Doctors Try New Approach to Reducing Cases of Hospital-Acquired Delirium

Andrew Kitchenman | April 23, 2014 | Health Care
Keeping ICU quiet at night, making sure patients are active help patients’ progress

Credit: Photo courtesy Dr. Sarah Bryczkowski.
Dr. Sarah Bryczkowski
Doctors have been concerned for decades about what can happen to some hospital patients — the experience itself can alter their mental state, leading to a condition known as hospital-acquired delirium.

The pressure to find ways to prevent this conditions had grown in recent years as researchers have linked delirium to longer stays in intensive care units and in hospitals overall, a risk of long-term cognitive impairment, and an increased chance of death within six months or a year. The symptoms of delirium include memory loss and disorientation.

That’s why Rutgers New Jersey Medical School faculty members and researchers are encouraged by a new approach to patients in University Hospital’s surgical intensive care unit, which decreased the amount of time that patients experienced delirium.

“Delirium is a huge issue – it’s really common and as the baby boomers are aging” it will become more common, according to Dr. Sarah B. Bryczkowski, a medical resident in general surgery at the school and an author of the study.

The statistics are disturbing. Fully 92 percent of trauma patients who require mechanical ventilation experience delirium. In addition, patients who experience delirium in an intensive care unit for one day see their chance of dying within six months increase threefold.

“I think part of the problem is that when patients are sick in the ICU a lot of the focus is on keeping them alive and getting (their immediate condition) better,” but this can occur at the expense of increasing the risk of delirium, Bryczkowski said.

While doctors once said that it was better to keep patients deeply sedated so that they wouldn’t remember the ICU, research now points to better outcomes – including fewer nightmares and less risk of post-traumatic stress – if patients are only lightly sedated, she said.

“What we thought was good care, actually was not,” Bryczkowski said of emphasizing patient comfort over patient awareness. “It’s not one at the expense of the other – I think we’re trying to do both now.”

The researchers did an extensive review of what other hospitals do to deal with delirium and developed new guidelines for treatment.

The new protocol include a mix of changes to the hospital environment, changes in the amount of medications that patients receive, and additions to the physical therapy that patients undergo.

Many of the factors that increase the risk of delirium – including whether the patient is older than 65, has dementia and is severely ill – couldn’t be modified in the study. But the protocol could help with a major cause of disorientation: the constant activity in an ICU, which can disturb a patient’s sleep cycle.

The protocols call for turning off lights and TVs in the ICU at night, leaving bright lights on during the day, playing relaxing music, and setting aside two 90-minute blocks of quiet time each day.

The protocol also called for minimizing the use of restraints, as well as limiting the use of drugs that are frequently used to sedate patients.

These techniques are based on the recognition that some attempts to calm patients down actually made them more disoriented and worsened their health outcomes.

Mary Jane Myslinski, a physical therapist and a professor at Rutgers School of Health Related Professions, taught her students about the physical therapy component of the protocol.

“I’ve been in ICUs since 1978 – back then there was no research, we used to call it ICU neurosis, and we saw this occur with many of the patients that were there for more than one to two days,” Myslinski said. “I think there’s a growing focus now. I think people are now recognizing different issues that will occur once a person is put in ICU” or a critical care unit.

“Our bodies do not like bed rest at all,” Myslinski said.

She added that her students would help get patients out of bed and get them moving.

“Once you get them moving, they’re sharp – it’s like they’re a whole different person,” said Myslinski, adding that an added benefit of the program is that it’s provided free to patients. The development of the protocol was funded by the Healthcare Foundation of New Jersey, which also provides funding to NJ Spotlight.

Bryczkowski said instituting the protocol required a “huge education program,” teaching both the ICU nurses as well as the patients and their families.

“So far, it’s been working,” she said of the change, which was instituted in mid-2012.

The researchers studied the results of the changes on a group of patients from March 2012 to March 2013.

While the new protocol didn’t reduce the number of patients who experienced delirium, the approach greatly reduced the number of days that patients experienced delirium. Before the change, the patients were averaging six days of delirium in the ICU — after it, only three days.

The amount of the anti-anxiety drug Lorazepam was also reduced by 37 percent and – perhaps most importantly – older patients with delirium spent less time in the ICU, dropping from an average of 13 days before the intervention to seven days after it.

The Journal of Surgical Research is publishing the results of the study.

Bryczkowski said she’s hopeful that the work will be replicated in ICUs at other hospitals, noting that doctors she met at two conferences were interested in the research.

“I think that it’s catching on,” she said.

Bryczkowski said the next step will be to check to see how the patients who were studied have been doing since then.