Care pathways to prevent, identify and treat delirium in UK cardiac surgery centres.

To the Editor: Delirium is a frequent complication after cardiac surgery. We report current UK practice around identification, prevention, diagnosis and management of delirium for patients undergoing cardiac surgery. An online survey was developed and piloted by a multidisciplinary research team (See Supplementary Material). A link to an online survey was sent to all 35 cardiac surgery centers in the UK. Sites were defined by geography rather than NHS Trust. An appropriate clinician (e.g. anesthetist, senior nurse) was identified and asked to complete the survey. Thirty-one of 35 cardiac surgery centers (91%) responded to the survey. Although 19/31 (61%) centers informed patients of the risk of delirium after cardiac surgery, only 2/31 (6%) performed a pre-operative risk-assessment for delirium and only 7/31 (23%) had a systematic care-package for the prevention of delirium after cardiac surgery. Twenty-seven of 31 (87%) centers screened for the presence of delirium after cardiac surgery. Delirium was noted in the medical record sometimes (41%) or always (59%). Most centers (93%) also used the CAM-ICU6 as the screening tool, but approximately one-fifth (19%) used clinician or nurse judgement. All centers that undertook screening did so in the ICU, but screening declined as the patients moved to the High Dependency Unit (17/27 (63%) centers) and then to the ward (5/27 (19%) centers). Twelve of 31 (39%) centers had a care-plan in place to manage delirium after diagnosis was established. The most common components of this plan included: avoidance of benzodiazepines (7/12), use of dexmedetomidine or clonidine (7/12), as required haloperidol (6/12), early mobilization (12/12) and regular re-orientation (12/12). Other broadly used interventions included early removal of invasive catheters (11/12), maintaining use of hearing aids and glasses (10/12), daytime activity (10/12), regular mealtimes (10/12) and sleep hygiene (10/12). Many centers (25/31 (80%)) provided education and training about delirium screening, prevention, or management to their clinical staff. Three of 31 (10%) did not. This survey showed the wide variation in delirium care for patients undergoing cardiac surgery in the UK. Most centers warn patients about the risk of delirium, but few have formal plans in place to prevent or treat this complication. Most centers deliver training about delirium staff, but do not have robust guidelines for staff to follow. Existing guidelines tend to be local, and interventions vary substantially between centers. 1American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. [DSM V]. 5th edition, Washington, DC. American Psychiatric Publishing. 20132Lin L, Zhang X, Xu S, et al. Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis. Front Cardiovasc Med. 2022;9:884144.3Rudolph JL, Jones RN, Levkoff SE, et al. Derivation and Validation of a Preoperative Prediction Rule for Delirium After Cardiac Surgery. Circulation, 2009;119:229-36.4Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive Trajectories after Postoperative Delirium. N Engl J Med. 2012;367:30-39.5Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46:e825-e873.6Ely EW, Margolin R, Francis J. et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29:1370-9.7UK National Adult Cardiac Surgery Audit (NACSA) 2022 Summary Report. 2022. https://www.nicor.org.uk/wp-content/uploads/2022/06/NACSA_2022-FINAL.pdf [accessed 21.08.2023]. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This study was funded by a Bristol and Weston Hospitals Charity grant. The views expressed are those of the authors and not necessarily those of University Hospitals Bristol and Weston NHS Foundation Trust or the Charitable Trustees. Download .pdf (2.27 MB) Help with pdf files