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 Background 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 assessment sedative and analgesic drugs7 Appropriate Use of Antipsychotics Assessment
• 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) positive) 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, Reassess Assess and treat pain and substance withdrawal sedation 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 Non-pharmacological intubated5 protocol2 Give adequate If tolerates SAT, Objective analgesic3 sedative for safety perform SBT if then minimize intubated6 Assure adequate pain control3
To evaluate the impact of a delirium assessment and treatment
Consider typical or Consider typical or atypical 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 Demographics Intervention 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) References 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 Disclosures
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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