CPCP: Update on Prevention and Treatment of Delirium by Dr. Sophia Yuan

Sophia Yuan, MD, PhD
Sophia Yuan, MD, PhD

Here’s another Clinical Problems in Consultation Psychiatry (CPCP), this time an excellent update on the prevention and treatment of delirium by one of our psychiatry residents, Dr. Sophia Yuan.

We had some interesting comments by the medical students rotating on the psychiatry consultation service, mostly along the lines of how difficult it is to change the culture of medicine regarding attitudes and beliefs regarding prevention and management of delirium. Change seems to be glacial in this field, but it does happen.

Prevention and management of delirium doesn’t necessarily require the psychiatric consultant to be the champion leading the charge in this important area of research and clinical management. As Scott Beach pointed out in a recent paper on the educational impact of a psychiatric liaison on attitudes and beliefs (essentially the culture) of critical care unit resident physicians and nurses:

Though this intervention was reported subjectively as being “very helpful” in terms of enhancing the overall care of patients and appeared to improve relations between medicine and psychiatry, thus fulfilling the goals of the liaison intervention, the presence of a psychiatry consultant rounding with the intensive care unit team once weekly for 9 months appeared to be insufficient to meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium [1].

1. Beach, S. R., MD,, D. T. Chen, MD,, et al. (2013) Educational Impact of a Psychiatric Liaison in the Medical Intensive Care Unit: Effects on Attitudes and Beliefs of Trainees and Nurses Regarding Delirium. The Primary Care Companion for CNS Disorders 15,  DOI: 10.4088/PCC.12m01499

Objective: Despite high rates and increased risk of mortality, delirium remains underdiagnosed and a minimal focus of formal medical education. This is the first study to examine the educational impact of a psychiatric liaison on beliefs and knowledge about delirium among both nurses and residents.

Method: One psychiatrist spent 9 months rounding weekly in the medical intensive care unit, interacting with critical care nurses and internal medicine residents. Preintervention and postintervention surveys were distributed in July 2009 and June 2010, respectively, to staff (critical care nurses: n = 23 and n = 25, respectively; internal medicine residents: n = 31 and n = 23, respectively) and a comparison group (psychiatry residents: n = 29 and n = 23, respectively). Participants responded to 12 statements regarding delirium on a 5-point Likert scale.

Results: There were no statistically significant differences between the presurveys and postsurveys for any item when examining all respondents together, as well as psychiatry and internal medicine residents as individual groups. Critical care nurses showed a significant change between surveys for the statements, “Patients with new-onset anxiety or depression in the intensive care unit most commonly have delirium” (17.4% agree presurvey vs 56.0% agree postsurvey, χ2 = 7.62, P = .006) and “Delirium is diagnosed less often than it actually occurs” (100% agree presurvey vs 80% agree postsurvey, χ2 = 5.13, P = .023).

Conclusions: Though introduction of a psychiatric liaison was very well received by clinical staff, we did not meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium. Robust and lasting changes in attitudes regarding delirium may require more intensive efforts involving longer intervention periods, greater rounding frequency, or additional didactic teaching.

That said, I firmly believe that psychiatric consultants and non-psychiatric clinicians can collaborate to promote change in the hospital culture which tends to retard progress toward the goal of delirium prevention.

I also like the butterflies on Dr. Yuan’s slides. It reminds me of the idea that a little creature like a butterfly could create a hurricane on the other side of the world. Maybe our time is now and just by doing little things like the CPCPs and sending them out for free–we can change the world.

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Author: Jim Amos

Dr. James J. Amos is Clinical Professor of Psychiatry in the UI Carver College of Medicine at The University of Iowa in Iowa City, Iowa. Dr. Amos received a B. S. degree in Distributed Studies (Zoology, Chemistry, and Microbiology) in 1985 from Iowa State University and an M.D. from The University of Iowa in Iowa City, Iowa in 1992. He completed his psychiatry residency, including a year as Chief Resident, in 1996 at the Department of Psychiatry at The University of Iowa. He has co-edited a practical book about consultation psychiatry with Dr. Robert G. Robinson entitled Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. As a clinician educator, among Dr. Amos’s most treasured achievements is the Leonard Tow Humanism in Medicine Award.