New Anesthesia Delirium Protocol Benefits Patients

For years, hospitals around the world experienced a phenomenon known as “sundowning,” a period when post-surgical patients – particularly older patients – experience delirium. They are disoriented, often agitated and uncertain about where they are and what they are doing.

Eventually, the medical community realized that this seemingly temporary condition had long-term implications. Studies have found a relationship, between post-surgical delirium and the onset and progression of dementia and Alzheimer’s disease.

Hoag is one of the few hospitals in the nation that is taking a serious look at this preventable situation. With a new protocol, Hoag’s anesthesia and nursing departments are working to identify people who are at risk of post-surgical delirium, alter the anesthesia that those patients receive and work post-surgically to help keep the patient calm and oriented.

“Before surgery, a patient gets a stress test to see if their heart is fit enough for surgery. Nobody has done anything similar to determine a person’s mental status,” said Tom Sinclair, M.D., an anesthesiologist who is heading up Hoag’s new efforts to minimize post-surgical delirium. “But mental status has as big an impact in a person’s quality of life as anything. This is a public health issue.”

The new protocol is aimed at reducing anesthesia dosage, getting family and friends involved in recovery, encouraging post-surgical mobility and giving patients plenty of visual cues to help orient them when they awake from surgery. Hoag is now recognized nationwide as a leader in this effort.

“We realized from the data that if you’re 60 and cognitively normal, chances are you’ll come out of surgery just fine. But if there is some sort of fragility in the brain, and we’re not as conservative with the anesthesia, the patient could experience delirium,” he said. “Having family members present in the recovery room and getting the patient out of bed and exercising – even if it’s just walking down the hall – that seems to help, too.”

Sinclair credits Meredith Padilla, Ph.D., M.S.N., RN, CCRN-CMC/CSC, a critical care nurse educator for developing the hospital’s delirium prevention protocol. Under her direction, the nursing staff in particular began flexing their creativity when approaching this problem.

Studies report that the incidence of postoperative delirium for patients undergoing abdominal procedures ranges from 5-15 percent. Within certain high-risk groups such as hip fracture patients, the range is 16-62 percent with an average of 35 percent.

At Hoag, patients having abdominal or lung surgeries have a 3.6 percent chance of having delirium, while 16 percent of hip fracture patients suffered from delirium.

“Part of the protocols include minimizing nighttime interruptions, so patients can get the restorative sleep they need,” Dr. Sinclair said “One enterprising nurse now wears a headlamp, instead of turning on the lights and tries do as much as she can in the dark. It’s changes like that that make a difference. We have one of the lowest post-operative delirium rates published in the country.”