Implementation of a delirium identification and treatment algorithm in the intensive care
unit: a focus on the appropriate use of antipsychotic medications
Samantha Moore, Pharmacy Intern; John Marshall, PharmD, BCPS; Charles J. Foster, PharmD
Beth Israel Deaconess Medical Center, Boston, MA
BIDMC ICU Delirium Protocol*
• Delirium occurs in up to 80% of patients treated in the intensive care RASS -3 to +5
RASS -4 or -5
Perform CAM ICU
Stupor or Coma while on
Sedation (RASS)
Patient Disposition Status
sedative and analgesic drugs7
Appropriate Use of Antipsychotics
• Pharmacologic management of delirium often involves the use of Intervention
p = 0.0449
antipsychotic medications; however, treatment optimization remains Non-delirious
Delirious (CAM-ICU
Does the patient require
(CAM-ICU negative)
deep sedation?
• To address these issues, a protocol for the identification and Reassess brain function every
Consider differential diagnosis e.g.
treatment of delirium was implemented at Beth Israel Deaconess Sepsis, CHF, metabolic disturbances,
Assess and treat pain and
substance withdrawal
Non-pharmacological protocol2
goal every
If tolerates
• The protocol incorporates delirium assessments utilizing the perform SBT6
Confusion Assessment Method (CAM-ICU) and decision support to Remove deliriogenic
Reassess target sedation
Is the patient in
RASS +2 to +4
RASS -1 to -3
goal or perform SAT if
Give adequate
If tolerates SAT,
sedative for safety
perform SBT if
then minimize
Assure adequate pain
To evaluate the impact of a delirium assessment and treatment Consider typical or
Consider typical or
atypical antipsychotics
protocol on the appropriate use of antipsychotic medications for the antipsychotics4
Abbreviations: RASS – Richmond Agitation Sedation Scale
Average ICU Length of Stay
treatment of delirium in the intensive care units at BIDMC Re-evaluate need for antipsychotic therapy on a daily
* This algorithm does not apply to patients with alcohol withdrawal basis and on transfer from ICU
Patients Discharged on Antipsychotic
Delirium Assessed
Delirium Assessed
with BIDMC
with CAM-ICU
Delirium Protocol
Age – year (mean ± SD)*
Male sex – n (%)
Prescribed Antipsychotics
Admitting diagnosis – n (%)
Respiratory failure
APACHE II score (mean ± SD)
Patients on mechanical ventilation - n (%)
Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Critical Care 2008; 12(Suppl 3):S3 Inclusion Criteria
Exclusion Criteria
The authors of the presentation have the following to disclose concerning possible financial or personal relationships with • Assessed for delirium within 24 hours of • Condition preventing delirium assessment commercial entities that may have a direct or indirect interest in the subject matter of this presentation:


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Maher Helmy Elsayed Helal Chemistry Dept., Faculty of Science, Helwan University, Cairo, Phone: (002)0225565548, Mobile: 0101154456, E-mail: ______________________________ Education .Ph.D., Organic Chemistry, Helwan Universit y 1990-1994 .M. Sc., , Organic Chemistry Helwan Universit y 1983-1990 .B. Sc., Chemistry, Elmnofia University 1982 _______________________

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