Confusion Assessment Method For The ICU (CAM-ICU)

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Confusion Assessment Method forthe ICU (CAM-ICU)The Complete Training ManualRevised Edition: October 2010This is a training manual for physicians, nurses and other healthcare professionalswho wish to use the Confusion Assessment Method for the ICU (CAM-ICU).The CAM-ICU is a delirium monitoring instrument for ICU patients. A completedetailed explanation of how to use the CAM-ICU, as well as answers to frequentlyasked questions and case studies are provided in this manual.Grant Support: The CAM-ICU was developed through funds from Dr Ely’s Paul Beeson Faculty Scholar Awardfrom the Alliance for Aging Research, a K23 from the National Institute of Health (AG01023-01A1), and supportfrom the VA Tennessee Valley Healthcare System Geriatric Research, Education, and Clinical Center(GRECC).Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

Dear Colleague,With the advent of technology and the aging of our society, critical care has quickly become amassive “business” occupying an increasingly large segment of the gross domestic product ofindustrialized nations worldwide. Hospitals are filled with patients suffering from complex diseaseprocesses, and there is a driving unmet need to improve care. Components of patients’ diseases orhospital course that drive mortality, cost of care, and long-term outcomes such as cognitive function willserve as increasingly important foci by which to improve not only our efficiency and resource utilization, butmore importantly, the ultimate quality of life of millions of humans. It is with this backdrop that I write thisintroduction to the revised training manual for the Confusion Assessment Method for the Intensive CareUnit (CAM-ICU).When the CAM-ICU was designed and validated (in concert with long-standing delirium experts inGeriatrics and Neuropsychology such as Dr. Sharon Inouye, Dr. Joseph Francis, and Dr. Robert Hart), wehad no idea that the need and desire to monitor delirium around the world would stimulate its translationinto over 20 languages and its implementation in dozens of countries. In fact, it is hard to believe thechanges that have taken place in recent years regarding our understanding of delirium in critically illpatients. All of us in medicine are resolute in our desire and vocation to serve patients and their families tothe best of our abilities. Just a few years ago we could not even objectively diagnose acute braindysfunction (delirium) in intubated ICU patients in a reliable manner, which meant that delirium could notbe routinely diagnosed by bedside nurses, physicians, or other non-psychiatrically trained clinicians.Perhaps this is one of those “if you build it, they will come” stories. Following the publication in 2001 ofvalid and reliable tools by which to detect the onset or resolution of delirium in non-verbal patients such asthose on mechanical ventilation (i.e., ICDSC [Intensive Care Delirium Screening Checklist] and CAM-ICU),we have seen an explosion of peer-reviewed publications, research teams, and large scale implementationof quality improvement initiatives around the world that reflect the prioritization of the human brain duringserious illness. While none of the existing tools are perfect, and while all of them involve changing theculture of ICU bedside care, which is a challenge, the tools have enabled us to learn a tremendous amountof valuable epidemiology and management lessons already.We have learned, for example, that duration of delirium in ICU patients is one of the strongestindependent predictors of (risk factors for) death, length of stay in the hospital, cost of care, and long-termcognitive impairment. Indeed, there are few developments in the course of critical illness that portend“worse news” for a patient or his/her loved ones than the development of delirium that does not readilyremit with a quick adjustment of medications or management of obvious causes. While the causes ofdelirium are legion, and not all delirium is “created equal,” it is safe to say that we should do our best todetect its onset as early as possible in order to rectify any modifiable causes. Since hypoactive deliriumgenerally portends a worse prognosis than hyperactive delirium and is missed in 75% of circumstances inthe absence of active monitoring, it is critical to adapt delirium monitoring as standard practice in allcritically ill patients.Many ongoing and already designed investigations hopefully will continue to edify ourunderstanding of how to handle delirium when it arises, to define subpopulations who may or may notbenefit from specific pharmacological and non-pharmacological interventions, and to better communicateto patients and caregivers prognostic information and long-term planning solutions. In the meantime, theglass is way more than half full. We have much we can do with information gained by using deliriummonitoring tools both individually and collectively to improve our care and that is the ultimate goal. Goodluck and please allow our team to be of service to you and your team in any way possible.Sincerely,E. Wesley Ely, MD, MPH, FCCM, FACPOn behalf of the ICU Delirium and Cognitive Impairment Study GroupProfessor of Medicine at Vanderbilt UniversityAssociate Director of Aging Research, VA Tennessee Valley GRECCwww.icudelirium.orgPage 2

What is new in this training manual?Since the last edition of the CAM-ICU training manual, scores of institutions have adopted the CAMICU to measure delirium. Many of those places have shared great ideas to improve our teachingmaterials. We decided to update the look of our training materials, and took the opportunity toincorporate some of these new teaching methods. This manual is intended to include all the materialsnecessary for training and implementation of the CAM-ICU. We envision that the manual would beused by those charged with training and only the flowsheet pocket card would be used at the bedside.What has not changed? The essentials of the CAM-ICU (the four delirium criteria) have notchanged. This update only includes rewording and reordering. Same content, different look.What is new in this update? New layout – The previous version of the training manual contained only a CAM-ICUworksheet. This edition contains both a CAM-ICU worksheet (page 7) and flowsheet (page 8).The content on each page is exactly the same; only the layout has changed. The CAM-ICUworksheet presents the information in a checklist format, while the CAM-ICU flowsheetpresents the information more like an algorithm. Generally, we have found the checklistbeneficial with initial teaching and the flowsheet really useful as a pocket reference. Havingboth available allows you to choose the style that works best for your team. Reordering of Feature 3 and Feature 4. According to the original CAM (and the DSM-IVcriteria) you must have Features 1 and 2 and either 3 or 4 to be delirious. Feature 3 isidentified as ‘Disorganized Thinking’ and Feature 4 is identified as ‘Altered Level ofConsciousness’. This has confused many CAM-ICU users who think the assessment must bedone in numerical order (i.e., 1, 2, 3, 4). There is no rule regarding the order of assessingCAM-ICU Features. In fact, the Features are most often assessed in this order: 1, 2, 4, then 3if necessary. Most of the time, Feature 3 is not necessary to assess in order to determine if apatient is delirious. As a result we have decided to flip the numbering of the Features so thatFeature 3 is ‘Altered Level of Consciousness’ and Feature 4 is ‘Disorganized Thinking’.Nothing has changed with the content of these Features. The numbering was changed toimprove CAM-ICU ease of use and reflect bedside assessment. Scoring by errors instead of number correct – Scoring was originally described as the“number correct” for each Feature. Mentally, this was a 2-step process (add the number oferrors and then subtract them from the possible total). One step is always better than two! Toeliminate the extra step, the scoring is now described as “number of errors”. For example,Feature 2 previously said “a score of less than 8 correct answers Inattention.” Now it reads“more than 2 errors Inattention”. The threshold has not changed; it is just worded in terms oferrors instead of number correct.Frequently Asked Questions (FAQs) – We have completely updated these.How to use these materials? Every institution has different educational needs and implementationstruggles. Please review the materials and determine what works for you and your unit. Mix andmatch to make it fit your team. Please don’t hesitate to contact us if we can help in any way,The CAM-ICU Training Manual Redesign TeamMitzi Baker, MSN, RNJoyce Okahashi, ADN, RNLeanne Boehm, MSN, RN, ACNS-BCBrenda T Pun, MSN, RN, ACNPJan Dunn, MSN, RN, CCRNCayce Strength, BSN, RNPage 3

Table of ContentsThe Details About Delirium5Assessing Consciousness6CAM-ICU Worksheet7CAM-ICU Flowsheet8Feature 1 Instructions & Questions9Feature 2 Instructions & Questions10 – 12Feature 3 Instructions & Questions13Feature 4 Instructions & Questions14 – 15Frequently Asked Questions for Putting the CAM-ICU into Practice16 – 20Case Studies and Answers21 – 26Road Map for Interdisciplinary Communication27References28Page 4

The Details About DeliriumWhat is Delirium?A disturbance of consciousness characterized by acute onset and fluctuating course of inattentionaccompanied by either a change in cognition or a perceptual disturbance, so that a patient’s abilityto receive, process, store, and recall information is impaired. Delirium develops over a short periodof time (hours to days), is usually reversible, and is a direct consequence of a medical condition,substance intoxication or withdrawal, use of a medication, toxin exposure, or a combination ofthese factors. Many delirious ICU patients have recently been comatose, indicating a fluctuation ofmental status. Comatose patients often, but not always, progress through a period of deliriumbefore recovering to their baseline mental status. Think: rapid onset, inattention, cloudedconsciousness (bewildered), fluctuating.ICU delirium is a predictor of: mortality, length of stay, time on vent, costs, re-intubation, long-term cognitive impairment, and discharge to long-term care facilityThere are three subtypes of delirium: hyperactive, hypoactive and mixed. Hyperactive delirium ischaracterized by agitation, restlessness, and attempts to remove tubes and lines. Hypoactivedelirium is characterized by withdrawal, flat affect, apathy, lethargy, and decreasedresponsiveness. Mixed delirium is when patients fluctuate between the two. In ICU patients mixedand hypoactive are the most common, and are often undiagnosed (invisible) if routine monitoring isnot implemented. Few ICU patients ( 5%) experience purely hyperactive delirium.What is it not?Dementia, which is characterized by a state of generalized cognitive deficits in which there is adeterioration of previously acquired intellectual abilities. Dementia usually develops over weeks,months, or even years with varying levels of cognitive impairment from mild to severe.Think: gradual onset, intellectual impairment, memory disturbance, personality/moodchange, no clouding of consciousness.What is the CAM-ICU?The Confusion Assessment Method (CAM) was created in 1990, and it was intended to be abedside assessment tool usable by non-psychiatrists by Dr. Sharon Inouye to assess for delirium.1The CAM-ICU is an adaptation of this tool for use in ICU patients (e.g., critically ill patients on andoff the ventilator who are largely unable to talk). Delirium is defined in terms of four diagnosticfeatures, and is deemed present when a patient has positive Feature 1 and Feature 2 and eitherFeature 3 or 4 (see CAM-ICU schematic on next page).What is the first step in assessing delirium?Delirium assessment is actually part of the overall consciousness assessment. Consciousness isdefined in two parts—arousal level plus content (see next page). The first step to assessingconsciousness is to assess level of consciousness. This is best done using a validatedsedation/arousal scale. The Richmond Agitation-Sedation Scale (RASS) is used in this trainingmanual, though other tools are fine to use with the CAM-ICU. For more information on othersedation scales see question #15 on page 19 in the “Putting it into Practice” section. The next stepis assessment of content of consciousness. At deeper levels of consciousness (i.e., RASS -4 &-5), it is difficult to ascertain content because the patient is not responsive. These levels arereferred to as coma or stupor, and in those situations we do not conduct the CAM-ICU, thusreferring to the patient as ‘unable to assess’. However, at the lighter levels of consciousness (i.e.,RASS -3 & above), patients are able to display at least the beginnings of meaningfulresponsiveness (i.e., response to voice). At these levels you are able to assess for clarity ofthought, specifically delirium. The following pages include the CAM-ICU in a worksheet format(page 7) and in a flowsheet format (page 8) – same material, different layout. Then starting at page9 are detailed instructions for assessing the four CAM-ICU features.Page 5

Assessing Consciousness: Linking Sedation and Delirium MonitoringStep 1 Level of Consciousness: RASSScaleLabelDescription 4COMBATIVECombative, violent, immediate danger to staff 3VERY AGITATEDPulls to remove tubes or catheters; aggressive 2AGITATEDFrequent non-purposeful movement, fights ventilator 1RESTLESSAnxious, apprehensive, movements not aggressive0ALERT & CALMSpontaneously pays attention to caregiver-1DROWSYNot fully alert, but has sustained awakening to voice(eye opening & contact 10 sec)-2LIGHT SEDATIONBriefly awakens to voice (eyes open & contact 10 sec)-3MODERATE SEDATIONMovement or eye opening to voice (no eye contact)If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)-4DEEP SEDATIONNo response to voice, but movement or eye openingto physical stimulation-5UNAROUSEABLENo response to voice or physical stimulationIf RASS is -4 or -5 STOP (patient unconscious), RECHECK laterSessler, et al. AJRCCM 2002;166 :1338-1344.3Ely, et al. JAMA 2003; 289:2983-2991.VOICETOUCH2Step 2 Content of Consciousness: CAM-ICUFeature 1: Acute change orfluctuating course of mental statusAndFeature 2: InattentionAndFeature 3: Altered level ofconsciousnessInouye, et. al. Ann Intern Med 1990; 113:941-948.4Ely, et. al. CCM 2001; 29:1370-1379.5Ely, et. al. JAMA 2001; 286:2703-2710.OrFeature 4: DisorganizedThinking1Page 6

CAM-ICU WorksheetFeature 1: Acute Onset or Fluctuating CourseIs the pt different than his/her baseline mental status?ORHas the patient had any fluctuation in mental status in the past 24 hours asevidenced by fluctuation on a sedation scale (i.e., RASS), GCS, or previousdelirium assessment?ScoreCheck hereif PresentEitherquestion Yes Feature 2: InattentionLetters Attention Test (See training manual for alternate Pictures)Directions: Say to the patient, “I am going to read you a series of 10 letters.Whenever you hear the letter ‘A,’ indicate by squeezing my hand.” Readletters from the following letter list in a normal tone 3 seconds apart.Number ofErrors 2 SAVEAHAARTErrors are counted when patient fails to squeeze on the letter “A” andwhen the patient squeezes on any letter other than “A.”Feature 3: Altered Level of ConsciousnessPresent if the Actual RASS score is anything other than alert and calm (zero)RASSanything otherthan zero Combinednumber oferrors 1 Feature 4:Disorganized ThinkingYes/No Questions (See training manual for alternate set of questions)1. Will a stone float on water?2. Are there fish in the sea?3. Does one pound weigh more than two pounds?4. Can you use a hammer to pound a nail?Errors are counted when the patient incorrectly answers a question.CommandSay to patient: “Hold up this many fingers” (Hold 2 fingers in front of patient)“Now do the same thing with the other hand” (Do not repeat number offingers) *If pt is unable to move both arms, for 2nd part of command ask patient to“Add one more finger”An error is counted if patient is unable to complete the entire command.Criteria Met Overall CAM-ICUFeature 1 plus 2 and either 3 or 4 present CAM-ICU positive CAM-ICUPositive(Delirium Present)Criteria Not Met CAM-ICUNegative(No Delirium)Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reservedPage 7

Confusion Assessment Method for the ICU (CAM-ICU) Flowsheet1. Acute Change or Fluctuating Course of Mental Status: Is there an acute change from mental status baseline?ORNO Has the patient’s mental status fluctuated during the past 24 hours?CAM-ICU negativeNO DELIRIUMYES2. Inattention: “Squeeze my hand when I say the letter ‘A’.”Read the following sequence of letters: S A V E A H A A R TERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’0-2ErrorsCAM-ICU negativeNO DELIRIUM If unable to complete Letters Pictures 2 Errors3. Altered Level of ConsciousnessCurrent RASS levelRASS otherthan zeroRASS zero4. Disorganized Thinking:1. Will a stone float on water?2. Are there fish in the sea?3. Does one pound weigh more than two?4. Can you use a hammer to pound a nail?Command: “Hold up this many fingers” (Hold up 2 fingers)“Now do the same thing with the other hand” (Do not demonstrate)OR “Add one more finger” (If patient unable to move both arms) 1 Error0-1ErrorCopyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reservedCAM-ICU negativeNO DELIRIUMPage 8Page 8

Feature 1 Specific CAM-ICU Instructions & Questions1. Acute Change or Fluctuating Course of Mental Status: Is there an acute change from mental status baseline? OR Has the patient’s mental status fluctuated during the past 24 hours?BasicsPatients with delirium will display changes from their mental status baseline and/or fluctuation inmental status. Feature 1 assesses for these changes.Feature 1 is present if either of the above questions is answered ‘yes’.Frequently Asked Questions for Feature 1:1. How do you determine baseline mental status?This is the patient’s pre-hospital mental status. Get this information from family, friends, or theH&P and document it in the patient’s record to facilitate communication between staff. Weencourage you to use critical thinking skills with this Feature. For example: If the patient is young (e.g. 65) and is admitted from home with no documentedneurocognitive disorder or history of stroke, then you could assume that the patient has a“normal” baseline mental status (i.e. alert and calm). If the patient is older, has documentation of a stroke or dementia, or came from a nursinghome, then you should probe family or the institution for more information on the patient’spre-hospital baseline mental status.2. Do you use that same ‘baseline’ with successive CAM-ICU assessments?Always, unless a permanent change in baseline occurs (see #3). You should consistently usethe patient’s established pre-hospital baseline.3. How do you handle a permanent change of baseline during the hospitalization – i.e., astroke or anoxic injury? Is that modified and permanent new baseline used for CAM-ICUpurposes?Yes. If there is a permanent change in baseline, the new baseline is used for subsequent CAMICU evaluations. This may be difficult to determine because of the difficulty in separatingdelirium from the new baseline. In practice, it is easiest to gather Feature 1 in such a situationby documenting ‘fluctuations’ in the mental status.4. Does it still count as fluctuation in mental status or change from baseline mental statuswhen a patient is on sedatives?Yes. Alteration in mental status includes those that are chemically induced by the healthcareteam, including fluctuation due to titration of sedatives. This is not the patient’s usual mentalstatus. It is often difficult to completely

This manual is intended to include all the materials necessary for training and implementation of the CAM-ICU. We envision that the manual would be used by those charged with training and only the flowsheet pocket card would be used at the bedside. What has not changed? The essentials of the CAM-ICU (the four delirium criteria) have not changed .

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