While recovering from a lung transplant at Philadelphia's Temple University Hospital, a patient became irritable and difficult to work with. She wouldn't follow directions. She banged on the furniture if nurses didn't respond immediately when she pressed her call button. And her respiratory therapists were unable to wean her off her ventilator even though she no longer needed it.
"The staff was fed up," says Nancy Ciccolella, PsyD, who has been a psychologist in Temple's department of physical medicine and rehabilitation since 1992 and a clinical assistant professor there since 2002.
When Ciccolella assessed the woman, it turned out she didn't have behavioral issues: She was suffering from intensive care unit (ICU) delirium. According to the ICU Delirium and Cognitive Impairment Study Groupopens in new window at Vanderbilt University Medical Center, about two-thirds of ICU patients experience this extreme confusion. These patients may have trouble paying attention, thinking clearly or even understanding where they are; some hallucinate. ICU delirium not only increases the chances of longer hospital stays and higher costs but also months-long cognitive problems and death, the study group says.
Once Ciccolella explained to the medical staff that the patient had delirium rather than behavioral problems, their attitude toward her changed. "It was mostly a matter of making the team feel they got help," she says. "I de-escalated the situation."
As part of the heart and lung transplant team, Ciccolella spends much of her time on cases of ICU delirium like this one. "Delirium by definition waxes and wanes," she says. "One moment they're fine; the next they think it's 1948 and they're at church." Delirium can go undetected until nurses, therapists or other medical staff realize a patient isn't cooperating with requests to get out of bed or participate in respiratory therapy.
When that happens, Ciccolella begins by supporting the medical team and soothing frayed tempers. "The team might feel like someone's a problem patient and not listen to the person anymore," she says. "I go in and try to calm everything down." Next, she advises the medical team to address possible causes of delirium. Often, it's medications—particularly pain medications—that are the problem. Lab work can detect metabolic issues that might induce confusion, while CAT scans can reveal whether the delirium has been prompted by a stroke.
"Sometimes, patients are just confused by anesthesia," says Ciccolella, explaining that it can take weeks for the effects to wear off in older patients.
She also works with the medical team and patient to set two or three simple goals, such as getting out of bed once a day. Or if a patient isn't adhering to medical recommendations, she works with the patient and medical team to simplify protocols and enlists the family's help in achieving compliance.
Prevention is key, adds Ciccolella. She advises medical staff to help patients avoid delirium with such simple steps as making sure patients wear their glasses when they're awake and having night-lights so patients can re-orient themselves if they wake up. Patients should also be able to see a clock and a whiteboard explaining where they are, the date and the name of the nurse on duty. Such tactics can also help prevent post-traumatic stress disorder (PTSD), says Ciccolella. "People can have terrifying delusions when they're delirious in the ICU," she says. "Fifteen years after they've left the ICU, those delusions can still be clear as a bell." PTSD after a critical illness differs from PTSD following combat or an assault, Ciccolella and colleagues explained in a paper in Rehabilitation Psychologyopens in new window earlier this year. The hallmark of this under-recognized, under-treated form of PTSD is future-oriented worries about having a recurrence of the illness and winding up in the ICU again, they explain. The result? Patients don't follow up well when it comes to medications or doctor visits.
In addition to detecting and intervening with delirium, Ciccolella also helps the medical staff address other psychological problems that can crop up in a busy transplant unit. One frequent request is help getting patients—whether they have delirium or not—off their ventilators. "The respiratory therapists sometimes have trouble figuring out why patients are having trouble weaning," she says.
Once Ciccolella and the team have ruled out physical reasons, she helps patients manage anxiety with cognitive restructuring. Patients who may be thinking, "I can't breathe. What if no one answers the call bell? I'm going to die!" for example, learn to tell themselves that their monitors are working, nurses can see them and that they will be OK. Ciccolella also teaches patients to use music, imagery and other distractions, although the usual emphasis on deep breathing is a no-no. "We want them to think about anything but breathing," says Ciccolella.
Working in the ICU is a relatively new niche for rehabilitation psychologists. For more information on the area, contact the APA Div. 22 (Rehabilitation Psychology) Rehabilitation Psychologists in Critical Care Special Interest Group, which facilitates consultation and support and shares new research and other information. To join, email Ciccolella at nancy.ciccolella@tuhs.temple.eduopens in new window.
