Development, Implementation, and Outcomes of a Delirium Protocol in the Surgical Trauma Intensive Care Unit.

BACKGROUND: Delirium in the critically ill is associated with increased mortality, length of stay (LOS), and prolonged cognitive dysfunction. Existing guidelines provide no recommendation for use of combination nonpharmacological and pharmacological prevention protocols or use of antipsychotic medications for the prevention or treatment of delirium. OBJECTIVE: This study evaluated the impact of implementing a delirium treatment protocol on the number of delirium-free days experienced by acutely delirious patients in the surgical trauma intensive care unit (STICU). METHODS: This retrospective, institutional review board-approved, pre-implementation (PRE) versus post-implementation (POST) cohort evaluated delirious patients admitted to the STICU. Patients were evaluated based on the duration of delirium. Secondary end points included ICU LOS, amount of atypical and typical antipsychotic medication used, amount of analgesia and sedation used, and adverse drug events associated with antipsychotics. RESULTS: Of the 593 evaluated, 89 patients were included (38 PRE vs 51 POST). Implementation of a delirium protocol reduced the number of delirious days, 8.2 ± 5.7 days PRE versus 4.5 ± 4.4 days POST; P = 0.001. ICU LOS in surviving patients and use of concomitant medications, intravenous morphine equivalents, and propofol were significantly reduced in the POST group. CONCLUSION: The implementation of a delirium protocol with nonpharmacological and pharmacological interventions had an impact on STICU patients experiencing acute delirium by significantly increasing delirium-free days and reducing the ICU LOS, in addition to decreased administration of concomitant medications.

The role of the pharmacist in the intensive care unit.

As our health care system has begun to place more emphasis on the provision of direct patient care activities and adherence to clinical guidelines, the profession of pharmacy has adapted to provide services, and practitioners, that meet these demands. Two areas of the hospital where pharmacy services are in high demand are the intensive care units and the emergency department; 2 dynamic environments that place a premium on providing appropriate medication therapy in a timely manner. The pharmacists working in these areas can provide a wide range of services that can expedite the arrival of medications and improve adherence to clinical practice guidelines and patient outcomes. In addition to processing medication orders and coordinating the arrival of medications, these pharmacists can also assist with therapeutic drug monitoring (vancomycin, aminoglycosides, and warfarin), medication dosing, renal dosing, and responding to medical emergencies (stroke, code blue, therapeutic hypothermia, rapid sequence intubation, etc). Critical care pharmacists also play an active role on hospital committees, in the education of staff, students, and residents (pharmacy and medical), and in the implementation of new institutional policies and protocols.