What’s Going on in the ICU? Six Essential Questions.

December 9, 2015 Deirdre McGuinness

Q1. What can negatively affect length of stay, mortality and post discharge recovery for some of the sickest patients?

Q2. What hospital event can induce post-traumatic stress disorder (PTSD) lasting many years?

Q3. What event is rarely recognized by clinicians when it occurs?

Answer: The occurrence of delirium during a hospital stay.

Delirium is a severe disruption in mental capacities that causes confused thinking and diminished awareness of surroundings. It has been reported that up to 80% of patients requiring ventilator support in the hospital experience some form of delirium. However, most cases are never diagnosed or treated.

So what do we do about a harmful condition that occurs frequently but is only rarely detected?

All delirium is not created equally 

Before I went to work in the intensive care unit (ICU), I thought of delirium as a patient thrashing around in bed, trying to pull equipment loose and tubes out. True enough, this is hyperactive delirium and easy to recognize. However, the other two forms of delirium – hypoactive delirium and a mixed form of delirium where the patient swings between the hyper- and hypo- active state – are frequently missed[1]. These two hard-to-spot types of delirium are also the most common.

All forms of inpatient delirium have the same excruciating effect on the patient, such as disorientation and hallucinations. These hallucinations can be extremely vivid where patients believe they are being kidnapped or tortured, witnessing murders or suicides around them, or otherwise viewing the clinical staff as enemies to be feared.

Contrary to the popularly held notion by us ICU nurses that “they won’t remember any of this,” patients do remember and desperately want to forget – but can’t. Even after discharge, patients are still unsure of what was real and what was a hallucination.

Q4. So what causes delirium?

Q5. How can we better recognize it in the future?

Q6. How do we prevent it?

A sedated patient is a happy patient, right? 

Some delirium risk can be reduced by the judicious use of appropriate drugs for pain management and sedation. Oftentimes the ICU protocol is sedation first, and then pain medication if the sedation isn’t working. Providers err on the side of keeping ventilator patients “snowed” (heavily sedated) so they won’t fight their tubes and cause harm to themselves.

However, sedation with the ever-popular benzodiazepines has been proven to be a significant risk factor for delirium. The American College of Critical Care has published guidelines on the management of pain, agitation and delirium. The latest guidelines emphasize pain management first, then sedation as necessary, avoiding benzodiazepines as much as possible.

First, do no harm

Reducing ICU delirium and its harmful long-term effects is not just about medication use. Do you keep the bright lights on in your ICU day and night? What about noise levels? Do patients get an opportunity for uninterrupted sleep during the night? Do they remain on bed rest while on a ventilator or do you encourage ambulation? (Yes, you CAN ambulate a patient on a ventilator!)

We have patients in our ICUs who believe they are witnessing murder, torture and kidnapping. While we work to improve the patient experience during a hospital stay, are we thinking enough about delirium and its effects after discharge? Ask questions like these to raise awareness of ICU delirium in your organization, get educated on the right steps to take, and work to ensure your patients don’t leave your ICU with PTSD.

[1] J Am Geriatr Soc. 2006 Mar;54(3):479-84.Delirium and its motoric subtypes: a study of 614 critically ill patients. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW.

Author information

Deirdre McGuinness

Deirdre McGuinness

I’m a registered nurse living in South Carolina and remembering my glory days working in ICUs and Operating Rooms. I now spend my working hours involved in the equally fascinating field of clinical data analytics. When I’m not working you’ll find me off to some exotic corner of the world or digging in my garden. Connect with me at deirdre_mcguinness@premierinc.com

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