Implementing the CAM-ICU April 19, 2012 The Webinar will begin at 2:00 PM PDT.

Implementing the CAM-ICU

April 19, 2012 The Webinar will begin at 2:00 PM PDT.

Implementing the CAM-Implementing the CAM-ICUICU

Michele Balas, PhD, RN, CRNP, CCRN University of Nebraska Medical Center

IMPLEMENTING THE CAM-ICU

Michele C. Balas PhD, RN, APRN-NP, CCRN

Assistant Professor

University of Nebraska Medical Center, College of

Nursing

[email protected]

OBJECTIVES

• Describe the importance of delirium monitoring in the

ICU setting

• Define the 4 delirium features assessed by the CAM-

ICU

• Demonstrate performance of CAM-ICU administration

• Provide case studies of delirium assessment using the

CAM-ICU

• Discuss strategies for successful CAM-ICU

implementation

University of Nebraska Medical Center

ICU DELIRIUMWHY SHOULD WE CARE?

•Incidence

1.70-87% Mechanically ventilated ICU patients

2.50-80% Surgical/Trauma/Burn ICU

3.20-50% Non mechanically ventilated ICU

•Outcomes• Independent predictor of higher ICU, hospital, & long-term

mortality rates

• 3 fold ↑ risk at 6 months

•Each day delirious ↑ 10% mortality!!!!!!



• Outcomes

• ICU & hospital LOS

• Poor functional recovery

• New institutionalization

• Multiple complications

• Long-term cognitive

impairment

• Cost • (38-152 BILLION $$ annually!!!!)



•10-50% of all ICU

survivors experience • PTSD

• Depression

• Anxiety

• Sleep disorders

• Need for caregiver

assistance


THE PROBLEM………..

• Recognition

•Weinert et al. (2007) CCM

•85% of 18,050 evaluations had

sedation (N=274)

•1 in 3 unarousable (32%)

•1 in 5 no spontaneous motor activity

(21%)

•Only 2.6% of providers thought

patients were “over-sedated”!!!!!!

WHAT IS DELIRIUM?-DSM IV DEFINITION

• Disturbance of consciousness (i.e., reduced clarity of awareness of

the environment) with reduced ability to focus, sustain or shift

attention

• A change in cognition or the development of a perceptual disturbance

that is not better accounted for by a preexisting, established or

evolving dementia

• The disturbance develops over a short period of time (usually hours

to days) & tends to fluctuate during the course of the day

• There is evidence from the history, physical examination or

laboratory findings that the disturbance is caused by the direct

physiological consequences of a general medical condition


WHAT IS THE CAM-ICU

• Bedside assessment tool intended for use by non- psychiatrists (i.e.

ICU RNs, MDs, RTs, PT/OT)

• Adapted from original CAM, for use in critically-ill, non-vocal (i.e.

mechanically ventilated) patients

• Delirium defined in terms of 4 diagnostic features

1. Feature 1-Acute onset or Fluctuating Course

2. Feature 2-Inattention

3. Feature 3-Altered level of consciousness

4. Feature 4-Disorganized thinking

• Delirium is present when patient displays features 1 AND 2 and

either 3 OR 4


TRUST MECAM-ICU QUICK & EASY

LESS THEN 90 SECONDS TO ADMINISTER


STEP 1ADMINISTER RASS

• Determine if you can even

administer the CAM-ICU

• Consciousness=arousal level

+ content

• “Are the lights on?”

• Use valid & reliable

sedation/arousal tool (i.e. the

RASS)



STEP 2ADMINISTER CAM-ICU

• To every patient except if they are comatose (i.e.

RASS -4 or -5)

• You do NOT have to assess all 4 features (only

those needed to determine if they are delirious)

• Delirium= Feature 1 AND Feature 2 AND either

Feature 3 OR 4

• Good news-you have already assessed for Feature

3


What is the CAM-ICU?

FEATURE 1MUST HAVE!!!!!

• Has the patient had an acute change from mental

status baseline?

OR

• Has the patient’s mental status fluctuated during the

past 24 hours?

__________________________________________

• If both of these questions are answered NO, STOP you

are done. The patient is NOT delirious!



FAQs

• How do you determine mental status baseline?

• Do you always use same baseline?

• How do you handle a permanent change of

baseline during hospitalization?

• Does it still count as fluctuation if patient is

receiving sedatives?



• Inattention

• “Squeeze my hand when I say the letter A”

1. SAVEAHAART

• Errors=No squeeze with “A” & squeeze on letter

other than “A”

• Feature 2 is present if the patient has >2 errors

• If inattention is NOT present, STOP you are done.

The patient is NOT delirious!



• Alternate Inattention

Assessment-

• Use of Pictures

• Step 1-5 pictures

• Step 2-10 pictures

• Scoring



FAQs• If the patient is RASS -3 or very lethargic, is the CAM-

ICU unable to assess? Is the patient delirious?

• Do I have to do both the letters & pictures on every

patient?

• How do I get the pictures?

• Are there other letter sequences I could use to assess

Feature 2?


FEATURE 3MUST HAVE EITHER THIS FEATURE

OR FEATURE 4• Altered Level of Consciousness

• Assess with RASS

• Feature is PRESENT when patient scores

anything other than a RASS of O (i.e. alert)

• If Features 1, 2 & 3 are deemed present,

STOP you are done, the patient is delirious

(CAM-ICU positive)


FEATURE 3MUST HAVE EITHER THIS FEATURE OF

FEATURE 4FAQs

• Is feature 3 positive in coma?

• What is the difference between Feature 3 and

Feature 1?

• What if we use a different sedation assessment

scale?



FEATURE 3• Disorganized thinking

• 2 steps

• Step 1-Questions

• Will a stone float on water?

• Are there fish in the sea?

• Does 1 pound weigh more than 2 pounds?

• Can you use a hammer to pound a nail?



FEATURE 3

• Step 2-Command

1. “Hold up this many fingers” (Hold up 2 fingers)

2. “Now do the same thing with the other hand” (Do not demonstrate)

3. OR-“Add one more finger” (If patient is uanble to move both arms)

• Feature 4 is present if there is >1 error for the combined

Questions & Command

• If Features 1, 2 & 4 are deemed present, STOP you are

done, the patient is delirious (CAM-ICU positive)


FEATURE 4FAQs

• How frequently do you have to assess for this

Feature?

• If the patient answers the 4 questions correctly,

do you still assess the command?

• Is there an alternate set of questions?


CASE STUDY #1

Mrs G. is a 65 y/o admitted for acute respiratory failure. She lives

independently in her own home, is active in her church, and still

drives herself everywhere. You walk into the room and she looks

at you immediately. She appears anxious as she is being

ventilated with BIPAP. Her arms are restrained and she is pulling

at them to get her BIPAP mask off. Her lowest RASS in the

previous 24 hours was –2, and highest RASS was +2. She

scored 5 on the Letters of Feature 2. She answers 2 questions

correctly and follows the commands of Feature 4.


CASE STUDY #4

You enter the room of a 78 y/o cardiac patient you have been

seeing over several days. She lives at home and cares for

her husband. She has been RASS -1 to 0 and CAM-ICU

negative for the past 48 hours. She is RASS 0 this morning

and greets you by saying “How do you think I look?” You

exchange pleasantries about how she is doing today. She

answers 2 questions correctly, follows commands but gets 6

letters and 5 pictures correct.


CASE STUDY #2

Your 80 y/o patient was successfully weaned from the

ventilator and extubated at 0800 after abdominal surgery. He

is alert and calm since all sedation and analgesia had been

stopped earlier in the morning. Yesterday evening and last

night he had periods of agitation with a documented RASS of

-1 to +3. He lives with family due to physical limitations with

mobility but is still cognitively intact. He correctly answers all

the questions and is able to identify the number of fingers the

interviewer holds up and follows the command. He squeezes

correctly on all the letters.


CASE STUDY #3

You enter the room of a 65 y/o patient you enrolled 2 days

ago after she had emergency abdominal surgery. She is still

on the ventilator, her eyes are closed, she does not open her

eyes to verbal stimuli but does respond to physical stimuli.

She was on paralytics and has been off them for 24 hours.

She is still receiving sedatives. She has been RASS -5 to -2

over the past 24 hours. She is unable to follow any

commands. Prior to surgery she had just retired from her

teaching job.


ISSUES IN IMPEMENTATIONFAQs

• Can I use the CAM-ICU outside the ICU?

• Can I use the CAM-ICU in my Neuro unit or

with patients with TBI?

• Can I perform a CAM-ICU on a patient with

known dementia?

• Can I use the CAM-ICU in patients having

ETOH withdrawal?



• How do I perform the CAM-ICU with non-English

speaking patients?

• How do you identify delirium in the depressed

patient?

• When should pharmacologic treatment for delirium

be discontinued?

• Is it necessary to assess for all 4 features of

delirium on every patient?



• How frequently should I administer the CAM-ICU?

• My patient is CAM-ICU negative, but is still acting

delirious. What does this mean?

• Do I need to do all 4 Features in order?

• How should I document the CAM-ICU?

• Should I do the CAM-ICU before or after an SAT?

• How do I know if my staff is performing the CAM-ICU

correctly?


RESOURCES• All information contained in this presentation was

retrieved from the website: www.icudelirium.org

1. CAM-ICU training manual

2. Case studies

3. Spot check forms

4. Example documentation forms

5. CAM-ICU/RASS pocket cards available upon request

• Coming soon-“ICUsurvivors.com”

• Supported by grant funds through the RWJF INQRI program


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Implementing the CAM-ICU April 19, 2012 The Webinar will begin at 2:00 PM PDT.

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