Critical Care Nurse Practitioner St. Louis Children's Hospital St. Louis, Missouri, United States
Abstract: Delirium is prevalent in pediatric patients admitted to the cardiac ICU (CICU) with reported prevalence of 17-57%. Risk factors for delirium include younger age, pre-existing developmental delay, severity of illness, duration of cardiopulmonary bypass, exposure to medications such as benzodiazepines, opioids, and anticholinergics, and parental absence from the bedside. Delirium is associated with increased vasoactive requirement, longer duration of mechanical ventilation and ICU stay, and increased mortality. Delirium is detected in pediatric patients with the use of the Cornell Assessment of Pediatric Delirium (CAPD) Score with scores >/= 9 suggestive of delirium. CAPD scores are recorded once a shift by bedside nurses. Baseline data collected of pediatric patients admitted to the SLCH CICU following cardiothoracic surgery in October & November 2021 reveals a delirium prevalence of 45% (October: 6/10, 60%; November: 3/10, 30%, Total: 9/20 patients) within the first 14 days of CICU admission. However, compliance for CAPD scoring was low at 47% (October: 48/100. 48%; November: 82/174, 47%, Total: 130/274 12 hour shifts), thus, the diagnosis of delirium may have been missed in some patients. SMART
Aim: We aim to decrease the incidence of delirium from 45% to 30% in post-cardiac surgery patients who were admitted from outpatient in the first 14 days of admission by June 1, 2022. Delirium is defined as a CAPD score >/= 9 or persistent CAPD >/= 9 with a variation in Richmond Agitation-Sedation Scale (RASS) by 2 within a 24 hours period. Global
Aim: We will aim to increase detection, treatment, and ultimately prevention of delirium. We instituted weekly delirium rounds in the CICU in addition to our daily bedside rounds. Members of the delirium team round with bedside nurses to review each patient's delirium scores and modifiable risk factors for delirium. Delirium rounds may be burdensome or helpful for bedside nurses. To minimize the burden, we timed delirium rounds at a convenient time for bedside nurses and created a teaching tool to keep the conversation brief and focused. The families were also included in the weekly delirium rounds to help identify areas of improvement. We monitored bedside nurse satisfaction with the use of a pre/post survey. With weekly education on delirium, we aimed to improve CAPD and RASS score compliance in the CICU. With improved compliance to CAPD and RASS scoring, we planned to improve detection of pediatric delirium which will allow for timely treatment with environmental interventions and medications. With the implementation of delirium rounds, there was an increase in RASS and CAP-D compliance from a baseline of 50% to 90%. In addition, there was a decrease in the prevalence of delirium from 48% to 30%. A more standardized approach for education, particularly on delirium rounds, will be key to delirium prevention, recognition, and treatment. Implementation of a rounding tool led to successful reduction in the incidence of delirium in our unit.
