guidelines. However, identifying which hospitalized patients are most likely to benefit from these interventions remains an area of uncertainty. One approach is to apply multicomponent interventions to all elderly hospitalized patients. Another approach is to use a screening tool that incorporates other delirium risk factors like cognitive impairment and illness severity to identify those at highest risk.

The AWOL delirium risk prediction rule was presented at the 2017 ADS meeting. The AWOL score calculates risk based on a patient’s age, ability to correctly spell “world” backward, orientation to state, county, city, hospital, and floor, and illness severity estimated by the admitting nurse.

Bedside nurses calculate an AWOL score for every patient within 24 hours of admission and screen for active delirium every 12 hours with the nursing delirium screening scale (NuDESC). Multicomponent non-pharmacologic interventions are applied to patients identified by the AWOL as high-risk and those identified as delirious by the NuDESC. Both the AWOL and the NuDESC are easy for nurses to learn and require very little time to administer and to chart.

Among patients who were not delirious at the time of admission, 6.5% developed delirium later during their hospitalization. For patients with an AWOL score of 2-4, the risk of developing delirium was 25% (positive predictive value), compared to 3.0% for those with a score of 0-1 (negative predictive value 97%); p<0.001 with Fisher’s exact test. The AWOL correctly classified 17 of the 28 patients (61% sensitivity) who developed delirium in the cohort. Specificity was 87%.

Compared to methods which categorize all patients over the age of 65 as having high delirium risk, the AWOL score identifies some high-risk patients who are younger than 65, and also identifies patients over age 65 with good cognitive function and mild illness who are at low risk for delirium. This approach may allow better allocation of delirium prevention resources than a simple age-based strategy.

Delirium: prevention, diagnosis, and management. In: NICE Guideline. National Institute for Health Care and Excellence; 2010.

Douglas VC, Hessler CS, Dhaliwal G, Betjemann JP, Fukuda KA, Alameddine LR, Lucatorto R, Johnston SC, Josephson SA: The AWOL tool: derivation and validation of a delirium prediction rule. J Hosp Med 2013, 8(9):493-499.

Managing Complexity: An Interprofessional Approach to Delirium in a Complex Critical Care Environment

Elizabeth Udeh Pharm.D., BCPS, Hartford Hospital, Hartford, Connecticut

Delirium prevention strategies are simple. However implementation, bedside application, and sustainability present complexity for many institutions, especially large institutions with Complex Critical Care Environments. Lack of ownership (dedicated practitioners with vested interest) to oversee standardization, continuous quality improvement and expansion as new strategies become available are primary reasons.

Through the cohesive efforts of an interprofessional committee established at an 850 bed, level 1, acute care hospital, delirium prevention strategies were standardized and optimized in a complex, multi-specialty ICU environment. The team ensures that all ICUs are represented and representation is maintained by addressing turnover.

• Delirium prevention strategies were standardized and expanded to all five adult ICUs.
• Methods for proactive dissemination of new and pertinent delirium information were implemented.
• Continuous quality assessments of initiatives were fine-tuned and sustained.
• Timely progress was shared and ongoing feedback was provided to practitioners.
• Consistent provider education was implemented to enhance awareness.
• Delirium risk assessment was initiated by providers as part of daily assessment.
• Enthusiasm about preventing delirium increased with 10 new IRB approved ICU delirium research projects in progress.
• Family engagement, ICU journals, noise reduction, and a bedside person-centered reference tool are all in progress.

Many professional are joining the team of gatekeepers to combat delirium and “Save A Brain”.

Hartford Hospital ICU delirium/sedation subcommittee. Content developed with Christine Waszynski DNP, RN, GNP-C

Changing the Culture of Delirium Care

Kimberly Jones, MSN, RN, CNL, VHA-CM, VA Healthcare System, Gainesville, Fl

With the ever-increasing complexity of inpatient medical/surgical care, short hospital stays and other facility needs, a multi-pronged approach to delirium is required to successfully translate evidence based care into everyday practice.

We took several steps to achieve our goal of changing the culture of delirium care. By improving the bedside nurses’ knowledge of delirium, providing access to consultative experts, and designing evidenced based decision-making tools we successfully elevated the science of delirium management to an art that flows efficiently.

Education equals empowerment and ownership, which was then strengthened by evidence based decision tools that are easy to use and incorporate into busy clinical practice. We also provided access to consultative experts who reinforce key concepts and offer insight into management of challenging cases.

In developing this approach, we have created a circle of sustainability: education of frontline nurses and clinical staff, empowerment to implement non-pharmacologic and other interventions, and interaction with content experts.

Education

• Educate nurses at every level
• Nonpharmacologic interventions speak to the core of nursing practice
• An educational module with multi-media components lends well to adult learners: Online, video and interactive modules, Simulated experience of dementia facilitates understanding and creates empathy

Clinical

• Embedded mandatory screening tool into nursing admission and daily assessment; positive screen triggers consult
• Inter-professional experts comprise our consultative delirium team
• Evidenced-based delirium order set allows for implementation in “waves” by multiple professionals (e.g., nursing, physician)

Leadership

• Support from the C-suite
• Joint Commission site visit: delirium team model is a “best practice” to emulate
• Aligns with Top 10 Patient Safety Concerns for Health Care Organizations 2017 (ERCI Institute)

Contributors: Colleen Campbell, DNP, Stephen Welch, MD, Uma Suryadevara, MD, Laurence Solberg, MD, Carmen Fernandez, PsyD, Michelle Rossi, MD

The impact of an educational intervention on housestaff knowledge regarding delirium and its association with patient care outcomes

Joel Wilken DO, Vanessa Gorospe MD, Christine Waszynski DNP RN, Robert Dicks MD, Jeffery Mather MS, Hartford Hospital, Hartford, CT

Knowledge Base of Housestaff (Medical Residents):

Knowledge base improved after a formal education session. Pre test and post test scores helped to show this improvement.

Two questions that showed the largest improvement:

1) The definition of CAM - Confusion Assessment Method. A tool that helps to identify patients with delirium.

2) The narcotic pain medication which has the most significant potential to cause delirium.

Patient Care Outcomes:

No statistically significant differences were noted between the non housestaff (private patients) and housestaff (medical residents with teaching attending) teams with regards to certain patient care outcomes.

Conclusion

1) It is important to prevent delirium from starting in the first place.

2) It is difficult to manage once a patient is found to have delirium

3) Even with an improved amount of knowledge - certain patient factors are difficult to modify and improve once a patient develops delirium

Inouye, S.K., Vandyke, C.H., Alessi, C.A., Balkin, S., Siegal, A.P., & Horowitz, R.I. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113, 941-948.

Meet an ADS Member

Dr. O'Regan completed her PhD through University College Cork in 2016, focusing on the identification of early indicators of delirium in older medical inpatients, as well as the motor subtyping of full-syndromal and sub-syndromal delirium presentations. As part of this and previous work, she has studied the diagnostic accuracy of the Months of the Year Backwards (MOTYB) as a delirium screening test. Additionally, prior to her move to Canada, she was involved in the development of a nationwide algorithm for delirium screening in hospital inpatients in Ireland.

Throughout her work, she has been struck by the challenges in translating evidence to practice, particularly relating to routine daily delirium screening in acute settings. This led her to her current area of research which is to explore the implementation feasibility of routine daily delirium screening when conducted by front-line staff. Most studies of delirium screening tests have been conducted with research personnel performing the assessments, and very few studies have examined the utility of tests when performed repeatedly. Both of these issues contribute to the knowledge translation gap when trying to implement research findings clinically.

For a delirium screening test to be feasible for use clinically, it must be simple, short, reliable, accurate, and acceptable to the staff members using it and to the patients being assessed. With this in mind, Niamh hypothesizes that a short screening algorithm using both MOTYB and RADAR (Recognizing Acute Delirium As part of your Routine, a nursing observational scale developed by Professor Philippe Voyer and colleagues in Université Laval, Montreal) may be an effective delirium screening method. The RADAR tool is extremely brief, requiring observation only for drowsiness, inattention and hypoactivity by nurses trained in its use. It appears very user-friendly, having been rated very favorably by staff during validation studies, and takes only a matter of seconds to complete, however sensitivity was only 73% (Voyer et al, 2015). There are ongoing studies of its use in different clinical settings. By adding MOTYB to the algorithm, Niamh hypothesizes that sensitivity could be increased.

This algorithm has been piloted as a ‘cognitive vital sign’ on the Acute Care of the Elderly (ACE) Unit in Victoria Hospital, London, Ontario in the past two months. Each ACE unit staff nurse was trained (in small groups of 1-4 participants) using a 30-minute training package (part of which was the original RADAR training package). Inter-rater reliability is currently above 90%. The study of feasibility is now underway - measuring the duration of the algorithm and its component parts; adherence and completion rates; refusal and withdrawal rates; diagnostic accuracy (measured against expert clinical assessment based on DSM-5 criteria); and nurse, patient and caregiver satisfaction. Niamh hopes that this study will help us better understand the elements of daily screening that are achievable in the busy acute setting and whether diagnostic accuracy is maintained with repeated testing.

Clinical assessment and management of delirium in the palliative care setting

In the last hours to weeks of life, almost 90% of patients develop delirium. Therefore it is incumbent on health care providers to improve our management of this distressing syndrome. Recent research in palliative care is leading to changes in clinical practice with a more judicious use of antipsychotics, and optimization of non-pharmacological interventions.

Our team on a 31-bed inpatient palliative care unit (PCU) recently implemented a delirium clinical practice guideline (CPG) for all members of the interprofessional team to improve care for both patients and their families.

This invited comprehensive review by 2 experienced palliative care physicians and PCU pharmacist was informed by a systematic literature search and complements the content of the CPG. Sections covered in the review include: Screening and diagnosis; Decision-making in the management approach; Management of potentially reversible precipitants; Non-pharmacological and pharmacological management; Palliative sedation; Education and support. Figures are used for an algorithm for delirium assessment and management, and haloperidol metabolism. A supplementary appendix provides more detail regarding medications that are used for the management of delirium symptoms in palliative care patients.

Bush SH, Tierney S, Lawlor PG. Clinical assessment and management of delirium in the palliative care setting. Drugs 2017 Oct;77(55):1623-1643. doi: 10.1007/s40265-017-0804-3. https://www.ncbi.nlm.nih.gov/pubmed/28864877

ADS @ AAGP

ADS board members (Babar Khan, Noll Campbell) and ADS research committee member (Sophia Wang) presented a symposium on aging and post intensive care syndrome at the American Association of Geriatric Psychiatry meeting held in Honolulu, HI last month.

Ways to Get Involved

ADS is seeking electronic educational materials for patients and families or health care professionals.

Submit materials, along with author/creator information and any required permissions to: info@americandeliriumsociety.org.

ADS is seeking volunteers for:

• Member Services- creating member communities to get more from your membership.

• Education- develop and review delirium educational materials for dissemination.

Contact: info@americandeliriumsociety.org