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Ulus M, Durmaz Edeer A. Delirium care burden of intensive care nurses caring for patients undergoing open-heart surgery: A mixed-method research. Nurs Crit Care 2024. [PMID: 39119786 DOI: 10.1111/nicc.13137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/19/2024] [Accepted: 07/20/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness. Delirium causes negative outcomes in patients, and patients with delirium increase the workload of nurses. Therefore, it is important to recognize the challenges and burdens experienced by nurses caring for patients with delirium. AIM To determine the subjective burden experienced by intensive care nurses caring for patients who have undergone open-heart surgery. STUDY DESIGN A mixed-method sequential explanatory design. A non-probability purposive sampling method was used for the quantitative stage. Using OpenEpi, we employed the method of sample calculation with an unknown universe. The sample size of the quantitive study comprised 130 nurses. Quantitative data were collected with Google survey. For gathering qualitative data, online video interviews were conducted with 10 nurses, an interpretive phenomenological approach was used and content analysis was performed. RESULTS In the quantitative phase, we found that the subjective burden was high. In the qualitative phase, five main themes emerged: difficulty in recognizing delirium, physical burden, emotional burden, burden in care management of patients with delirium and the effect of patients with delirium on other patients. The nurses experienced physical and emotional burden in delirium management and felt lonely while caring for patients with delirium. CONCLUSIONS Because nurses play a key role in the care of patients with delirium, reducing the burden nurses experience when caring for patients with delirium should be considered important in ensuring that this patient population receives adequate care. RELEVANCE TO CLINICAL PRACTICE Delirium patients create a care burden for intensive care nurses. To reduce this burden of care, in-service training in patient management and bedside teaching support should be provided to nurses. Furthermore, the use of a valid scale to diagnose delirium should be integrated into health policies. Nurses should not be left alone in the management of delirium. Managing delirium patients with a team including physicians, nurses and professionals from other health disciplines will ensure that patients receive high-quality care, thereby reducing the care burden of nurses.
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Affiliation(s)
- Meltem Ulus
- Department of Surgical Nursing, Dokuz Eylul University, Health Sciences Institute, Izmir, Turkey
| | - Aylin Durmaz Edeer
- Department of Surgical Nursing, Dokuz Eylül University Faculty of Nursing, Izmir, Turkey
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Kaneko S, Morimoto T, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Effect of remimazolam on the incidence of delirium after transcatheter aortic valve implantation under general anesthesia: a retrospective exploratory study. J Anesth 2022; 37:210-218. [PMID: 36463532 DOI: 10.1007/s00540-022-03148-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/27/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Delirium after transcatheter aortic valve implantation (TAVI) should be prevented because it is associated with worse patient outcomes. Perioperative administration of benzodiazepines is a risk factor for postoperative delirium; however, the association between remimazolam, a newer ultrashort-acting benzodiazepine for general anesthesia, and postoperative delirium remains unclear. This study aimed to evaluate whether remimazolam administration during TAVI under general anesthesia affected the incidence of postoperative delirium. METHODS This single-center retrospective study recruited all adult patients who underwent transfemoral TAVI (TF-TAVI) under general anesthesia between March 2020 and May 2022. Patients were divided into the remimazolam (R) and propofol (P) groups according to the sedative used for anesthesia. In the R group, all patients received flumazenil after surgery. The primary endpoint was the incidence of delirium within 3 days after surgery. Factors associated with delirium after TF-TAVI were examined by multiple logistic regression analysis. RESULTS Ninety-eight patients were included in the final analysis (R group, n = 40; P group, n = 58). The incidence of postoperative delirium was significantly lower in the R group than in the P group (8% vs. 26%, p = 0.032). Multiple logistic regression analysis revealed that remimazolam (odds ratio 0.17, 95% CI 0.04-0.80, p = 0.024) was independently associated with the incidence of postoperative delirium, even after adjustment for age, sex, preoperative cognitive function, history of stroke, and TF-TAVI approach. CONCLUSION Remimazolam may benefit TF-TAVI in terms of postoperative delirium; however, its usefulness must be further evaluated in extensive prospective studies.
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Affiliation(s)
- Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Takayuki Morimoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Osamu Yoshitomi
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Deeken F, Sánchez A, Rapp MA, Denkinger M, Brefka S, Spank J, Bruns C, von Arnim CAF, Küster OC, Conzelmann LO, Metz BR, Maurer C, Skrobik Y, Forkavets O, Eschweiler GW, Thomas C. Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Surg 2022; 157:e216370. [PMID: 34910080 PMCID: PMC8674802 DOI: 10.1001/jamasurg.2021.6370] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
Importance Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored. Objective To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures. Design, Setting, and Participants This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021. Interventions First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion. Main Outcomes and Measures Postoperative delirium incidence and duration. Results Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98; P = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99; P = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99; P = .54). Conclusions and Relevance This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.
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Affiliation(s)
- Friederike Deeken
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Alba Sánchez
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Michael A. Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
- Social and Preventive Medicine, Department of Sports and Health Sciences, Intrafaculty Unit of Cognitive Sciences, Faculty of Human Science, and Faculty of Health Sciences Brandenburg, Research Area Services Research and e-Health, University of Potsdam, Potsdam, Germany
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Simone Brefka
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
| | - Juliane Spank
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Carola Bruns
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Christine A. F. von Arnim
- Division of Geriatrics, University Medical Center Goettingen, Göttingen, Germany
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | | | | | - Brigitte R. Metz
- Geriatric Center Karlsruhe, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Christoph Maurer
- Center for Geriatrics and Gerontology, Medical Center University of Freiburg, Freiburg, Germany
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Oksana Forkavets
- Department of Neurology, University Hospital Ulm, Ulm, Germany
- Geriatric Center at the University Hospital Tübingen, Tübingen, Germany
| | - Gerhard W. Eschweiler
- Geriatric Center at the University Hospital Tübingen, Tübingen, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - Christine Thomas
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
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Blodgett TJ, Blodgett NP. Melatonin and melatonin-receptor agonists to prevent delirium in hospitalized older adults: An umbrella review. Geriatr Nurs 2021; 42:1562-1568. [PMID: 34749057 DOI: 10.1016/j.gerinurse.2021.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/07/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Alterations in circadian rhythm play an important role in the development of delirium. In this umbrella review, we examined the efficacy of melatonin and ramelteon for delirium prevention in hospitalized older adults. METHODS Umbrella review methodology from the Joanna Briggs Institute guided the review process. Only meta-analyses were included. Risk of bias was evaluated using the AMSTAR-2 checklist. RESULTS Three meta-analyses were included in this review. The quality of studies was low-to-moderate. Two meta-analyses reported a significant reduction in delirium using melatonin or ramelteon (pooled OR and 95% confidence intervals ranged from 0.41 [0.19-0.86] to 0.63 [0.46-0.87]). Melatonergics significantly reduced delirium on medical units (OR = 0.25, 95% CI 0.07-0.88) but not surgical units (OR = 0.62, 0.16-2.43). Heterogenity was high, with I2 ranging from 72.14% to 84%. CONCLUSIONS Melatonergics appear to prevent delirium among hospitalized older adults, particularly those on medical units. Based on these results, providers may consider using melatonergics as complements to high-quality multicomponent delirium prevention.
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Affiliation(s)
- Thomas J Blodgett
- Duke University School of Nursing, 311 Trent Drive, Durham, NC, USA, 27710.
| | - Nicole P Blodgett
- Duke University School of Nursing, 311 Trent Drive, Durham, NC, USA, 27710
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Parker AM, Aldabain L, Akhlaghi N, Glover M, Yost S, Velaetis M, Lavezza A, Mantheiy E, Albert K, Needham DM. Cognitive Stimulation in an Intensive Care Unit: A Qualitative Evaluation of Barriers to and Facilitators of Implementation. Crit Care Nurse 2021; 41:51-60. [PMID: 33791762 DOI: 10.4037/ccn2021551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium in the intensive care unit is associated with poor patient outcomes. Recent studies support nonpharmacological therapy, including cognitive stimulation, to address delirium. Understanding barriers to cognitive stimulation implemented by nurses during clinical care is essential to translating evidence into practice. OBJECTIVE To use qualitative methods through a structured quality improvement project to understand nurses' perceived barriers to implementing a cognitive stimulation intervention in a medical intensive care unit. METHODS Data were collected through semistructured interviews with nurses in a medical intensive care unit. Data were categorized into themes by using thematic analysis and the Consolidated Framework for Implementation Research. During cognitive stimulation, nurses reviewed with patients a workbook of evidence-based tasks (focused on math, alertness, motor skills, visual perception, memory, problem-solving, and language). RESULTS The 23 nurses identified 62 barriers to and 26 facilitators of cognitive stimulation. These data were summarized into 12 barrier and 9 facilitator themes corresponding to the following Consolidated Framework for Implementation Research domains: Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals. Nurses also identified several facilitators within the Process domain. Patient-specific variables, including sedation, were the most frequently reported barriers. Other barriers included cognitive stimulation not being prioritized, nursing staff-related issues, documentation burden, and a lack of understanding of, or appreciation for, the evidence supporting cognitive stimulation. CONCLUSIONS Implementation of cognitive stimulation requires a multidisciplinary approach to address perceived barriers arising from the organization, context, and individuals associated with the intervention, as well as the intervention itself.
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Affiliation(s)
- Ann M Parker
- Ann M. Parker is an assistant professor, Division of Pulmonary and Critical Care Medicine, and a member of the Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Louay Aldabain
- Louay Aldabain is an internal medicine resident, Medstar Health, Baltimore, Maryland
| | - Narges Akhlaghi
- Narges Akhlaghi is a postdoctoral research fellow, Division of Pulmonary and Critical Care Medicine, and a member of the OACIS Research Group, Johns Hopkins University
| | - Mary Glover
- Mary Glover is a lead clinical nurse in the medical intensive care unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stephanie Yost
- Stephanie Yost is a bedside nurse in the intensive care unit, University of Vermont Medical Center in Burlington, Vermont
| | - Michael Velaetis
- Michael Velaetis is a critical care physician assistant in the medical intensive care unit, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
| | - Annette Lavezza
- Annette Lavezza is the acute care therapy manager, Johns Hopkins Hospital, and a member of the OACIS Research Group, Johns Hopkins University
| | - Earl Mantheiy
- Earl Mantheiy is a senior clinical program coordinator, Critical Care Physical Medicine and Rehabilitation Program, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine
| | - Kelsey Albert
- Kelsey Albert is a research program assistant, Critical Care Physical Medicine and Rehabilitation Program, and a member of the OACIS Research Group, Johns Hopkins University
| | - Dale M Needham
- Dale M. Needham is a professor, Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, School of Nursing, and a member of the OACIS Research Group, Johns Hopkins University
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Öztürk Birge A, Tel Aydın H, Salman F. The development of a delirium knowledge test for intensive care nurses: A validity and reliability study. Intensive Crit Care Nurs 2020; 61:102900. [DOI: 10.1016/j.iccn.2020.102900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 05/13/2020] [Accepted: 05/31/2020] [Indexed: 10/23/2022]
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Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care. Aust Crit Care 2020; 34:226-234. [PMID: 33909556 DOI: 10.1016/j.aucc.2020.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity. DESIGN This is a prospective observational study. SETTING The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital. PATIENTS The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h. INTERVENTIONS No interventions were provided in the study. MEASUREMENTS AND MAIN RESULTS Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01). CONCLUSIONS Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.
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Weber C, Fierz K, Katapodi M, Hasemann W. An advanced practice nurse-led delirium consultation service reduces delirium severity and length of stay in orthopedic patients: A nonrandomized posttest only evaluation study. Perspect Psychiatr Care 2020; 56:804-810. [PMID: 32128829 DOI: 10.1111/ppc.12495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 01/02/2020] [Accepted: 02/22/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Delirium is an acute neuropsychiatric disorder and is a common and serious complication during hospitalization for older people. This study evaluated the value of an advanced practice nurse (APN)-led delirium consultation service on patient outcomes DESIGN AND METHODS: This was a retrospective chart review of 137 patients over 65 years, hospitalized between 2012 and 2015 in a tertiary care setting in Switzerland, who underwent orthopedic surgery and experienced delirium. FINDINGS Of the 137 eligible patients, 53 received the delirium consultation service and 84 received the standard care. The group receiving "early" delirium consultation experienced significantly reduced delirium severity over the course of time and the shortest length of stay. PRACTICE IMPLICATIONS The APN-led delirium consultation service had a positive effect on patient outcomes.
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Affiliation(s)
- Christa Weber
- Department of Orthopedic and Traumatology, University Hospital of Bern, Bern, Switzerland
| | - Katharina Fierz
- ZHAW Zurich University of Applied Sciences, School of Health Professions, Institute of Nursing, Winterthur, Switzerland
| | - Maria Katapodi
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Wolfgang Hasemann
- Practice Development Unit, Department of Nursing and Allied Health Professions, University Hospital Basel, Basel, Switzerland.,University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
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Sanson G, Marino C, Valenti A, Lucangelo U, Berlot G. Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge. Heart Lung 2020; 49:407-414. [PMID: 32067723 DOI: 10.1016/j.hrtlng.2020.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/24/2020] [Accepted: 02/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients discharged from intensive care units (ICUs) are at risk for adverse events (AEs). Establishing safe discharge criteria is challenging. No available criteria consider nursing complexity among risk factors. OBJECTIVES To investigate whether nursing complexity upon ICU discharge is an independent predictor for AEs. METHODS Prospective observational study. The Patient Acuity and Complexity Score (PACS) was developed to measure nursing complexity. Its predictive power for AEs was tested using multivariate regression analysis. RESULTS The final regression model showed a very-good discrimination power (AUC 0.881; p<0.001) for identifying patients who experienced AEs. Age, ICU admission reason, PACS, cough strength, PaCO2, serum creatinine and sodium, and transfer to Internal Medicine showed to be predictive of AEs. Exceeding the identified PACS threshold increased by 3.3 times the AEs risk. CONCLUSIONS The level of nursing complexity independently predicts AEs risk and should be considered in establishing patient's eligibility for a safe ICU discharge.
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Affiliation(s)
- Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy.
| | - Cecilia Marino
- Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Andrea Valenti
- Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Umberto Lucangelo
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy; Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Giorgio Berlot
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy; Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
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Sánchez A, Thomas C, Deeken F, Wagner S, Klöppel S, Kentischer F, von Arnim CAF, Denkinger M, Conzelmann LO, Biermann-Stallwitz J, Joos S, Sturm H, Metz B, Auer R, Skrobik Y, Eschweiler GW, Rapp MA. Patient safety, cost-effectiveness, and quality of life: reduction of delirium risk and postoperative cognitive dysfunction after elective procedures in older adults-study protocol for a stepped-wedge cluster randomized trial (PAWEL Study). Trials 2019; 20:71. [PMID: 30665435 PMCID: PMC6341754 DOI: 10.1186/s13063-018-3148-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 12/18/2018] [Indexed: 12/20/2022] Open
Abstract
Background Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. The probability of delirium after surgery increases with patients’ age, with pre-existing cognitive impairment, and with comorbidities, and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria, risk factors, and treatment options of the medical staff. In this study, we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline (POCD) in patients older than 70 years undergoing elective surgery. Additionally, we will analyze whether the intervention is cost-effective. Methods The study will be conducted at five medical centers (with two or three surgical departments each) in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Measurements are performed at six consecutive points: preadmission, preoperative, and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2, 6, and 12 months after surgery. Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures (cardiac, thoracic, vascular, proximal big joints and spine, genitourinary, gastrointestinal, and general elective surgery procedures). Discussion Results of the trial should form the basis of future standards for preventing delirium and POCD in surgical wards. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia. Furthermore, from an economic perspective, we expect benefits and decreased costs for hospitals, patients, and healthcare insurances. Trial registration German Clinical Trials Register, DRKS00013311. Registered on 10 November 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3148-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alba Sánchez
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany
| | - Christine Thomas
- Department of Old Age Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Friederike Deeken
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany
| | - Sören Wagner
- Department of Anaesthesiology and Intensive Care, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Stefan Klöppel
- Center for Geriatrics and Gerontology, University Medical Center Freiburg, Freiburg, Germany.,University Hospital of Old Age Psychiatry, University of Bern, Bern, Switzerland
| | - Felix Kentischer
- Department of Surgery, Medical Center-University of Freiburg, Freiburg, Germany
| | | | - Michael Denkinger
- Agaplesion Bethesda Clinic, Geriatric Center Ulm University, Ulm, Germany
| | | | | | - Stefanie Joos
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen, Tübingen, Germany
| | - Heidrun Sturm
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen, Tübingen, Germany
| | - Brigitte Metz
- Geriatric Center Karlsruhe, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Ramona Auer
- Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg, Stuttgart, Germany
| | - Yoanna Skrobik
- Department of Medicine, McGill University Health Center, Glen Campus, Montreal, QC, Canada
| | | | - Michael A Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany.
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Surgical delay is a risk factor of delirium in hip fracture patients with mild-moderate cognitive impairment. Aging Clin Exp Res 2019; 31:41-47. [PMID: 29949026 DOI: 10.1007/s40520-018-0985-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/01/2018] [Indexed: 12/30/2022]
Abstract
AIM To investigate the relationship between onset of delirium and time to surgery in hip fracture (HF) patients with a different degree of cognitive impairment. METHODS Retrospective analysis of a prospective database of 939 older adults, aged ≥ 75 years admitted with a fragility HF. Subjects underwent a Comprehensive Geriatric Assessment on admission, evaluating health status, prefracture functional status in basic and instrumental activities of daily living, and walking ability. According to the Short Portable Mental Status Questionnaire score, patients were stratified into three categories: cognitively healthy (0-2 errors), mildly to moderately impaired (3-7 errors) and severely impaired (8-10 errors). Time to surgery (from admission) was expressed as days. The occurrence of delirium was ascertained daily by Confusion Assessment Method. RESULTS Two hundred ninety-two (31.1%) patients experienced delirium during in-hospital stay. They were older, with a higher degree of comorbidity and functional impairment compared to patients without delirium. In multivariate analysis, surgical delay resulted a significant independent risk factor for delirium (HR 1.11, 95% CI 1.01-1.24), along with age, prefracture functional disability and cognitive impairment. When the analysis was performed accounting for the cognitive categories, surgical delay demonstrated to increase the risk of delirium only in the subcategory of mildly to moderately impaired patients, while no significant effect was demonstrated in patients cognitively healthy or severely impaired. CONCLUSIONS The study supports the concept that older adults with HF should undergo surgery quickly. Patients with mild-to-moderate cognitive impairment should be primarily considered as the best target for interventions aiming to reduce time to surgery.
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Evaluation of the adherence of distress screening with the distress thermometer in cancer patients 4 years after implementation. Support Care Cancer 2018; 27:2799-2807. [PMID: 30539312 DOI: 10.1007/s00520-018-4579-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 11/27/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Identifying and assessing psychosocial distress with an appropriate screening instrument is essential when caring for cancer patients. Since 2012, the distress thermometer (DT) has been used by nurses for all cancer inpatients at the Comprehensive Cancer Center Zurich. We wanted to identify nurses' adherence to the screening protocol, differences between screened and not screened patients and the relationship between screening rate and productivity. METHODS This retrospective descriptive study used screening and referral data as well as socioeconomic and disease-related data of inpatients at the Comprehensive Cancer Center Zurich. This was collected from the electronic patient documentation system. Additionally, data showing the productivity of all wards was used. All data were analyzed descriptive. RESULTS Since 2012, 40.6% (4541) of the 11,184 patients have been screened. The screening rate was initially significantly lower but settled at 40% after 2 years. There was a higher screening rate among Swiss, married, male, and emergency patients and patients with hematology diseases, brain tumors, or head and neck cancer (p < 0.001). Every fourth patient with a moderate to severe distress level requested referral to a psychosocial service. Significantly more screened patients were referred to the social service (44.7%) than to the psycho-oncology service (9.4%). Only 22.9% of all referrals were made on the day of screening or a day later. There were only two wards of 15 with a significant relationship between productivity and screening rate. CONCLUSIONS Screening is useful in recognizing distress among patients, but screening practice needs to be reconsidered.
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Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs 2018; 27:2109-2119. [PMID: 29603815 DOI: 10.1111/jocn.14365] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2018] [Indexed: 01/10/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the relationship of delirium and risk factors for cardiology intensive care unit (ICU) patients with the nursing workload. BACKGROUND Delirium is a common syndrome in patients with cardiac problems. The risk factors causing delirium and the presence and type of delirium affect the nurse workload and patient care quality adversely. DESIGN This cross-sectional study was conducted with 133 patients staying at the cardiology ICU of a university hospital between 5 January-31 March 2017. METHOD The study data were collected using the Patient Information Form, Delirium Risk Factors' Form and Therapeutic Intervention Scoring System-28 (TISS-28) scale to identify the nurse workload. The statistical analysis of the data was performed using frequency, chi-square, Mann-Whitney U, correlation and regression analyses. RESULTS It was found that patients who developed delirium were 65 years or older, they had more nasogastric/total parenteral nutrition (NG/TPN), benzodiazepine and physical restraints in comparison with those with no delirium development, and that the prevalence of hypoxia and hypoalbuminemia were higher in these patients. The mean TISS-28 score was higher in patients with delirium, compared with those without delirium. There was a positive correlation between the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and the mean TISS-28 score of the patients. The mean TISS-28 score was found to significantly increase with being at the age of 65 and above and the administration of mechanical ventilation. The patients with delirium required a mean of 60-min additional care. CONCLUSIONS Our study results suggest that the presence of delirium and the delirium risk factors, irrespective of delirium, increase the nurse workload. RELEVANCE TO CLINICAL PRACTICE An effective management of delirium risk factors can improve the patient care quality by reducing delirium occurrence and nurse workload.
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Affiliation(s)
| | - Tülin Bedük
- Ankara University Faculty of Health Sciences, Ankara, Turkey
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Exploring the Knowledge Structure of Nursing Care for Older Patients With Delirium: Keyword Network Analysis. Comput Inform Nurs 2018; 36:216-224. [PMID: 29494362 DOI: 10.1097/cin.0000000000000424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prevention of delirium is considered a critical part of the agenda for patient safety and an indicator of healthcare quality for older patients. As the incidence rate of delirium for older patients has increased in recent years, there has been a significant expansion in knowledge relevant to nursing care. The purposes of this study were to analyze the knowledge structure and trends in nursing care for older adults with delirium based on a keyword network analysis, and to provide a foundation for future research. Data analysis showed that knowledge structure in this area consists of three themes of research: postoperative acute care for older patients with delirium, prevention of delirium for older patients in intensive care units, and safety management for the improvement of outcomes for patients with delirium. Through research trend analysis, we found that research on care for patients with delirium has achieved both quantitative and qualitative improvements over the last decades. Concerning future research, we propose the expansion of patient- and family-centered care, community care, specific nursing interventions, and the integration of new technology into care for patients with delirium. These results provide a reference framework for understanding and developing nursing care for older adults with delirium.
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Delirium after cardiac surgery. Incidence, phenotypes, predisposing and precipitating risk factors, and effects. Heart Lung 2018; 47:408-417. [PMID: 29751986 DOI: 10.1016/j.hrtlng.2018.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In cardiac surgical patients little is known about different phenotypes of delirium and how the symptoms fluctuate over time. OBJECTIVES Evaluate risk factors, incidence, fluctuations, phenotypic characteristics and impact on patients' outcomes of delirium. METHODS Prospective longitudinal study. In postoperative intensive care unit 199 patient were assessed three-times a day through an adapted versions of the Intensive Care Delirium Screening Checklist. RESULTS Delirium and subsyndromal delirium incidence were 30.7% and 31.2%, respectively. Delirium manifested mostly in the hypoactive form and showed a fluctuating trend for several days. Atrial fibrillation, benzodiazepine/opioids dosages, hearing impairment, extracorporeal circulation length, SAPS-II and mean arterial pressure were independent predictors for delirium. Delirium was a statistically significant predictor of chemical/physical restraint use and hospital length of stay. CONCLUSIONS Given the fluctuating and phenotypic characteristics, delirium screening should be a systematic/intentional activity. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.
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Choi J, Campbell ML, Gélinas C, Happ MB, Tate J, Chlan L. Symptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research. Heart Lung 2017; 46:239-245. [PMID: 28487184 DOI: 10.1016/j.hrtlng.2017.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/01/2017] [Accepted: 04/07/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Symptom assessment in critically ill patients is challenging because many cannot provide a self-report. OBJECTIVES To describe the state of the science on symptom communication and the assessment of selected physical symptoms in non-vocal ICU patients. METHODS This paper summarizes a 2014 American Thoracic Society Annual International Conference symposium presenting current evidence on symptom communication, delirium, and the assessment of common physical symptoms (i.e., dyspnea, pain, weakness, and fatigue) experienced by non-vocal ICU patients. RESULTS Symptom assessment begins with accurate assessment, which includes an evaluation of delirium, and assistance in symptom communication. Simple self-report measures (e.g., 0-10 numeric rating scale), observational measures (e.g., Respiratory Distress Observation Scale and Critical-Care Pain Observation Tool), or objective measures (e.g., manual muscle testing and hand dynamometry) have demonstrated utility among this population. CONCLUSION Optimizing symptom assessment with valid and reliable instruments with minimum patient burden is necessary to advance clinical practice and research in this field.
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Affiliation(s)
- JiYeon Choi
- University of Pittsburgh School of Nursing, Pittsburgh, PA, USA.
| | | | - Céline Gélinas
- McGill University Ingram School of Nursing, Montreal, Quebec, Canada
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - Judith Tate
- The Ohio State University College of Nursing, Columbus, OH, USA
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Wassenaar A, Rood P, Schoonhoven L, Teerenstra S, Zegers M, Pickkers P, van den Boogaard M. The impact of nUrsiNg DEliRium Preventive INnterventions in the Intensive Care Unit (UNDERPIN-ICU): A study protocol for a multi-centre, stepped wedge randomized controlled trial. Int J Nurs Stud 2016; 68:1-8. [PMID: 28013104 DOI: 10.1016/j.ijnurstu.2016.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delirium is a common disorder in Intensive Care Unit (ICU) patients and is associated with serious short- and long-term consequences, including re-intubations, ICU readmissions, prolonged ICU and hospital stay, persistent cognitive problems, and higher mortality rates. Considering the high incidence of delirium and its consequences, prevention of delirium is imperative. This study focuses on a program of standardized nursing and physical therapy interventions to prevent delirium in the ICU, called UNDERPIN-ICU (nUrsiNg DEliRium Preventive INterventions in the ICU). OBJECTIVE To determine the effect of the UNDERPIN-ICU program on the number of delirium-coma-free days in 28days and several secondary outcomes, such as delirium incidence, the number of days of survival in 28 and 90days and delirium-related outcomes. DESIGN AND SETTING A multicenter stepped wedge cluster randomized controlled trial. METHODS Eight to ten Dutch ICUs will implement the UNDERPIN-ICU program in a randomized order. Every two months the UNDERPIN-ICU program will be implemented in an additional ICU following a two months period of staff training. UNDERPIN-ICU consists of standardized protocols focusing on several modifiable risk factors for delirium, including cognitive impairment, sleep deprivation, immobility and visual and hearing impairment. PARTICIPANTS ICU patients aged ≥18years (surgical, medical, or trauma) and at high risk for delirium, E-PRE-DELIRIC ≥35%, will be included, unless delirium was detected prior ICU admission, expected length of ICU stay is less then one day or when delirium assessment is not possible. DISCUSSION For every intervention the balance between putative benefit and potential unwanted side effects needs to be considered. In non-ICU patients, it has been shown that a similar program resulted in a significant reduction of delirium incidence and duration. Recent small studies using multi component interventions to prevent delirium in ICU patients have also shown beneficial effect, without unwanted side effects. We therefore feel that the proportionality of potential positive effects of the UNDERPIN-ICU program, weighed against potential unwanted side effects is favourable. Since this has not been rigorously proven in ICU patients, we will study the effects of this program in ICU patients using a stepped wedge design. TRIAL REGISTRATION The study is registered in the clinical trials registry: https://clinicaltrials.gov/. REPORTING METHOD Standard Protocol Items: Recommendations for Interventional Trails (SPIRIT).
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Affiliation(s)
- Annelies Wassenaar
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
| | - Paul Rood
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
| | - Lisette Schoonhoven
- Faculty of Health Sciences, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK; Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
| | - Steven Teerenstra
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
| | - Marieke Zegers
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands; Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, The Netherlands.
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Leuenberger DL, Fierz K, Hinck A, Bodmer D, Hasemann W. A systematic nurse-led approach to withdrawal risk screening, prevention and treatment among inpatients with an alcohol use disorder in an ear, nose, throat and jaw surgery department-A formative evaluation. Appl Nurs Res 2016; 33:155-163. [PMID: 28096011 DOI: 10.1016/j.apnr.2016.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 11/14/2016] [Accepted: 11/19/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Among patients with head and neck cancer comorbid alcohol use disorder is frequent which contributes to higher risk of developing perioperative alcohol withdrawal syndrome/delirium or delirium due to medical conditions. Although guidelines emphasize prevention and treatment of alcohol withdrawal in hospitalized patients, a validated systematic approach for management of these patients is still lacking. Our aim was to formatively evaluate our newly developed systematic approach in view of nurses' adherence to screening patients for regular alcohol consumption and managing their withdrawal symptoms using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised. METHODS We conducted a formative evaluation to improve the project's design and performance and used a retrospective chart review in a consecutive sample of all adult inpatients with head and neck cancer being assigned for surgery in a university hospital. Our bundle of interventions consisted of nurses' screenings for regular alcohol consumption, withdrawal risk assessment, offering patients a substitution therapy, nurses' assessments of withdrawal symptoms and symptom oriented withdrawal management. Proximate endpoints were analyzed descriptively at each component of the bundle in terms of frequencies and severity of withdrawal symptoms, frequencies of nurses' and doctors' screenings and nurses' assessments performed as required. RESULTS Between 2013 and 2014, 87 inpatients met inclusion criteria and screenings by doctors/ nurses revealed 49 alcohol consumers, where six screenings were omitted by nurses and six by doctors. Twenty-one consumers were at risk and six of them developed an alcohol withdrawal syndrome. None of the 87 showed an alcohol withdrawal delirium, but five developed a delirium due to medical conditions. Nurses correctly conducted all preventive elements of the intervention bundle in 14 (58%) patients at risk but overall, only performed 50% of the required assessments. CONCLUSIONS Although nurses safely managed patients' symptoms, nurses' adherence to the interventions was suboptimal and requires stronger leadership.
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Affiliation(s)
- Deborah Linda Leuenberger
- Department of Orthopaedic and Traumatology, Clinical Nurse Specialist, Inselspital, University Hospital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Katharina Fierz
- Institute of Nursing Science, Scientific Collaborator, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland.
| | - Andreas Hinck
- Clinic for Otolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland; University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Daniel Bodmer
- Clinic for Otolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland; University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Wolfgang Hasemann
- Department of Nursing and Allied Health Professions, Practice Development Unit Nursing, University Hospital Basel, Hebelstrasse 2, CH-4031 Basel, Switzerland; University Hospital Basel, Hebelstrasse 2, CH-4031 Basel, Switzerland.
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Rizk P, Morris W, Oladeji P, Huo M. Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery. Geriatr Orthop Surg Rehabil 2016; 7:100-5. [PMID: 27239384 PMCID: PMC4872181 DOI: 10.1177/2151458516641162] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.
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Affiliation(s)
- Paul Rizk
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William Morris
- Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Philip Oladeji
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael Huo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Detroyer E, Dobbels F, Debonnaire D, Irving K, Teodorczuk A, Fick DM, Joosten E, Milisen K. The effect of an interactive delirium e-learning tool on healthcare workers' delirium recognition, knowledge and strain in caring for delirious patients: a pilot pre-test/post-test study. BMC MEDICAL EDUCATION 2016; 16:17. [PMID: 26768589 PMCID: PMC4714469 DOI: 10.1186/s12909-016-0537-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/05/2016] [Indexed: 05/30/2023]
Abstract
BACKGROUND Studies investigating the effectiveness of delirium e-learning tools in clinical practice are scarce. The aim of this study is to determine the effect of a delirium e-learning tool on healthcare workers' delirium recognition, delirium knowledge and care strain in delirium. METHODS A pilot pre-posttest study in a convenience sample of 59 healthcare workers recruited from medical, surgical, geronto-psychiatric and rehabilitation units of a university hospital. The intervention consisted of a live information session on how to use the e-learning tool and, a 2-month self-active learning program. The tool included 11 e-modules integrating knowledge and skill development in prevention, detection and management of delirium. Case vignettes, the Delirium Knowledge Questionnaire, and the Strain of Care for Delirium Index were used to measure delirium recognition, delirium knowledge and experienced care strain in delirium respectively. Subgroup analyses were performed for healthcare workers completing 0 to 6 versus 7 to 11 modules. RESULTS The delirium recognition score improved significantly (mean 3.1 ± SD 0.9 versus 2.7 ± 1.1; P = 0.04), and more healthcare workers identified hypoactive (P = 0.04) and hyperactive (P = 0.007) delirium in the posttest compared to the pretest phase. A significant difference in the change of recognition levels over time between the 0 to 6 and 7 to 11 module groups was demonstrated (P = 0.03), with an improved recognition level in the posttest phase within the 7 to 11 module group (P = 0.007). After adjustment for potential confounders, this difference in the change over time was not significant (P = 0.07) and no change in recognition levels within the 7 to 11 module group was noted (P = 0.19). The knowledge score significantly improved in the posttest compared to the pretest phase (mean 31.7 ± SD2.6 versus 28.3 ± 4.5; P < 0.001), with a significant increased level within the 7 to 11 module group (unadjusted P < 0.001/adjusted P = 0.02). Overall, no difference between posttest and pretest phases was documented for care strain (P = 0.46). CONCLUSION The e-learning tool improved healthcare workers' delirium recognition and knowledge. The effect of the tool is related to its level of completion, but was less explicit after controlling for potential confounders and warrants further investigation. The level of strain did not improve.
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Affiliation(s)
- Elke Detroyer
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35 - PB 7001/4, 3000, Leuven, Belgium.
- Group Health and Welfare, UC Leuven-Limburg, Genk, Belgium.
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35 - PB 7001/4, 3000, Leuven, Belgium.
| | - Deborah Debonnaire
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35 - PB 7001/4, 3000, Leuven, Belgium.
| | - Kate Irving
- Department of Nursing, Dublin City University, Dublin, Ireland.
| | - Andrew Teodorczuk
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
- Campus for Ageing and Vitality, Newcastle upon Tyne, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Donna M Fick
- College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, USA.
- Department of Psychiatry, College of Medicine, The Pennsylvania State University, University Park, Pennsylvania, USA.
| | - Etienne Joosten
- Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium.
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35 - PB 7001/4, 3000, Leuven, Belgium.
- Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium.
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Hasemann W, Tolson D, Godwin J, Spirig R, Frei IA, Kressig RW. A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment. Int J Nurs Stud 2015; 53:27-38. [PMID: 26323529 DOI: 10.1016/j.ijnurstu.2015.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear. AIM To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment. DESIGN AND METHODS This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication. SETTINGS The study was conducted within four medical wards of an acute care university hospital in urban Switzerland. PARTICIPANTS A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively. RESULTS Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units. CONCLUSIONS The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.
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Affiliation(s)
| | - D Tolson
- University of West of Scotland, Scotland, UK.
| | - J Godwin
- Glasgow Caledonian University, Scotland, UK.
| | - R Spirig
- University Hospital Zürich, Switzerland; Institute of Nursing Science, University Basel, Switzerland.
| | - I A Frei
- University Hospital Basel, Switzerland; Institute of Nursing Science, University Basel, Switzerland.
| | - R W Kressig
- Felix Platter Hospital Basel, University Center for Medicine of Aging, Basel, Switzerland.
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A qualitative study on experience of nurses caring for patients with delirium in ICUs in China: Barriers, burdens and decision making dilemmas. Int J Nurs Sci 2015. [DOI: 10.1016/j.ijnss.2015.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Hynninen N, Saarnio R, Isola A. The care of older people with dementia in surgical wards from the point of view of the nursing staff and physicians. J Clin Nurs 2014; 24:192-201. [DOI: 10.1111/jocn.12669] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2014] [Indexed: 01/25/2023]
Affiliation(s)
- Nina Hynninen
- Department of Nursing Science and Health Administration; Faculty of Medicine; University of Oulu; Oulu University Hospital; Oulu Finland
| | | | - Arja Isola
- Department of Nursing Science and Health Administration; Faculty of Medicine; University of Oulu; Oulu University Hospital; Oulu Finland
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Wand AP, Thoo W, Sciuriaga H, Ting V, Baker J, Hunt GE. A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study. Int J Nurs Stud 2014; 51:974-82. [DOI: 10.1016/j.ijnurstu.2013.11.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 09/13/2013] [Accepted: 11/15/2013] [Indexed: 11/27/2022]
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Oh SH, Park EJ, Jin Y, Piao J, Lee SM. Automatic delirium prediction system in a Korean surgical intensive care unit. Nurs Crit Care 2013; 19:281-91. [PMID: 24165109 DOI: 10.1111/nicc.12048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND In Korea, regular screening for delirium is not considered essential. In addition, delirium is often associated with vague concepts, making it harder to identify high-risk patients and impeding decision-making. AIMS To assess the impact of the Automatic PREdiction of DELirium in Intensive Care Units (APREDEL-ICU) system on nursing-sensitive and patient outcomes for surgical ICU patients and to evaluate nurse satisfaction with the system and its usability. METHODS A pre-post research design was adopted. Our study included 724 patients admitted before the implementation of the APREDEL-ICU (January to December 2010) and 1111 patients admitted after the system was installed (May 2011 to April 2012). The APREDEL-ICU uses a pop-up window message to inform the nursing staff of patients at risk for delirium, allowing evidence-based nursing interventions to be applied to the identified patients. A total of 42 nurses were surveyed to determine the system's usability and their level of satisfaction with it. RESULTS After the implementation of APREDEL-ICU, high-risk patients, determined using a prediction algorithm, showed a slight decrease in the incidence of delirium, but the changes were not significant. However, significant decreases in the number and duration of analgesic/narcotic therapies were observed after the implementation of the system. Nurse self-evaluation results showed an improvement in all categories of knowledge regarding delirium care. CONCLUSION The use of a prediction and alerting system for ICU patients at high risk of delirium showed a potential increase in the quality of delirium care, including early detection and proper intervention.
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Affiliation(s)
- Suk-Hwa Oh
- Surgical Intensive Care Unit, Seoul St. Mary's Hospital, Seoul, Korea
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Tate JA, Sereika S, Divirgilio D, Nilsen M, Demerci J, Campbell G, Happ MB. Symptom communication during critical illness: the impact of age, delirium, and delirium presentation. J Gerontol Nurs 2013; 39:28-38. [PMID: 23755732 PMCID: PMC4006194 DOI: 10.3928/00989134-20130530-03] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 04/30/2013] [Indexed: 11/20/2022]
Abstract
Symptom communication is integral to quality patient care. Communication between patients and nurses in the intensive care unit (ICU) is complicated by oral or endotracheal intubation and fluctuating neurocognitive status or delirium. We report the (a) prevalence of delirium and its subtypes in non-vocal, mechanically ventilated, critically ill patients; (b) impact of age on delirium; and (c) influence of delirium and age on symptom communication. Videorecorded interactions between patients (N = 89) and nurses (N = 30) were analyzed for evidence of patient symptom communication at four time points across 2 consecutive days. Delirium was measured at enrollment and following sessions. Delirium prevalence was 23.6% at enrollment and 28.7% across sessions. Participants age >60 were more likely to be delirious on enrollment and during observational sessions. Delirium was associated with self-report of pain, drowsiness, and feeling cold. Patients were significantly less likely to initiate symptom communication when delirious. Symptom identification should be carefully undertaken in older adults with or without delirium.
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Affiliation(s)
- Judith A Tate
- Department of Psychiatry, CRISMA Center, Department of Critical Care Medicine, Pittsburgh, PA 15238, USA.
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Deschodt M, Braes T, Flamaing J, Detroyer E, Broos P, Haentjens P, Boonen S, Milisen K. Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatr Soc 2012; 60:733-9. [PMID: 22429099 DOI: 10.1111/j.1532-5415.2012.03899.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the effect of inpatient geriatric consultation teams (IGCTs), which have been introduced to improve the quality of care of older persons hospitalized on nongeriatric wards, on delirium and overall cognitive functioning in older adults with hip fracture. DESIGN Controlled trial. SETTING Two trauma wards in a university hospital setting. PARTICIPANTS One-hundred seventy-one people with hip fracture aged 65 and older assigned to a multidisciplinary geriatric intervention (n = 94) or usual care (n = 77). MEASUREMENTS Incidence and duration of delirium were measured using the Confusion Assessment Method, severity of delirium using the Delirium Index, and cognitive status using the 12-item Mini-Mental State Examination. RESULTS Significantly more controls (53.2%; n = 41) than intervention group participants (37.2%; n = 35; P = .04; odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.04-3.54) were delirious at any point after surgery. No significant difference was found between the groups for duration or severity of delirium episodes. The proportion of participants with cognitive decline at discharge was higher in controls than in those assigned to geriatric intervention (38.7% vs 22.6%; P = .02; OR = 2.16, 95% CI = 1.10-4.24). CONCLUSION Delirium episodes and cognitive decline during hospitalization were found to be common in older adults with hip fracture, as expected, but an IGCT intervention reduced the incidence of these adverse outcomes. In participants who developed delirium, a geriatric consultation had no effect on severity or duration of the delirium episode.
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Affiliation(s)
- Mieke Deschodt
- Center for Health Services and Nursing Research, KU Leuven, Leuven, Belgium
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van den Boogaard M, Schoonhoven L, van der Hoeven JG, van Achterberg T, Pickkers P. Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study. Int J Nurs Stud 2011; 49:775-83. [PMID: 22197051 DOI: 10.1016/j.ijnurstu.2011.11.016] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 11/17/2011] [Accepted: 11/28/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Delirium is a serious and frequent psycho-organic disorder in critically ill patients. Reported incidence rates vary to a large extent and there is a paucity of data concerning delirium incidence rates for the different subgroups of intensive care unit (ICU) patients and their short-term health consequences. OBJECTIVES To determine the overall incidence and duration of delirium, per delirium subtype and per ICU admission diagnosis. Furthermore, we determined the short-term consequences of delirium. DESIGN Prospective observational study. PARTICIPANTS AND SETTING All adult consecutive patients admitted in one year to the ICU of a university medical centre. METHODS Delirium was assessed using the Confusion Assessment Method-ICU three times a day. Delirium was divided in three subtypes: hyperactive, hypoactive and mixed subtype. As measures for short-term consequences we registered duration of mechanical ventilation, re-intubations, incidence of unplanned removal of tubes, length of (ICU) stay and in-hospital mortality. RESULTS 1613 patients were included of which 411 (26%) developed delirium. The incidence rate in the neurosurgical (10%) and cardiac surgery group (12%) was the lowest, incidence was intermediate in medical patients (40%), while patients with a neurological diagnosis had the highest incidence (64%). The mixed subtype occurred the most (53%), while the hyperactive subtype the least (10%). The median delirium duration was two days [IQR 1-7], but significantly longer (P<0.0001) for the mixed subtype. More delirious patients were mechanically ventilated and for a longer period of time, were more likely to remove their tube and catheters, stayed in the ICU and hospital for a longer time, and had a six times higher chance of dying compared to non-delirium ICU patients, even after adjusting for their severity of illness score. Delirium was associated with an extended duration of mechanical ventilation, length of stay in the ICU and in-hospital, as well as with in-hospital mortality. CONCLUSIONS The delirium incidence in a mixed ICU population is high and differs importantly between ICU admission diagnoses and the subtypes of delirium. Patients with delirium had a significantly higher incidence of short-term health problems, independent from their severity of illness and this was most pronounced in the mixed subtype of delirium. Delirium is significantly associated with worse short-term outcome.
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Affiliation(s)
- Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands.
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Wand APF. Evaluating the effectiveness of educational interventions to prevent delirium. Australas J Ageing 2011; 30:175-85. [DOI: 10.1111/j.1741-6612.2010.00502.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Delirium in Switzerland. Eur Geriatr Med 2010. [DOI: 10.1016/j.eurger.2010.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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