Delirium can have lifechanging consequences for hospital patients. In intensive care units (ICUs), where two out of three patients will experience delirium, it's a common problem.
For some people, symptoms such as trouble focusing, confusion and sudden changes in behaviour, only last a few days. But for the sickest patients, including those on breathing machines, they are vulnerable to the long-term impacts of delirium, including poorer brain function and mental health, muscle weakness and reduced quality of life.
University of Victoria nursing graduate Fiona Howarth's groundbreaking research project has found an inexpensive solution that reduces incidences of delirium and improves the recovery and quality of life of critically ill patients.
This week, Howarth will walk across the stage to receive her MSc in Nursing degree in Advanced Leadership Practice while knowing her research is improving the standard of care for patients in ICUs across BC, Canada and worldwide.
I love supporting patients and families in the most difficult part of their lives and want to make the experience as best as it can be given that it's typically lifechanging."
Fiona Howarth, nursing graduate
Over sedation in ICUs
In 2020, Howarth, a clinical care nurse specialist at Fraser Health, teamed up with the JBI University of Victoria Centre for Evidence and Health. The group of researchers, clinicians, and students led by UVic Associate Professor Dzifa Dordunoo, conducts surveys to identify practice-of-care issues.
Nurses in Howarth's team identified delirium as an ongoing, pervasive problem among their patients. Howarth decided to try using an inexpensive piece of equipment called SedLine, used in hospitals to monitor changes in brain function under anesthesia during surgery, to measure the level of sedation in ICU patients on mechanical ventilators.
The team found patients were being more deeply sedated than they needed to be, impacting brain activity, something that did not bode well for the patients' long-term recovery.
So, Howarth devised a study with Dordunoo, who encouraged Howarth to enroll in a master's degree to formalize the research.
Exciting findings
Over a year in 2022, Howarth's team put electrodes on the heads of 144 patients who required mechanical ventilation, using SedLine brain monitoring equipment to assess the level of patient sedation. They then titrated the level of intravenous drugs given to keep the patient unconscious but not so deeply sedated that electrical activity in the brain stopped.
As part of Howarth's capstone project, she compared the drug dosing change when using the SedLine monitor with patients in the same ICU prior to the monitor's implementation in 2021. Howarth compared the number of days monitored patients stayed on mechanical ventilation versus unmonitored patients, as well as rates of delirium, and length of time in hospital.
The results were dramatic and exciting.
"We found that there were reduced amounts of sedatives used in the patients using the SedLine monitor, reduced time on mechanical ventilation for patients, and reduced duration and incidents of delirium," Howarth says.
The practice now has become a standard of care in the Fraser Health Authority, and Howarth has helped implement the brain monitoring equipment in other health authorities' ICUs in Canada and the US. She presented the findings at a conference in Helsinki during the spring, and Dordunoo and Howarth are working on a paper publishing the research.
I'm so excited about this research. There haven't been a lot of breakthroughs and changes in delirium rates in ICU patients for a long time. My hope is by implementing something like this, we can change patient outcomes."
Fiona Howarth, nursing graduate
Low cost, big impact
For the second part of the study going forward, Howarth is following up after three months with patients who returned home after ICU. So far, her findings suggest patients don't have the kind of cognitive impairment health practitioners would expect to see after being on mechanical ventilation. She has found fewer incidences of mental health disorders and cognitive impairment in former ICU patients.
"My patients are returning to what looks like a relatively normal level at one-month post-ICU discharge," she says. "Most patients have these impairments for greater than five years if they ever get better."
Ultimately, Howarth's goal is that ICUs send patients home in better shape and improve their chances of living a good quality life while recovering from serious health issues such as cardiac arrest, physical trauma and severe respiratory failure.
Dordunoo says Howarth's master's project is worthy of a doctoral degree.
This innovative approach is set to transform how critical care nurses in Canada manage these powerful [sedation] drugs to enhance patient outcomes, particularly delirium and post-intensive care syndrome. Fiona's work also highlights the type of clinically focused work nurses with master's degrees can be leading.
Dzifa Dordunoo, associate professor
Howarth, meanwhile, wants to conduct a bigger study on the long-term outcomes associated with using brain monitoring equipment to titrate sedation levels in ICU patients. She hopes to see her findings adopted by every ICU across Canada and internationally.
"It should be standard practice. It's cheap as chips and not a burden on staff. It's low impact in that way, but high impact on patients."
