Can you create a smart phrase for intensive care unit delirium care?

ICU Delirium Care Smart Phrase

Implement routine delirium screening using CAM-ICU or ICDSC every shift, combined with a multicomponent non-pharmacological prevention bundle focused on early mobilization, sleep optimization, and family engagement. 1

Delirium Assessment Protocol

Screen all ICU patients for delirium ≥4 times per shift using validated tools:

• CAM-ICU (Confusion Assessment Method for ICU) - preferred
• ICDSC (ICU Delirium Screening Checklist) - alternative 1, 2

Document results in EHR each assessment. Positive screen triggers immediate intervention bundle.

Risk Factor Identification

Baseline risk factors to document:

• Pre-existing dementia
• History of hypertension
• History of alcoholism
• High severity of illness at admission 1

Modifiable risk factors to address:

• Coma (independent risk factor) 1
• Benzodiazepine use (strong association with delirium development) 1
• Immobility
• Sleep deprivation
• Sensory impairment (vision/hearing)

Prevention Bundle (Implement for ALL ICU Patients)

1. Sedation Management

• Avoid benzodiazepine infusions - use propofol or dexmedetomidine instead 1, 2
• Target light sedation (RASS 0 to -1) or implement daily sedation interruption 1
• Use analgesia-first approach - treat pain before sedating 1

2. Early Mobilization (HIGHEST PRIORITY)

Initiate mobilization as early as feasible to reduce delirium incidence and duration 1, 2

• Out-of-bed activities when hemodynamically stable
• Progressive mobility protocol each shift
• Physical therapy consultation within 24 hours of admission

3. Sleep Hygiene Protocol

• Minimize nighttime noise and light exposure
• Cluster care activities to protect sleep cycles
• Reduce stimuli between 22:00-06:00 1
• Avoid unnecessary nighttime vital signs/procedures

4. Cognitive/Sensory Optimization

• Reorientation strategies (clocks, calendars, windows)
• Ensure hearing aids and eyeglasses available and functioning
• Cognitive stimulation activities
• Family presence and engagement 2, 3, 4

Pharmacological Considerations

Prevention

DO NOT use prophylactic antipsychotics (haloperidol or atypical antipsychotics) to prevent delirium 1, 2

Sedation in At-Risk Patients

• Prefer dexmedetomidine over benzodiazepines in mechanically ventilated patients at risk for delirium 1
• Exception: alcohol or benzodiazepine withdrawal (use benzodiazepines) 1

Treatment of Active Delirium

Non-Pharmacological (FIRST-LINE)

Continue/intensify prevention bundle above, with emphasis on:

• Identifying and treating underlying causes (infection, metabolic derangement, hypoxia)
• Removing deliriogenic medications
• Maximizing family presence 3, 4

Pharmacological Treatment

Antipsychotics:

• No evidence that haloperidol reduces delirium duration 1
• Atypical antipsychotics may reduce duration (weak evidence) 1
• Do NOT routinely use haloperidol or atypical antipsychotics 2

Contraindications to antipsychotics:

• Baseline QTc prolongation
• History of Torsades de Pointes
• Concurrent QT-prolonging medications 1

Dexmedetomidine:

• Use for agitated delirium when sedation needed AND agitation is preventing weaning/extubation 2
• Preferred over benzodiazepines for sedation in delirious patients (except ETOH/benzo withdrawal) 1

DO NOT use rivastigmine - increases mortality 1

Documentation Template

DELIRIUM ASSESSMENT:
□ CAM-ICU: [Positive/Negative] 
□ Risk factors present: [list]
□ Prevention bundle implemented:
  □ Light sedation target (RASS goal: ___)
  □ Benzodiazepines avoided
  □ Early mobilization: [activity level]
  □ Sleep hygiene measures active
  □ Sensory aids in place
  □ Family engagement: [details]

IF DELIRIUM PRESENT:
□ Underlying causes addressed: [list interventions]
□ Deliriogenic medications reviewed/discontinued
□ QTc checked if antipsychotic considered: ___ ms
□ Sedation strategy: [dexmedetomidine/other/none]

Key Pitfalls to Avoid

• Never skip delirium screening - it remains underdiagnosed despite validated tools 5, 6
• Benzodiazepines are NOT first-line sedation in ICU patients at risk for delirium 1, 2
• Antipsychotics are NOT for prevention and have limited evidence for treatment 1, 2
• Immobility is modifiable - early mobilization has strongest evidence for prevention 1, 2
• Check QTc before any antipsychotic administration 1

Clinical Significance

Delirium is associated with:

• Increased mortality 1
• Prolonged ICU and hospital length of stay 1
• Post-ICU cognitive impairment 1
• Long-term psychological burden 7, 5

The most effective interventions are non-pharmacological and require coordinated multidisciplinary implementation 2, 7, 3, 4