Implementing delirium screening in the ICU: secrets to success

Abstract

Objective: To review delirium screening tools available for use in the adult ICU and PICU, to review evidence-based delirium screening implementation, and to discuss common pitfalls encountered during delirium screening in the ICU.

Data sources: Review of delirium screening literature and expert opinion.

Results: Over the past decade, tools specifically designed for use in critically ill adults and children have been developed and validated. Delirium screening has been effectively implemented across many ICU settings. Keys to effective implementation include addressing barriers to routine screening, multifaceted training such as lectures, case-based scenarios, one-on-one teaching, and real-time feedback of delirium screening, and interdisciplinary communication through discussion of a patient's delirium status during bedside rounds and through documentation systems. If delirium is present, clinicians should search for reversible or treatable causes because it is often multifactorial.

Conclusion: Implementation of effective delirium screening is feasible but requires attention to implementation methods, including a change in the current ICU culture that believes delirium is inevitable or a normal part of a critical illness, to a future culture that views delirium as a dangerous syndrome which portends poor clinical outcomes and which is potentially modifiable depending on the individual patients circumstances.

Figure 1

The Confusion Assessment Method for the ICU (CAM-ICU). The CAM-ICU assesses for the four features of delirium: Feature 1 is an acute change in mental status or a fluctuating mental status, Feature 2, is inattention, Feature 3, is altered level of consciousness and Feature 4, is disorganized thinking. Only patients who are arousable to voice can be assessed for delirium (Richmond Agitation Sedation Scale [RASS] −3, Sedation Agitation Scale [SAS] 3 or more alert). A patient screens positive for delirium if Features 1 and 2 and either Feature 3 or Feature 4 are present. See text for additional details of how to perform the CAM-ICU.