A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings

Abstract

A B S T R A C TPediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed. a NewYork-Presbyterian/Weill

Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study

“…This flowchart provides recommendations to clinicians under these headings: “Prevention and Identification of Pediatric Delirium” and “Diagnosis and Management of Pediatric Delirium.” Recommendations for physiological, pharmacological, and environmental factors should be taken into account, according to the flowchart of “Prevention and Identification of Pediatric Delirium”. 28 One of the most important factors in delirium management, under these headings, is reducing the patient's anxiety by allowing the parents to stay with the patient. Where possible, factors such as allowing a parent or loved one to stay with the patient on a continuous basis, and having the same nurses caring for the patient, are beneficial for children with delirium.…”

Practice Variability in Screening and Treating Pediatric Critical Illness Delirium: Survey

“…They can also serve as a guide for providers and improve outcomes for patients. 8,24 The PAED scale, introduced in the early 2000s, was the first validated bedside screening tool for PD. 18 The PAED scale is primarily used to screen for emergence delirium in children but can also be used in the PICU, although it does not screen for hypoactive delirium.…”

“…4,14,15 Despite that, the majority of children's hospitals do not routinely screen for delirium and guidelines outlining a standardized approach to screening, prevention, and treat-ment of PD do not exist. 8 Routine screening for PD in PICUs is important as signs and symptoms of delirium overlap with those of pain, agitation, and withdrawal. Thus, delirium can be missed.…”

Pediatric Consultation-Liaison Psychiatry: An Update and Review

“…There are pathways for both prevention and management of pediatric delirium, which can be helpful in guiding management of this condition. 38 Antipsychotics have been the mainstay of delirium treatment, with haloperidol, risperidone, olanzapine, and quetiapine showing equivalent safety profiles and improvement in agitation, sleep-wake disturbance, and symptom severity. [39][40][41] They may also result in decreased utilization of deliriogenic agents.…”

“…Clinical pathways have been developed in an attempt to standardize the care of SSRDs, delirium, and suicide risk screening, based on evidence, when available, and expert consensus. 13,15,38 This growing trend for evidence-based and best practices in child psychiatric consultation aims to improve quality of care. Given the success of these pathways, and the broad range of complicated illnesses evaluated by child psychiatric consultants, there is ample opportunity in the field for creation of future pathways.…”