Validation of a multidisciplinary care protocol for critically ill patients with delirium

Souza, Thieli Lemos de; Azzolin, Karina de Oliveira; Souza, Emiliane Nogueira de

doi:10.1590/1983-1447.2020.20190165

Thieli Lemos de Souza

Hospital Nossa Senhora da Conceição (HNSC), Porto Alegre, Rio Grande do Sul, Brasil.

https://orcid.org/0000-0003-1428-1088

Karina de Oliveira Azzolin

Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil.

https://orcid.org/0000-0002-2363-2858

Emiliane Nogueira de Souza

Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Pós-Graduação em Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil.

https://orcid.org/0000-0002-3873-4304

Corresponding author:
Thieli Lemos de Souza E-mail: thielils@gmail.com

Associate editor:

Wiliam Wegner

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Tables (5)
Formulas (1)

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Table 1
Diagnosis, pain management, sedation pause and medications. Protocol Multiprofessional care for critically ill patients with delirium

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Table 2
Cognitive orientation. Multiprofessional care protocol for critically ill patients with delirium

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Table 3
Sleep Promotion. Multiprofessional care protocol for critically ill patients with delirium

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Table 4
Environment and family. Multiprofessional care protocol for critically ill patients with delirium

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Care of the Multiprofessional Protocol for Patients with Delirium in the ICU Diagnosis, pain management, sedation pause and medications Awaken the patient daily (sedation pause: 6:30 am or 7:30 am). Awaken the patient and perform ventilation test. Assess delirium with CAM-ICU. Perform early mobilization. Assess pain with validated scales. Administer non-opioid analgesics. Ensure analgesia before interventions. Limit the use of medications associated with delirium. Choose sedations that are not a risk factor for delirium. administrate haloperidol. Cognitive Orientation Encourage the team to practice verbal / written orientations whenever possible. Call the patient by name when starting an interaction. Encourage the patient with predetermined questions, established in protocol. Inform the characteristics of the unit, visiting hours, meals and procedures. Explain any noise produced by infusion pumps, alarms and / or ventilator. Provide information to the patient about their health status, prognosis and treatments. Offer means of listening to music and television. From 6 am to 8 pm. Provide glasses and hearing aids for personal use as soon as possible. Sleep Promotion Assess patients for sleep maintenance (Sleep period: 00:00 to 4:00 or 22:00 to 4:00). Prevent the patient from sleeping during the day. Cluster care for uninterrupted sleep. During the night: bath until 10 pm. Avoid administering medication at night - reschedule. Do not interrupt sleep. Record vital signs provided by the central monitor during sleep. Provide ear plugs and / or eye mask for sleep. Individualize the alarm. Check the patient's preference for the sleeping environment. Inform the benefits of the sleep-wake cycle. Assess the risk for PU and the permanence without changing position during sleep. Interrupt the sleep period if the patient's clinical status changes / or if there is instabilities. Environment and Family Participation Orientate using clocks and calendars. Allow family members to bring items: magazines, books, etc. Reduce light at night. Orientate professionals - avoid talking by the bed. Control noise at night. Make family access more flexible. Promote care planning, facilitating family access. Perform rounds in visiting hours to offer orientations about delirium. Encourage family interaction with the patient. Develop educational materials. Remove devices early. Perform “box glove” mechanical restraint. Keep the bed rails high. Provide the patient with a means of calling professionals, eg, bell or light. Identify the bed of the patient who is in delirium, in order to maintain the care protocol.

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	Recommendation
Care	Nurse n(%)	Physical therapist n(%)	Physician n(%)	Others n(%)	CVI^*
Awaking the patient daily	18(94.7)	8(100)	9(90.0)	2(33.3)	0.97
Pausing sedation at 6:30 am	5(27.8)	5(62.5)	4(40.0)	2(50.0)
Pausing sedation at 7:30 am	13(72.2)	3(37.5)	6(60.0)	2(50.0)
Performing spontaneous ventilation tests	13(68.4)	6(75.0)	7(70.0)	1(16.7)	0.81
Awaking the patient and performing a ventilation test	15(78.9)	7(87.5)	9(90.0)	1(16.7)	0.91
Evaluating the delirium with CAM-ICU ^†	18(94.7)	7(87.5)	8(80)	4(66.7)	0.97
Performing early mobilization	19(100)	8(100)	10(100)	6(100)	1
Assessing pain with validated scales	17(89.5)	7(87.5)	10(100)	4(66.7)	0.97
Using opioids as the drug of choice to treat pain	9(50.0)	5(62.5)	7(70.0)	0(0.0)	0.75
Administrating non-opioid analgesics	18(100)	7(87.5)	9(90.0)	5(83.3)	1
Ensuring analgesia before interventions	19(100)	7(87.5)	10(100)	5(83.3)	1
Limiting the use of medications associated with delirium	18(94.7)	7(87.5)	9(90.0)	4(66.7)	1
Choosing sedations that are not a risk factor for delirium	19(100)	8(100)	8(80.0)	4(66.7)	1
Administrating haloperidol	9(50.0)	6(75.0)	10(100)	10(100)	0.93

	Recommendation
Care	Nurse n(%)	Physical therapist n(%)	Physician n(%)	Others n(%)	CVI^*
Encouraging the staff to practice verbal / written orientation whenever possible	19(100)	8(100)	10(100)	6(100)	1
Calling the patient by name when starting an interaction	19(100)	8(100)	10(100)	6(100)	1
Stimulating the patient with predetermined questions, established in the protocol	16(84.2)	6(75.0)	9(90.0)	5(83.3)	0.92
Informing the characteristics of the unit, visiting hours, meals and procedures	19(100)	8(100)	10(100)	6(100)	1
Explaining any noise produced by infusion pumps, alarms and / or ventilators	19(100)	8(100)	10(100)	5(83.3)	0.97
Providing information to the patient about their health status, prognosis and treatments	18(94.7)	7(87.5)	7(70)	6(100)	0.97
Offering means of listening to music and television from 6 a.m. to 8 p.m.	18(94.7)	8(100)	10(100)	5(83.3)	1
Providing glasses and hearing aids for personal use as soon as possible	19(100)	8(100)	10(100)	5(83.3)	1

	Recommendation
Care	Nurse n(%)	Physical therapist n(%)	Physician n(%)	Others n(%)	CVI^*
Assessing patients for sleep maintenance	19(100)	7(87.5)	10(100)	4(66.7)	0.97
a) Sleep period 12:00 a.m. to 4:00 a.m.	5(26.3)	2(25.0)	1(11.1)	0(0.0)
b) Sleep period 10:00 p.m. to 4:00 a.m.	14(73.7)	6(75.0)	8(88.8)	5(100)
Preventing the patient from sleeping during the day	18(94.7)	8(100)	8(80.0)	6(100)	1
Performing many care actions at once, aiding uninterrupted sleep. During the night: bath until 10 p.m.	18(94.7)	8(100)	9(90)	6(100)	0.97
Avoiding administering medication at night - rescheduling, not to interrupt sleep	19(100)	8(100)	10(100)	5(83.3)	0.97
Registering vital signs considering the central monitor during sleep	18(94.7)	8(100)	9(90.0)	3(33.3)	1
Providing ear plugs and / or eye mask for sleep	13(68.4)	6(75.0)	6(60.0)	2(33.3)	0.90
Individualizing alarm signs	18(94.4)	8(100)	10(100)	5(83.3)	1
Checking the patient's preference regarding the sleeping environment	15(83.3)	6(75.0)	9(90.0)	6(100)	1
Informing the benefits of the sleep-wake cycle	19(100)	8(100)	10(100)	5(8.3)	1
Assessing the risk for PU ^† and the permanence without change of position during sleep	17(89.5)	7(87.5)	9(90.0)	5(83.3)	1
Interrupting the sleep period if the patient's presents clinical changes / instabilities	19(100)	7(87.5)	9(90.0)	4(66.7)	1

	Recommendation
Care	Nurse n(%)	Physical therapist n(%)	Physician n(%)	Others n(%)	CVI^*
Orientating them to use clocks and calendars	19(100)	8(100)	10(100)	6(100)	1
Allowing family members to bring items: magazines, books, etc.	18(94.7)	7(87.5)	10(100)	6(100)	0.97
Reducing light at night	19(100)	8(100)	10(100)	6(100)	1
Orientating the professionals to avoid talking around the bed	19(100)	8(100)	10(100)	6(100)	1
Controlling noise at night	16(84.2)	6(75.0)	10(100)	6(100)	0.97
Making family access more flexible	19(100)	7(87.5)	10(100)	6(100)	1
Promoting care management, facilitating family access	18(100)	7(87.5)	9(90.0)	6(100)	0.97
Performing rounds in visiting hours to offer orientations about delirium	19(100)	7(87.5)	6(60.0)	5(83.3)	0.95
Encouraging family interaction with the patient	14(73.7)	8(100)	8(80.0)	5(83.3)	1
Developing educational materials	18(94.7)	7(87.5)	9(90.0)	6(100)	0.95
Removing devices early	19(100)	8(100)	10(100)	6(100)	1
Performing mechanical restraints using “box gloves”	15(78.9)	5(62.5)	6(60.0)	4(66.7)	0.93
Not arresting bed restraint	13(68.4)	5(62.5)	7(70.0)	7(70.0)	0.87
Keeping the bed rails high	19(100)	8(100)	9(90.0)	5(83.3)	1
Providing the patient with means of calling professionals, e.g., bell or light	19(100)	7(100)	9(90.0)	5(100)	1
Providing 90 minutes of quiet time twice a day	12(63.2)	5(62.5)	3(30)	1(16.7)	0.87
Identifying the bed of the patient with delirium, in order to maintain the protocol	18(94.7)	8(100)	6(60.0)	6(100)	0.97

Care of the Multiprofessional Protocol for Patients with Delirium in the ICU
Diagnosis, pain management, sedation pause and medications
Awaken the patient daily (sedation pause: 6:30 am or 7:30 am).
Awaken the patient and perform ventilation test.
Assess delirium with CAM-ICU.
Perform early mobilization.
Assess pain with validated scales.
Administer non-opioid analgesics.
Ensure analgesia before interventions.
Limit the use of medications associated with delirium.
Choose sedations that are not a risk factor for delirium.
administrate haloperidol.
Cognitive Orientation
Encourage the team to practice verbal / written orientations whenever possible.
Call the patient by name when starting an interaction.
Encourage the patient with predetermined questions, established in protocol.
Inform the characteristics of the unit, visiting hours, meals and procedures.
Explain any noise produced by infusion pumps, alarms and / or ventilator.
Provide information to the patient about their health status, prognosis and treatments.
Offer means of listening to music and television. From 6 am to 8 pm.
Provide glasses and hearing aids for personal use as soon as possible.
Sleep Promotion
Assess patients for sleep maintenance (Sleep period: 00:00 to 4:00 or 22:00 to 4:00).
Prevent the patient from sleeping during the day.
Cluster care for uninterrupted sleep. During the night: bath until 10 pm.
Avoid administering medication at night - reschedule. Do not interrupt sleep.
Record vital signs provided by the central monitor during sleep.
Provide ear plugs and / or eye mask for sleep.
Individualize the alarm.
Check the patient's preference for the sleeping environment.
Inform the benefits of the sleep-wake cycle.
Assess the risk for PU and the permanence without changing position during sleep.
Interrupt the sleep period if the patient's clinical status changes / or if there is instabilities.
Environment and Family Participation
Orientate using clocks and calendars.
Allow family members to bring items: magazines, books, etc.
Reduce light at night.
Orientate professionals - avoid talking by the bed.
Control noise at night.
Make family access more flexible.
Promote care planning, facilitating family access.
Perform rounds in visiting hours to offer orientations about delirium.
Encourage family interaction with the patient.
Develop educational materials.
Remove devices early.
Perform “box glove” mechanical restraint.
Keep the bed rails high.
Provide the patient with a means of calling professionals, eg, bell or light.
Identify the bed of the patient who is in delirium, in order to maintain the care protocol.

[1] Corresponding author:
Thieli Lemos de Souza E-mail: thielils@gmail.com

Brasil

Brasil

Validation of a multidisciplinary care protocol for critically ill patients with delirium

Validación de protocolo multiprofesional de cuidados para paciente crítico con delirium

ABSTRACT

Objective:

Method:

Results:

Conclusion: