Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults

Abstract

Background: Hospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age>50 y) admitted to the SICU.

Methods: A prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1-10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis.

Results: Of 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12-6/12) and 66 postintervention (7/12-3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P=0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P=0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P=0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P=0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P=0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P=0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P=0.02), received less total opioids (pre 401 versus 260 mg, P=0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P=0.04).

Conclusions: Although delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.

Keywords: Benzodiazepines; Delirium; Elderly; ICU; Mechanical ventilation; Old; Outcomes; SICU; Surgery; Trauma.