Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU

Abstract

Objectives: To examine the impact of an ICU bundle on delirium screening and prevalence and describe characteristics of delirium cases.

Design: Quality improvement project with prospective observational analysis.

Setting: Nineteen-bed PICU in an urban academic medical center.

Patients: All consecutive patients admitted from December 1, 2013, to September 30, 2015.

Interventions: A multidisciplinary team implemented an ICU bundle consisting of three clinical protocols: delirium, sedation, and early mobilization using the Plan-Do-Study-Act cycles as part of a quality improvement project. The delirium protocol implemented in December 2013 consisted of universal screening with the Cornell Assessment of Pediatric Delirium revised instrument, prevention and treatment strategies, and case conferences. The sedation protocol and early mobilization protocol were implemented in October 2014 and June 2015, respectively.

Measurements and main results: One thousand eight hundred seventy-five patients were screened using the Cornell Assessment of Pediatric Delirium revised tool. One hundred forty patients (17%) had delirium (having Cornell Assessment of Pediatric Delirium revised scores ≥ 9 for 48 hr or longer). Seventy-four percent of delirium positive patients were mechanically ventilated of which 46% were younger than 12 months and 59% had baseline developmental delays. Forty-one patients had emerging delirium (having one Cornell Assessment of Pediatric Delirium revised score ≥ 9). Statistical process control was used to evaluate the impact of three ICU bundle process changes on monthly delirium rates over a 22-month period. The delirium rate decreased with the implementation of each phase of the ICU bundle. Ten months after the delirium protocol was implemented, the mean delirium rate was 19.3%; after the sedation protocol and early mobilization protocols were implemented, the mean delirium rate was 11.84%.

Conclusions: Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and treatment and is associated with decreased delirium prevalence.