Delirium Order Set: Ban Delirium Now!

I got in touch with colleagues about that delirium order set I wrote about in a previous post.

They’re all for sharing. They’re also enthusiastic about Dr. George Dawson’s suggestion to publish it eventually. I’m going to take their statement literally that they’ve been sharing it freely and offer a link to last year’s version, Delirium Order Set UIHC 2012.

It probably has not changed much since then. I would appreciate any feedback about it and hope to hear suggestions from out there about how to improve it.

I noticed an item some might say is missing and should be in there. One is that it’s necessary to check for any medical contraindications to using haloperidol to manage the agitation from delirium. For example, if the EKG shows a prolonged QTc interval, then doctors should think about the benefit to risk ratio using haloperidol, especially injectable formulations. It can worsen QTc prolongation and potentially raise the risk for torsades de pointes (TdP) and other deadly arrhythmias.

One potential substitute for antipsychotics, at least in the critical care unit, might be dexmedetomidine. However, this is not a psychotropic drug and intensivists would need to decide whether or not to use it.

This reminds me of the sometimes polarized debate on what we consider to be the main “treatment” for delirium. I still hear some say that it’s antipsychotic. Others insist that it’s treating the underlying medical conditions causing the delirium. This debate is filtering down to health journalists, as illustrated in this article.

The argument to focus on the underlying medical cause can go further, with some doctors calling for a ban on haloperidol.

That said, the agitation from delirium can interfere with the medical evaluation and treatment of the underlying physical illnesses that are by definition the causes of delirium. While the effect antipsychotics have on agitation from delirium in critical care units may be less than impressive, they can be helpful elsewhere in the general hospital for moderating hallucinations, fragmented delusions, and violent behavior that puts patients and others at risk for harm.

I think it’s very important to highlight the nonpharmacologic measures for preventing delirium, which research shows can work in about a third of patients, as long as the interventions are closely adhered to.

Moreover, the delirium order set could help non-psychiatric physicians feel more empowered and confident in their ability to manage delirium in hospitalized patients.

And if you feel somebody leaning over your shoulder, don’t fret. It’ll be me–making sure you find that delirium order set in Epic.

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