A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study

Reliability and Validity of the Spanish Adaptation of the Stanford Proxy Test for Delirium in Two Clinical Spanish-Speaking Communities

BACKGROUND

Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depends on constant surveillance and screening. This allows for the timely diagnosis and correction of its underlying causes and implementation of management strategies.

OBJECTIVE

It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about 1 minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method).

METHODS

The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and intensive care unit services, either at the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service by means of an independent neuropsychiatric evaluation based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013, which is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results within an hour of each other.

RESULTS

In the receiver operator characteristic (ROC) curve analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5 as the classification reference standard. Using a cutoff point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The area under the curve indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of delirium. Accordingly, the S-PTDsv's positive predictive value = 0.93, and the negative predictive value = 0.97. The internal reliability measured with Cronbach's alpha was 0.96. Confirmatory factor analysis revealed a 1-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity.

CONCLUSIONS

The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of delirium, in the Spanish-speaking populations. These results are comparable and consistent with previously published studies in the English language version.

Correlates of delirium care competency among shift leader nurses in acute medical wards in Japan: A cross-sectional study

AIM

This study identified the correlates of delirium care competency among shift leader nurses in acute medical wards in Japan.

METHODS

A cross-sectional study was conducted from November 2019 to February 2020. We sent request letters to a random sample of 381 general acute care hospitals in Japan. Of these, 68 agreed to participate and distributed 735 self-administered questionnaires to shift leader nurses working in their acute medical wards. The questionnaire included the Self-rated Delirium Care Competency Scale for Shift Leader Nurses in Acute Medical Wards (DCSL-M), developed by the authors. It gathered data on the respondents' demographics and delirium care competency, and investigated a total of 25 variables. We calculated descriptive statistics and examined associations between delirium care competency and the demographics using multiple logistic regression analysis.

RESULTS

Of the total, 301 (40.9%) questionnaires were returned. Delirium care competency was high among shift leader nurses who: (1) had experience as a clinical practice preceptor for nursing students; (2) had experience attending training related to dementia or delirium care; (3) worked at a hospital/ward that charged additional medical fees for dementia care; and (4) had access to consulting psychiatrists to refer patients with delirium.

CONCLUSIONS

The results suggest the need for efforts to improve delirium care competency among shift leader nurses who work in hospitals that do not charge additional medical fees for dementia care or that do not have consulting psychiatrists to refer patients with delirium.

[Development and content validity of a questionnaire to assess knowledge about delirium]

BACKGROUND

Delirium is a neuropsychiatric syndrome that can have serious consequences and is often overlooked by healthcare professionals. The level of knowledge about delirium is often insufficient among nursing and medical staff. At the current time there is no suitable questionnaire to record the level of knowledge in German-speaking countries.

AIM

Development of a questionnaire and evaluation of content validity.

METHODS

Following a literature search to identify current best practice, several questionnaires were identified. An already published questionnaire with the dimensions of basic knowledge of delirium and risk factors has been translated, adapted and extended by the dimension of nonpharmacological delirium prevention. Delirium experts assessed the relevance of the questionnaire items in two rounds of reviews. Content validity was calculated using the Content Validity Index (CVI) at item (I-CVI) and scale (S-CVI) level. Additionally, the modified Kappa (k*) was calculated using a lower 95% confidence interval (CI).

RESULTS

The original 30-item questionnaire was expanded to include 18 delirium prevention items. After the first round of scoring 30 out of 48 items showed good to excellent I‑CVI scores. Considering the comments, 6 items were discarded and 12 were adapted in terms of language and content. In the final version of the questionnaire 41 items with excellent scores remained. The total scale score increased from 0.88 in the first version to 1.0 in the final version. Nurses were identified as the target group, potentially also therapists and medical personnel.

CONCLUSION

The delirium knowledge questionnaire is content-valid.

Quality Improvement in Delirium Health Literacy in Older Adult Patients and Their Caregivers Attending a Geriatric Clinic

Background

Delirium is a common medical condition that is highly prevalent in older adults who are at increased risk for its development with any illness, post-surgery or during hospitalization. The purpose of our study was to evaluate the health literacy of older adult patients and their caregivers about delirium, offer a brief educational intervention, and reevaluate their knowledge post intervention.

Materials and Methods

We conducted a quality improvement project, focused on delirium health literacy in older adult patients ≥60 years and their caregivers. Delirium knowledge of participants was evaluated in a pre-education survey after which they were given a delirium education booklet to read. A post-education delirium survey was conducted within 2-3 weeks of the educational intervention. Chi-square test was used to analyze the knowledge base of older adults.

Results

The study population consisted of a total of 70 older adults who participated in pre-education (n=35) and post-education (n=35) surveys. Older adult patients and their caregivers had significant knowledge gaps about the potential causes or etiologies, risk factors, symptomatology, and prevention of delirium in the pre-education survey. After the educational intervention, in the post-education survey, there were overall improvements in knowledge base of older adults in differentiating delirium with dementia (43% vs 94%, p<0.01) recognizing signs and symptoms (77% vs 94%, p<0.05), complications (76% vs 100%, p<0.01) and identifying the etiological factors associated with delirium.

Conclusion

The quality improvement project demonstrated that older adults and caregivers have significant knowledge deficits about the common condition of delirium. This study also demonstrated that older adults were able to improve their health literacy regarding delirium after the intervention. Appropriate education on delirium for patients and caregivers might help in earlier identification, prevention, and better overall management of delirium.

Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study

BACKGROUND

Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials.

AIM

To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'.

DESIGN

A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework.

SETTING/PARTICIPANTS

Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer.

RESULTS

Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention).

CONCLUSION

This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.

The effect of delirium information training given to intensive care nurses on patient care: quasi-experimental study

Background

Training programs aiming to improve delirium diagnosis and management skills increase nurses' care efficiency and improve patients' health outcomes. This study was conducted to examine the effect of delirium information training on patient care by intensive care nurses.

Methods

In the research, one group pretest-posttest quasi-experimental design was used. The study sample consisted of 30 nurses working in four intensive care units of a university hospital between November 05, 2018, and February 15, 2019. The Personal Information Form, the Checklist for the Care of the Patient in Delirium, and the Confusion Assessment Scale for the Intensive Care Unit were used to collect the data. Intensive care nurses were provided with information training supported by a training booklet in two sessions of 40 min each.

Results

In the study, according to the Checklist for the Care of the Patient in Delirium, while the pre-test point average of the nurses was 6.17 ± 2.29, the post-test point average had increased to 11.17 ± 1.51 (p < 0.001). After the training, it was determined that there was a significant increase in the percentage of nurses who stated that they evaluated and detected whether their patients had pain, hallucinations, and delusions (p < 0.001). As a result, it has been determined that providing delirium information training to intensive care nurses positively affects the care of patients with delirium. In addition, it has been determined that with the Confusion Assessment Scale for Intensive Care Unit, nurses can provide the care they need to patients at risk in terms of delirium by identifying delirium.

Can multifaceted educational intervention improve clinical practice and patient outcomes regarding delirium in nursing homes?

AIM

We aimed to develop and evaluate a multifaceted and evidence-based delirium educational program for practitioners in nursing home settings.

METHODS

A pre- and posttest comparison group design was employed. The recruited practitioners included nurses and care workers from two nursing homes. The intervention group (n = 51) received the developed delirium educational program for 3 weeks, whereas the control group (n = 23) received a delirium handbook. We examined pre- and posttest differences in the scores for delirium knowledge and confidence in providing delirium care. We also examined the nurses' ability to clinically detect delirium in patients and delirium incidence for 8-week periods both before and after the intervention.

RESULTS

There were significant improvements in the participants' aptitudes (delirium knowledge and confidence in providing delirium care) and clinical practice (ability to clinically detect delirium in the patients) only in the intervention group; however, there were no significant differences in patient outcomes (incidence of delirium) between either group. Additionally, it was observed that the nurses' improved understanding of distinct clinical features of delirium, such as acute change or fluctuation, was the key factor that directly affected the success of delirium screening.

CONCLUSIONS

This study revealed that implementation of a multifaceted and evidence-based delirium educational program for practitioners in nursing home settings was effective in promoting the knowledge, confidence, and ability to detect delirium. The developed program can also be implemented in settings where most patients are older individuals, such as geriatric care units, or long-term care hospitals.

The critical need for nursing education to address the diagnostic process

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.

Perceptions of current occupational therapy practice with older adults experiencing delirium

OBJECTIVES

To describe the perceptions of Australian occupational therapists of their role, knowledge and skills in enabling older adults with delirium to participate in meaningful occupations.

METHODS

This is a mixed-methods cross-sectional study. Participants (n = 91) completed an online survey, with quantitative data analysed descriptively and qualitative data subjected to content analysis.

RESULTS

Occupational therapists had good general delirium knowledge, but less understanding of specific risk factors. Participants asserted the importance of occupational therapy assessment and treatment for older people experiencing delirium and generally felt confident or somewhat confident in their skills. While all participants provided collaborative care with multidisciplinary team members, only a minority thought colleagues had a satisfactory knowledge of the occupational therapy role with delirium.

CONCLUSION

Currently, the role of occupational therapy with older people experiencing delirium remains emerging rather than established, and there are many opportunities for further research and development in this practice area.

Prevention of Delirium in Older Adults With Dementia: A Systematic Literature Review

Although dementia is the largest independent risk factor for delirium and leads to poor health outcomes, we know little about how to prevent delirium in persons with dementia (PWD). The purpose of the current systematic literature review was to identify interventions designed to prevent delirium in older PWD. Seven studies meeting inclusion criteria were extracted. Five studies were in the acute care setting and two were community settings. One study used a randomized controlled trial design. Five of the seven interventions comprised multiple components addressing delirium risk factors, including education. Two studies addressed delirium by administration of medication or vitamin supplementation. Using the GRADE framework for the evaluation of study quality, we scored three studies as moderate and four studies as low. Thus, high-quality research studies to guide how best to prevent delirium in PWD are lacking. Although more research is required, the current review suggests that multicomponent approaches addressing delirium risk factors should be considered by health care professionals when supporting older PWD. [Journal of Gerontological Nursing, 46(10), 43-54.].

Multicomponent, nonpharmacological delirium interventions for older inpatients : A scoping review

BACKGROUND

Older people represent a risk group for acquiring or further development of delirium during hospitalization, therefore requiring suitable nonpharmacological delirium interventions.

OBJECTIVE

This scoping review analyzed nonpharmacological intervention programs for older inpatients with or without cognitive decline on regular or acute geriatric wards to present the range of interventions.

METHODS

A systematic literature search was conducted using scientific databases. A total of 4652 records were screened by two independent reviewers, leaving 81 eligible articles for full-text screening and 25 studies were finally included. Inclusion criteria were older patients ≥65 years in regular or acute geriatric wards and nonpharmacological multicomponent interventions.

RESULTS

More than a half of the included studies (14, 56%) recruited patients with pre-existing cognitive decline as part of the study population and 12% focused exclusively on patients with cognitive decline. On average 11 intervention components were integrated in the programs and two programs included full coverage of all 18 identified components.

CONCLUSION

Only few programs were described for older inpatients and even fewer regarding pre-existing cognitive decline. The low numbers of interventions and data heterogeneity restricted the assessment of outcomes; however, delirium incidence, as reported by two thirds of the studies was reduced by nonpharmacological multicomponent interventions.

Differentiation of delirium, dementia and delirium superimposed on dementia in the older person

Delirium is an acute clinical emergency that requires prompt clinical intervention. A predisposing factor for delirium is dementia, and delirium may highlight the vulnerability of a patient to developing dementia. However, delirium also occurs during an acute illness in patients diagnosed with dementia; this is classified as delirium superimposed on dementia. This complex interplay of both dementia syndromes and the condition of delirium has been extensively studied. However, delirium continues to be under-recognised in the acute setting, which impacts negatively on patient outcomes. Nurses are the health professionals best placed to recognise a change in a patient's cognitive symptoms, but nurses caring for the older person have suggested the identification of and differentiation between delirium, dementia and delirium superimposed on dementia remains very confusing. A need for further education with supportive guidelines and protocols is required to empower nurses caring for an older person to verbalise changes in patients' cognitive status in a reliable, robust and systematic manner.

Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients

BACKGROUND

The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings.

METHODS

A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

RESULTS

A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients.

CONCLUSION

The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.

Can education improve clinical practice concerning delirium in older hospitalised patients? Results of a pre-test post-test study on an educational intervention for nursing staff

BACKGROUND

Delirium is a common and serious complication of hospitalisation in older adults. It can lead to prolonged hospital stay, institutionalisation, and even death. However, it often remains unrecognised or is not managed adequately. The aim of this study was to evaluate the effects of an educational intervention for nursing staff on three aspects of clinical practice concerning delirium in older hospitalised patients: the frequency and correctness of screening for delirium using the 13-item Delirium Observation Screening score (DOS), and the frequency of geriatric consultations requested for older patients. The a priori expectations were that there would be an increase in all three of these outcomes.

METHODS

We designed an educational intervention and implemented this on two inpatient hospital units. Before providing the educational session, the nursing staff was asked to fill out two questionnaires about delirium in older hospitalised patients. The educational session was then tailored to each unit based on the results of these questionnaires. Additionally, posters and flyers with information on the screening and management of delirium were provided and participants were shown where to find additional information. Relevant data (outcomes, demographics and background patient data) were collected retrospectively from digital medical files. Data was retrospectively collected for four different time points: three pre-test and one post-test.

RESULTS

There was a significant increase in frequency of delirium screening (P = 0.001), and both units showed an increase in the correctness of the screening. No significant effect of the educational intervention was found for the proportion of patients who received a geriatric consultation (P = 0.083).

CONCLUSION

The educational intervention was fairly successful in making positive changes in clinical practice: after the educational session an improvement in the frequency and correctness of screening for delirium was observed. A trend, though not significant, towards an increase in the proportion of geriatric consultations for older hospitalised patients was also observed.

Falls and delirium in an acute care setting: A retrospective chart review before and after an organisation-wide interprofessional education

AIM AND OBJECTIVES

To describe and compare identification of delirium, length of stay and discharge locations in two patient samples of falls, before and after an organisation-wide interprofessional delirium education and practice change along with implementation of a policy.

BACKGROUND

Delirium is a common and severe problem for hospitalised patients, with occurrence ranging from 14%-56%, morbidity and mortality from 25%-33%. Recent studies report that 73%-96% of patients who fell during a hospital stay had symptoms of delirium; however, the delirium went undiagnosed and untreated in 75% of the cases.

DESIGN

A descriptive, retrospective observational study using a pre/postdesign.

METHODS

Two chart reviews were performed on patient falls as identified in the hospital safety reporting system in 2009-2010 (98 fallers) and 2012 (108 fallers). An organisation-wide education was planned and implemented with monitoring of policy compliance.

RESULTS

After the education, documentation of the "diagnosis of delirium" and "no evidence of delirium" increased from 14.3%-29.5% and from 27.6%-44.4%. The documentation of "evidence of delirium" decreased significantly from 58.2%-25.9% (p < .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16.

CONCLUSION

The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay.

RELEVANCE TO CLINICAL PRACTICE

The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re-education, and the re-enforcement of learning along with the implementation of a policy.

Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population

OBJECTIVE

To measure the diagnostic accuracy of the 4A's test in screening for delirium in geriatric inpatients from culturally diverse backgrounds.

METHODS

A prospective study was conducted with patients admitted to the geriatric and orthogeriatric services of a tertiary teaching hospital. Consenting participants aged 65 years and over were screened for delirium with the 4AT by nursing staff within 72 h of admission. The diagnosis of delirium was made separately by expert assessors, responsible for the participant's clinical care, blinded to the 4AT score, within 30 min of the 4AT assessment using the DSM 5 criteria and the Confusion Assessment Method. Interpreters were used for non-English speaking patients. The Informant Questionnaire for Cognitive Decline in the Elderly was completed by a carer/relative to assess for probable dementia.

RESULTS

A total of 257 participants (mean age 85) were recruited over five months. Delirium was diagnosed in 159 (62%) by the expert assessors and 158 (62%) by the 4AT assessment. A total of 205 participants (80% of total population) had probable dementia. The sensitivity and specificity of the 4AT were 87% and 80%, respectively, in detecting delirium overall, 86% and 71% in people with probable dementia and 91% and 71% for non-English speaking participants. The area under the receiver operating characteristic curve for delirium in the whole population was 0.92, 0.89 in the probable dementia subgroup and 0.90 in non-English speaking participants.

CONCLUSIONS

The 4AT is a sensitive and specific screening tool for delirium in geriatric inpatients, including those with probable dementia or who are non-English speaking. Copyright © 2016 John Wiley & Sons, Ltd.

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action

Nurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses’ engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses’ ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.

The new diagnostic team

The National Academy of Medicine (NAM) in the recently issued report Improving Diagnosis in Health Care outlined eight major recommendations to improve the quality and safety of diagnosis. The #1 recommendation was to improve teamwork in the diagnostic process. This is a major departure from the classical approach, where the physician is solely responsible for diagnosis. In the new, patient-centric vision, the core team encompasses the patient, the physician and the associated nursing staff, with each playing an active role in the process. The expanded diagnostic team includes pathologists, radiologists, allied health professionals, medical librarians, and others. We review the roles that each of these team members will need to assume, and suggest “first steps” that each new team member can take to achieve this new dynamic.

CogChamps - a model of implementing evidence-based care in hospitals: study protocol

BACKGROUND

Delirium and dementia (cognitive impairment; CI), are common in older hospital patients, and both are associated with serious adverse outcomes. Despite delirium often being preventable, it is frequently not recognized in hospital settings, which may be because hospital nurses have not received adequate education or training in recognizing or caring for those with CI. However, the most effective way of increasing nurses' awareness about delirium and dementia, and initiating regular patient screening and monitoring to guide best practices for these patients in hospital settings is not known. Hence this current project, conducted in 2015-2017, aims to redress this situation by implementing a multi-component non-pharmacological evidence-based intervention for patients with CI, through educating and mentoring hospital nurses to change their practice.

METHODS

The development of the practice change component is informed by recent findings from implementation science that focuses on facilitation as the active ingredient in knowledge uptake and utilization. This component focuses on educating and empowering experienced nurses to become Cognition Champions (CogChamps) across six wards in a large Australian tertiary referral hospital. The CogChamps will, in turn, educate other nursing team members to more effectively care for patients with CI. The hospital leadership team are supportive of the project and are directly involved in selecting the CogChamps. CogChamps will be provided with comprehensive education in evidence-based delirium assessment, prevention and management, and practice change management skills. They will receive continuing support from research and education staff about raising awareness, upskilling other staff in delirium assessment and in the adoption of best practices for preventing and managing delirium. Both qualitative and quantitative data are being collected at multiple time-points to evaluate process, impact and outcome, and to provide clarity regarding the most effective aspects of the intervention.

DISCUSSION

This paper describes the study protocol for the implementation of multi-component evidence-based non-pharmacological practices designed to improve the care of older hospital patients with CI. Findings will inform subsequent initiatives directed towards enhancing the capacity of the nursing workforce to implement best practices for providing high quality care for this growing patient population throughout their acute care hospital stay.

A nursing protocol targeting risk factors for reducing postoperative delirium in patients following coronary artery bypass grafting: Results of a prospective before-after study

Objective

The results of postoperative delirium (POD) warrant testing for prevention. The purpose of this study was to determine whether a nursing intervention targeting risk factors could decrease the incidence of POD among patients who had coronary artery bypass grafting (CABG) in China.

Methods

A prospective before-after study was conducted between April 2014 and April 2015. A nursing delirium intervention protocol targeting risk factors for delirium was performed for 141 patients undergoing CABG in a cardiothoracic ICU from November 2014 to April 2015. Intervention consisted of screening for delirium risk factors, followed by targeted risk factor modification, including pain control, early catheter removal, patient orientation using the 5W1H procedure, increased family visits, minimizing care-related interruptions, comfortable nursing and monitoring for sleeping difficulties. Outcomes of the Intervention Group were compared with those of the Control Group for 137 CABG patients from April 2014 to October 2014. Delirium was assessed using the confusion assessment method for the intensive care unit (CAM-ICU). The sample size was justified by PASS2000, based on previous data of delirium incidence in our institution (30%).

Main results

Delirium incidence during the first seven postoperative days was significantly lower in the Intervention Group at 13.48% (19/141) vs. 29.93% (41/137) for the Control Group (χ2 = 11.112, P = 0.001). In addition, POD in the Intervention Group occurred between the 3rd and 6th postoperative days, while POD in the Control Group mainly occurred on the first three days postoperatively. Delirium in the Intervention Group occurred later than delirium in the Control Group (χ2 = 12.743, P < 0.001). Length of ICU stay was reduced significantly (Z = −6.026, P < 0.001).

Conclusion

The application of a nursing protocol targeting risk factors in this study seems to be associated with a lower incidence of POD in patients after CABG. This finding suggests that managing the predictors properly is one of the effective strategies to prevent delirium.

•

A nursing intervention program of postoperative delirium was cultivated for CABG patients.

•

The study estimated the efficacy of the intervention through a before-after study.

•

The risk-targeted nursing intervention may decrease delirium incidence in CABG patients.

The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses

OBJECTIVE

This study aims to investigate the effect of nonpharmacological intervention training on delirium recognition and the intervention strategies of intensive care (ICU) nurses.

METHOD

This is a quasi-experimental study conducted using a pretest-posttest design. The study sample included a total of 95 patients staying in the medical ICU of a university hospital and 19 nurses working in these units. The data were collected using the Patient and Nurse Introduction, Confusion Assessment Method for the ICU, and Delirium Risk Factors, and Non-pharmacological Interventions in Delirium Prevention Forms.

RESULTS

Delirium was identified in 26.5% and 20.9% of the patients in the pre- and posttraining phase, respectively. Patients with delirium had a longer duration of stay in the ICU, lower mean Glasgow Coma Scale score and a higher number of medications in daily treatment (p<0.05). The risk of delirium increased 8.5-fold by physical restriction and 3.4-fold by the presence of hypo/hypernatremia. The delirium recognition rate of nurses increased from 7.7% to 33.3% in the post-training phase.

CONCLUSION

Our study results show that training can increase the efficiency of ICU nurses in the management of delirium.

Capacity and consent: Knowledge and practice of legal and healthcare standards

INTRODUCTION:

Healthcare practitioners have a legal, ethical and professional obligation to obtain patient consent for all healthcare treatments. There is increasing evidence which suggests dissonance and variation in practice in assessment of decision-making capacity and consent processes.

AIMS:

This study explores healthcare practitioners' knowledge and practices of assessing decision-making capacity and obtaining patient consent to treatment in the acute generalist setting.

METHODS:

An exploratory descriptive cross-sectional survey design, using an online questionnaire, method was employed with all professional groups invited via email to participate. Data were collected over 3 months from July to September 2015. Survey content and format was reviewed by the liaison psychiatry team and subsequently contained five sections (demographics, general knowledge and practice, delirium context, legal aspects and education/training). Descriptive, univariate and bivariate analysis of quantitative data and qualitative content analysis of qualitative data were undertaken.

ETHICAL CONSIDERATIONS:

The study was approved by the institutional Human Research and Ethics Committee and informed consent was taken to be provided by participants upon completion and submission of the de-identified survey.

RESULTS:

In total, 86 participants engaged the survey with n = 24, exiting at the first consent question. Almost two-thirds of respondents indicated that all treatments required patient consent. Knowledge of consent and decision-making capacity as legal constructs was deficient. Decision-making capacity was primarily assessed using professional judgement and perceived predominantly as the responsibility of medical and psychology staff. A range of patient psychological and behavioural symptoms were identified as indicators requiring assessment of decision-making capacity. Despite this, many patients with delirium have their decision-making capacity assessed and documented only sometimes. Uncertain knowledge and inconsistent application of legislative frameworks are evident. Many participants were unsure of the legal mechanisms for obtaining substitute consent in patients with impaired decision-making capacity and refusing treatment.

CONCLUSION:

The legal context of decision-making capacity and consent to treatment appears complex for healthcare practitioners. Professional, ethical and legal standards of care in this context can benefit from structured education programmes and supportive governance processes. An understanding of why 'duty of care' is being used as a framework within the context of impaired decision-making capacity is warranted, alongside a review of the context of Duty of Care within health policy, guidance and faculty teaching.

A point prevalence study of the use of psychotropic medication in an acute general hospital

BACKGROUND

There are high rates of cognitive problems and organic and functional psychiatric disorders in patients admitted to general hospital wards, which may necessitate the use of psychotropic medications. There is evidence of over-prescription of medications such as antipsychotics and antidepressants in community settings such as residential care. However, the prevalence of psychotropic use in general hospitals is unknown.

METHODS

A point prevalence study of the use of psychotropic medications in an acute general hospital was conducted by auditing medication charts for type, dose, indication, and other clinical processes associated with their use.

RESULTS

The files of 197 patients were audited, 139 (70%) were aged 65 years and over. Eighty-nine (45%) of patients were prescribed a psychotropic, with 35 (17.7%) antidepressants; 21 (11%) antipsychotics; 19 (10%) benzodiazepines; six (3%) mood stabilizer; five (2%) cholinesterase inhibitors; one (0.5%) anti-parkinsonian medication, and one (1%) patient on zolpidem and another patient melatonin (1%). Most prescriptions (72%) were in people 65 years and over and 27 (20%) of indications were found to be off label prescribing. There were deficits in the documentation of indications for the use of psychotropic medications and follow up arrangements.

CONCLUSIONS

Rates of benzodiazepines use were less than that reported incomparable settings. Concerns regarding off label prescribing, under-dosing, and lack of adequate documentation of indications and follow-up instructions were raised. Given the potential adverse effects of psychotropic medication, improved governance, and education regarding their use is required.

Pilot study of a preventive multicomponent nurse intervention to reduce the incidence and severity of delirium in hospitalized older adults: MID-Nurse-P

BACKGROUND

Although multicomponent interventions are the gold standard for delirium management, few nurse-led interventions in Acute Geriatric Units (AGU) are described.

OBJECTIVES

To analyze if a preventive multicomponent non-pharmacologic nurse-led intervention randomized clinical trial (MID-Nurse Study) is feasible (pilot study), and can reduce the incidence, duration, and severity of delirium in hospitalized older adults in an AGU.

DESIGN

Parallel-group double-blind randomized clinical trial (pilot Study).

SETTING

AGU Complejo Hospitalario Universitario, Albacete (Spain).

PARTICIPANTS

50 patients ≥65 years hospitalized in the AGU. Intervention group (IG) 21, control group (CG) 29.

INTERVENTION

After risk factor analysis, all participants in the IG received a daily multicomponent non-pharmacologic intervention (orientation, sensorial deficit, sleep, mobilization, hydration, nutrition, drug chart review, elimination, oxygenation, pain) by the intervention nurses. The CG received usual care.

MEASUREMENTS

Daily delirium presence with the Confusion Assessment Method (CAM), and severity with the Delirium Rating Scale-Revised-98 (DRS). Outcome measures were delirium incidence, prevalence, severity, and number of days with delirium, mortality, length of stay, use of physical restraint measures, and use of drugs for delirium control.

RESULTS

Mean age 86.5 (48% women). 21 participants presented delirium during hospitalization (14CG and 7 IG). Process, resources, management, and scientific objectives were considered positive, making the study feasible. Delirium prevalence (33.3% vs 48.3%) and incidence (14.3% vs 41.4%; p=0.039) were reduced in the IG compared to CG. Total delirium severity was lower in the IG compared to the CG (35.0 vs 65.0; p=0.040). Mortality was not different between groups (CG 17.2% vs IG 19.0%).

CONCLUSION

The MID-Nurse Study is feasible, and a multicomponent nurse-led intervention on patients with delirium in an AGU can reduce delirium prevalence, incidence, and severity. The clinical trial registration number ClinicalTrials.gov ID: NCT02558777.

Relationship between timeliness of contact and length of stay in older and younger patients of a consultation-liaison psychiatry service

Aim and methods The aims were to determine whether the timeliness of contact with a consultation-liaison psychiatry (CLP) service is associated with shorter lengths of stay (LOS), whether this relationship persists for stays greater than 4 days and whether this association varies with age. The length of stay was correlated with the time from admission to contact with the service (the referral lag (REFLAG)), and the REFLAG's proportion of length of stay (REFLAG/LOS) for all 140 in-patients, those with stays greater than 4 days, and for those under and over 65 years. Results The length of stay was significantly correlated with referral lag and logREFLAG/logLOS for all patients and for patients with stays greater than 4 days. The correlations remained significant for both age groups, but were stronger in the younger group. Clinical implications Timeliness of contact with CLP was associated with shorter length of stay, particularly in younger patients. Psychiatric factors influencing length of stay in older patients should be studied by CLP services.

Experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium: one year follow-up

Background

Cardiovascular disease is common among old people and many undergo cardiac surgery. Scientific knowledge is available on cardiac surgery from several perspectives. However, we found few studies focusing on older patients’ experiences of cardiac surgery. The aim of this study was to illuminate experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium, a one year follow-up.

Methods

Qualitative interviews were conducted with 49 participants (aged ≥70 years) diagnosed with delirium after cardiac surgery. Data were collected in Sweden during 2010 through individual, semi-structured interviews in participants’ homes one year after surgery. The interviews were analyzed using qualitative content analysis.

Results

Four themes with sub-themes were formulated: Feeling drained of viability includes having a body under attack, losing strength and being close to death. Feeling trapped in a weird world describes participants having hallucinations, being in a nightmare and being remorseful for their behavior. Being met with disrespect includes feeling disappointed, being forced, and feeling like cargo. On the other hand, Feeling safe, including being in supportive hands and feeling grateful, points to participants’ experiences of good care and the gift of getting a second chance in life.

Conclusions

Even one year after cardiac surgery, participants described in detail feelings of extreme vulnerability and frailty. They also had felt completely in the hands of the health care professionals. Participants described experiences of hallucinations and nightmares during hospitalization. Cardiac surgery was a unique, fearful, traumatic and unpleasant experience yet could also include pleasant or rewarding aspects. It seems that health care professionals need deeper knowledge on postoperative delirium in order to prevent, detect and treat delirium to avoid and relieve the suffering these experiences might cause.

The effect of an e-learning course on nursing staff's knowledge of delirium: a before-and-after study

BACKGROUND

Delirium is a common condition in hospitalized patients, associated with adverse outcomes such as longer hospital stay, functional decline and higher mortality, as well as higher rates of nursing home placement. Nurses often fail to recognize delirium in hospitalized patients, which might be due to a lack of knowledge of delirium diagnosis and treatment. The objective of the study was to test the effectiveness of an e-learning course on nurses' delirium knowledge, describe nursing staff's baseline knowledge about delirium, and describe demographic factors associated with baseline delirium knowledge and the effectiveness of the e-learning course.

METHODS

A before-and-after study design, using an e-learning course on delirium. The course was introduced to all nursing staff of internal medicine and surgical wards of 17 Dutch hospitals.

RESULTS

1,196 invitations for the e-learning course were sent to nursing staff, which included nurses, nursing students and healthcare assistants. Test scores on the final knowledge test (mean 87.4, 95% CI 86.7 to 88.2) were significantly higher than those on baseline (mean 79.3, 95% CI 78.5 to 80.1). At baseline, nursing staff had the most difficulty with questions related to the definition of delirium: what are its symptoms, course, consequences and which patients are at risk. The mean score for this category was 74.3 (95% CI 73.1 to 75.5).

CONCLUSIONS

The e-learning course significantly improved nursing staff's knowledge of delirium in all subgroups of participants and for all question categories. Contrary to other studies, the baseline knowledge assessment showed that, overall, nursing staff was relatively knowledgeable regarding delirium.

TRIAL REGISTRATION

The Netherlands National Trial Register (NTR).

TRIAL NUMBER

NTR 2885 , 19 April 2011.

Wand A. Quality indicators for a consultation-liaison psychiatry service

Purpose

– Consultation-liaison psychiatry (CLP) researchers have not yet developed accepted quality indicators to measure efficiency or effectiveness. The purpose of this paper is to combine objective and subjective quality indicators to assess hospital-based CLP service utilisation, efficiency and effectiveness.

Design/methodology/approach

– Service utilisation rate was calculated over the service's first four years. Patient characteristics and objective quality indicators relating to response timeliness in 2012 were examined. Totally, 41 staff and 52 consecutive patients completed evaluation surveys to subjectively evaluate effectiveness.

Findings

– The utilisation rate increased initially and then slightly declined to 1.03 per cent of all hospital admissions. In 2012, 91.5 per cent were seen on the same referral day and 99.4 per cent by the next day. The benchmark for urgent referrals was not met (77.4 per cent). Patients rated involvement with the CLP service a positive experience (90 per cent), but were less clear about follow-up plans (68 per cent). Staff believed that the service improved the patients’ hospital course (98 per cent) and was communicated well (93-95 per cent). Only 63 per cent agreed that relevant CLP education was provided and 76 per cent rated follow-up plans as clear.

Originality/value

– This CLP service was evaluated by measuring utilisation rates, referral response timeliness and consumer feedback. Referral to contact time is a useful objective quality indicator but should be combined with subjective yet standardised measures surveying service recipients (patients and referring staff) to be comprehensive and meaningful.