Attitudes, knowledge and practices concerning delirium: a survey among intensive care unit professionals

A world-wide study on delirium assessments and presence of protocols

BACKGROUND

Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities.

OBJECTIVE

To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols.

DESIGN

Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023.

SETTING

Cross-sectional online survey including hospitals, rehabilitation and long-term facilities.

METHODS

Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers.

RESULTS

Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions.

CONCLUSION

Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.

Spanish Translation and Cultural Adaptation of the Intensive Care Unit Delirium Playbook

Background

A lack of high-quality provider education hinders the delivery of standard-of-care delirium detection and prevention practices in the intensive care unit (ICU). To fill this gap, we developed and validated an e-learning ICU Delirium Playbook consisting of eight videos and a 44-question knowledge assessment quiz. Given the increasing Spanish-speaking population worldwide, we translated and cross-culturally adapted the playbook from English into Spanish.

Objective

To translate and culturally adapt the ICU Delirium Playbook into Spanish, the second most common native language worldwide.

Methods

The translation and cross-cultural adaptation process included double forward and back translations and harmonization by a 14-person interdisciplinary team of ICU nurses and physicians, delirium experts, methodologists, medical interpreters, and bilingual professionals representing many Spanish-speaking global regions. After a preeducation quiz, a nurse focus group completed the playbook videos and posteducation quiz, followed by a semistructured interview.

Results

The ICU Delirium Playbook: Spanish Version maintained conceptual equivalence to the English version. Focus group participants posted mean (standard deviation) pre- and post-playbook scores of 63% (10%) and 78% (12%), with a 15% (11%) pre-post improvement (P = 0.01). Participants reported improved perceived competency in performing the Confusion Assessment Method for the ICU and provided positive feedback regarding the playbook.

Conclusion

After translation and cultural adaptation, the ICU Delirium Playbook: Spanish Version yielded significant knowledge assessment improvements and positive feedback. The Spanish playbook is now available for public dissemination.

Delirium care in hospitals in Ireland on World Delirium Awareness Day 2023

BACKGROUND

Acute, transient, but sometimes persistent, delirium is characterized by a sharp disruption in attention, consciousness, and cognitive function, and can be caused by many medications and disorders. Delirium occurrence and negative consequences, such as falls and functional decline, can be decreased with multifactorial prevention and timely detection.

AIMS

To describe current clinical practice in relation to the prevention, assessment, and management of delirium in Irish hospitals; awareness-raising and educational activities; and barriers to good practice.

METHODS

On World Delirium Awareness Day (15th March 2023), a global survey was conducted of delirium prevalence and care. A senior clinical staff member on each participating ward reported on delirium prevalence at 8AM and 8PM, and on usual ward practice; this data was entered into an online survey by a data collector (typically a clinician from the site, visiting several wards to record data). This study reports data from Irish hospitals.

RESULTS

In total, 132 wards from 15 hospitals across Ireland participated. Almost 60% of wards used 'personal judgment' for delirium assessment. Having at least one delirium training session in the preceding year was associated with greater use of a formal assessment tool (60.3% versus 18.8%; p < 0.001). Wards reported staff training/education as the main priority to improve care, but 72.7% of wards identified insufficient time to train staff as a key barrier.

CONCLUSIONS

Clinical practice related to delirium care requires improvement. Awareness raising and staff training require more focus and time in busy clinical settings.

Attitudes, knowledge and practices concerning delirium among paediatric intensive care unit nurses: a multisite cross-sectional study in Sichuan, China

BACKGROUND

Delirium is an acute mental state associated with poor outcomes. The incidence of delirium is high, especially in the paediatric intensive care unit (PICU). It is important for staff, particularly nurses, to understand delirium and implement interventions to prevent it. We performed a survey with the aim of evaluating and analysing the factors influencing the knowledge, attitudes and behaviour of PICU nurses towards delirium.

METHODS

This cross-sectional descriptive study included 215 PICU nurses in 6 PICUs from five teaching hospitals in Sichuan Province, China. An online survey about the knowledge, attitudes and practices related to delirium care was conducted among PICU nurses used a self-made and validated questionnaire. The data were analysed using descriptive statistics; differences between groups were compared using t tests, ANOVA and rank-sum tests. Variables with a significance level of 0.05 in the univariate analysis were entered into the multivariable regression analysis to identify predictors.

RESULTS

Only 14.4% of the nurses had a good understanding of delirium, and 40.9% had received relevant training. The mean knowledge score was 9.01 ± 3.86, and the overall passing rate of knowledge was 49.8%. The mean attitude and behaviour scores were 40.95 ± 5.62 and 40.33 ± 8.01, respectively. Among the hospitals, different delirium assessments for children and specific training were performed, explaining approximately 10% of the variability in knowledge scores (F = 6.152), approximately 10% of the variability in attitude/belief scores (F = 5.908), and approximately 17% of the variability in practice scores (F = 10.767).

CONCLUSIONS

PICU nurses have poor knowledge of delirium, particularly regarding its clinical manifestations, influencing factors and medications used, and they have adequate attitudes and confidence and good behaviour regarding delirium in children. To better prevent delirium, we suggest that PICU departments routinely assess delirium and conduct delirium training for nurses.

TRIAL REGISTRATION

Not applicable.

Intensive care nurses' perceptions and awareness of delirium and delirium prevention guidelines

BACKGROUND

Delirium is an acute and fluctuating disturbance of cognition and is a common occurrence in critically ill patients. It is a manifestation of an acute brain dysfunction often attributed to higher survival rates and a subsequently aging population. Intensive Care Unit (ICU) treatment and survival often contributes towards development of delirium, and lack of or inappropriate management can translate into the development of long-term psychological effects that last even after discharge. While a lot is already known about this topic, and several assessment tools exist, these are not being consistently used by ICU nurses and as a result delirium often goes unrecognized, with unwarranted consequences.

AIMS

The study aimed to explore the perception of delirium among ICU nurses, and the extent of their awareness about guidelines to assess and prevent delirium in ICU patients. It also sought to understand the application of delirium guidelines in ICU practice.

STUDY DESIGN

A quantitative, exploratory, self-reporting survey was conducted among 145 ICU nurses from one critical care unit in the Republic of Ireland.

RESULTS

The overall response rate was 71% (103/145). Most nurses (85%) who participated in this survey believed delirium was expected. However, only 45% acknowledged it is a complication. Only 31% of nurses monitored delirium using a validated scale and few observed this as a part of routine care. Most nurses had received education; however, this did not translate to their clinical practice.

CONCLUSIONS

Guidelines on managing delirium may not be routinely implemented in the ICU settings of hospitals in the Republic of Ireland.

RELEVANCE TO CLINICAL PRACTICE

As the findings suggest, a gap exists between theory and practice, necessary revision of policy or creating a new policy, supplemental educational sessions such as bedside sessions, e-learning module, study day or seminars need to be organized to improve nurses' awareness related to delirium and delirium prevention guidelines.

Assessment of level of knowledge, attitude, and associated factors toward delirium among health professionals working in intensive care unit multicenter, cross-sectional study, Amhara region comprehensive specialized hospitals, Northwest Ethiopia, 2023

Background

Patients in Intensive Care Unit (ICU) are at high risk of developing delirium. Lack of early detection and the inability to provide prompt management of delirium remain challenges of ICU patient care. This study aimed to assess the level of knowledge, attitude, and associated factors toward delirium among healthcare providers working in ICU.

Methods

A multicenter, cross-sectional survey was conducted in comprehensive specialized hospitals from 15 April to 5 June 2023. Data were collected using a pretested, self-administered questionnaire. Ordinal logistic regression analysis was performed at p < 0.05 with a 95% confidence interval (CI). The odds ratio with 95% CI was calculated to determine the strength of the association between independent and outcome variables.

Results

A total of 202 health professionals were included in this study, with a response rate of 87%. The proportions of good, moderate, and poor knowledge about delirium in ICU were 29.21 (95% CI: 23-36), 52.48 (95% CI: 45.3-59.5) and 18.32 (95% CI:13.2-24.4), respectively. The overall proportion of negative, neutral and positive attitude were 13.9 (95% CI: 9.4-19.4), 65.8 (95% CI: 58.9-72.4) and 20.3 (95% CI: 15-26.5) respectively. Being an anesthetist and exposure to training were positively associated with a good knowledge while belief in screening tool to change care and reading, and using guidelines were positively associated with a positive attitude. However, believing the impossibility of changing the practice of delirium care, and negative attitudes were delaying factors for a good knowledge. Also, workload and poor knowledge were hindering factors for a positive attitude.

Conclusion

More than half of health professionals had moderate knowledge and neutral attitude toward delirium. However, some of them had poor knowledge and a negative attitude. We recommend stakeholders prepare regular training for delirium care. Also, we urge health professionals to update themselves by reading guidelines and to use screening protocols for delirium.

Effect of protocol-based family visitation on physiological indicators in ICU patients: a randomized controlled trial

BACKGROUND

Intensive care unit (ICU) patients often experience significant physiological stress. This study evaluated the effect of a defined family visitation protocol on physiological responses in the ICU.

METHODS

A randomized, block-randomized clinical trial was conducted on 78 ICU patients at Imam Reza Hospital between February 8, 2017, and August 8, 2017. The intervention group received protocol-based visits, and the control group continued with standard visitation. Block randomization was utilized for group assignments. The primary outcome was the measurement of physiological signs using designated monitoring devices. Data were analyzed using SPSS version 22, employing independent t-tests, Mann-Whitney U test, repeated measures analysis, and Friedman's test.

RESULTS

The results showed no significant differences in systolic blood pressure, diastolic blood pressure, mean arterial pressure, respiratory rate, and arterial blood oxygen levels between the two groups. However, heart rate in the intervention group was significantly lower in three stages before, during, and after the meaningful visiting (P = 0.008).

CONCLUSION

Protocol-based scheduled family visits in the ICU may reduce physiological stress, as evidenced by a decrease in patients' heart rate. Implementing tailored visitation protocols sensitive to patient preferences and clinical contexts is advisable, suggesting the integration of family visits into standard care practices for enhanced patient outcomes.

TRIAL REGISTRATION

IRCT20161229031654N2; 25/01/2018; Iranian Registry of Clinical Trials ( https://en.irct.ir ).

Monitoring delirium in the intensive care unit: Diagnostic accuracy of the CAM-ICU tool when performed by certified nursing assistants - A prospective multicenter study

BACKGROUND

Monitoring delirium in critically ill patients is recognized as a major challenge. Although involving certified nursing assistants could be a valuable help in this field, such strategy has never been formally investigated.

OBJECTIVES

Following theoretical training, we conducted a prospective multicenter study assessing the diagnostic accuracy of a CAM-ICU delirium screening strategy performed by CNAs in clinical settings, compared to parallel blinded evaluations conducted by nurses and physicians.

METHODS

From October 2020 to June 2022, adult intensive care patients admitted in three French University teaching hospitals with Richmond Agitation Sedation Scale ≥-2 were independently assessed for delirium by the three members of the care team (clinical nursing assistant, nurse and physician) using CAM-ICU in a random order. Physician's assessment served as the reference standard for comparisons.

RESULTS

We analyzed results from 268 triplets of CAM-ICU assessments performed sequentially on 203 patients. Prevalence of delirium was 22%. Compared to physician's assessments, clinical nursing assistants demonstrated a sensitivity (Se) of 88% CI95% [80-96] and a specificity (Sp) of 95% [92-98] in detecting delirium. There was no significant difference in the performance of clinical nursing assistants and nurses (Se = 90 % [82-97] p = 0.77, Sp = 98 % [95-100] p = 0.19). We observed high agreement between results obtained by physicians and clinical nursing assistants (ĸ = 0.82) and clinical nursing assistants performance remained consistent in the subgroups at higher risk of delirium.

CONCLUSION

Evaluation of the CAM-ICU by clinical nursing assistants is feasible and should be seen as an opportunity to increase routine monitoring of delirium in intensive care patients.

IMPLICATION FOR CLINICAL PRACTICE

Delirium is a severe and underestimated complication of intensive care unit stay. This study results demonstrate the great performance of trained clinical nursing assistants in detecting delirium using the CAM-ICU. Further research is needed to define the most effective role for clinical nursing assistants in the routine management of delirium in intensive care patients.

Intensive care unit nurses' perception of three different methods for delirium screening: A survey (DELIS-3)

BACKGROUND

Delirium is common in critically ill patients with detrimental effects in terms of increased morbidity, mortality, costs, and human suffering. Delirium detection and management depends on systematic screening for delirium, which can be challenging to implement in clinical practice.

OBJECTIVES

The aim of this study was to explore how nurses in the intensive care unit perceived the use of Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Confusion Assessment Method for the Intensive Care Unit-7 (CAM-ICU-7), and Intensive Care Delirium Screening Checklist (ICDSC) for delirium screening of patients in the intensive care unit.

METHODS

This was a cross-sectional, electronic-based survey of nurses' perceptions of delirium screening with the three different instruments for delirium screening. Nurses were asked to grade their perception of the usability of the three instruments and how well they were perceived to detect delirium and delirium symptom changes on a 1- to 6-point Likert scale. Open questions about perceived advantages and disadvantages of each instrument were analysed using the framework method.

RESULTS

One hundred twenty-seven of 167 invited nurses completed the survey and rated the CAM-ICU-7 as faster and easier than the ICDSC, which was more nuanced and reflected changes in the patient's delirium better. Despite being rated as the fastest, easiest, and most used, the CAM-ICU provided less information and was considered inferior to the CAM-ICU-7 and ICDSC. Using familiar instruments made delirium screening easier, but being able to grade and nuance the delirium assessment was experienced as important for clinical practice.

CONCLUSIONS

Both the ICDSC and the CAM-ICU-7 were perceived well suited for detection of delirium and reflected changes in delirium intensity. The CAM-ICU was rated as fast and easy but inferior in its ability to grade and nuance the assessment of delirium. Emphasis on clinical meaningfulness and continued education in delirium screening are necessary for adherence to delirium management guidelines.

Knowledge, attitude and practice regarding hypoactive delirium among ICU nurses: A nationwide cross-sectional study

AIMS AND OBJECTIVES

This study aimed to assess the knowledge, attitude and practice (KAP) of intensive care unit (ICU) nurses in patients with hypoactive delirium in China.

BACKGROUND

The presentation of hypoactive delirium is not obvious and tends to be ignored. However, it has a high incidence and can cause critical impairment. Although nurses are the primary caregivers of patients, the evidence of the current status of KAP of hypoactive delirium among ICU nurses is insufficient in China.

DESIGN

The study participants were 2835 ICU nurses from 201 hospitals in 69 cities from 31 provinces in China.

METHODS

The current status of KAP of hypoactive delirium among ICU nurses was determined using a self-reported structured questionnaire, including 52 questions covering general personal information; three dimensions of KAP; and relevant issues. Descriptive analyses of the sample distribution were reported as percentages and medians. The factors were detected using univariate and multivariate analyses. To guide the reporting of the research, a STROBE checklist of cross-sectional studies was used.

RESULTS

Of the 3101 returned questionnaires, 2835 were analyzed. Approximately 64. 94 % and 53. 30 % of them were identified with a positive attitude and appropriate practice, respectively, whereas only 1. 48 % showed a good level of knowledge. The regression analysis showed that age, years of working in the ICU, educational background, professional title, caring for patients with delirium, attending training on hypoactive delirium and hospital grading were significantly associated with their KAP status(P＜005).

CONCLUSIONS

Hypoactive delirium is an ignored entity by nursing professionals, with no definite nursing procedure. This study shows that receiving relevant training is a factor affecting KAP status, indicating that training should be strengthened. Additionally, appropriate screening and nursing procedures should be developed to standardize the behavior of ICU nurses and improve the quality of care.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses have poor knowledge of hypoactive delirium and related training should be strengthened, especially for middle-aged nurses. Screening and nursing procedures should be set up, which is critical to promote nursing practice.

NO PATIENT OR PUBLIC CONTRIBUTION

None.

Psychological stress and associated factors in caring for patients with delirium among intensive care unit nurses: A cross-sectional study

BACKGROUND

Caring for patients with delirium is challenging and overwhelming for intensive care unit (ICU) nurses. Investigating the psychological impact of delirium care on ICU nurses is crucial to maintaining their psychological health and improving the quality of care.

OBJECTIVE

The objective of this study was to investigate the psychological stress of ICU nurses in caring for patients with delirium and potential factors.

METHODS

A total of 355 nurses from three tertiary care hospitals in Hunan Province, China, participated in this cross-sectional survey. Data were collected using the demographic sheet, Impact of Event Scale-Revised, Connor-Davidson Resilience Scale, and Occupational Coping Self-Efficacy Scale for Nurses. Descriptive and multiple linear regression analyses were used to examine the factors associated with psychological stress.

RESULTS

ICU nurses suffered moderate psychological stress related to delirium care. The recent time to care for patients with delirium (P < 0.001), familiarity with delirium-related knowledge (P = 0.002), satisfaction with delirium-related support (P = 0.046), psychological resilience (P < 0.001), and occupational coping self-efficacy (P < 0.001) were significant contributors to psychological stress.

CONCLUSION

Nurse managers and researchers need to focus on the psychological well-being of ICU nurses in caring for patients with delirium, especially those who are currently caring for patients with delirium, and provide tailored support, increase their knowledge of delirium, and also boost psychological resilience and coping skills.

Knowledge, barriers, and training needs of nurses working in delirium care

BACKGROUND

Nurses' competency in delirium care is important because delirium can extend hospitalization and increase patient mortality.

AIM

This study aimed at identifying and comparing the perceived knowledge, barriers, importance, performance, and training priorities between the intensive care unit (ICU) and ward nurses working in delirium care.

STUDY DESIGN

This cross-sectional descriptive study included 71 ICU nurses and 149 ward nurses at one university hospital. Nurses' self-reported knowledge, barriers, importance, and performance of delirium care were surveyed. Data were analysed using descriptive statistics, chi-squared test or Fisher's exact test, Wilcoxon signed-rank tests, Mann-Whitney U tests, and the importance-performance analysis matrix.

RESULTS

Compared to ward nurses, ICU nurses reported lower overall knowledge level (57.1% vs 60.7%, z = -2.005, P = .045) but higher overall gap between the importance and performance of delirium care (0.5 vs 0.2, z = -4.008, P < .001). The level of overall barriers to delirium care was similar between the two groups (3.8 vs 3.8, z = -1.190, P = .234). The highest training priority, showing high importance but low performance in the importance-performance matrix, was "family involvement and education" for ICU nurses and "non-pharmacological management" for ward nurses.

CONCLUSIONS

The highest training priority for delirium care was different between ICU and ward nurses. To enhance the delirium care competency of hospital nurses, the nurse educator should develop training programs that target knowledge deficits, perceived barriers, and training priorities.

RELEVANCE TO CLINICAL PRACTICE

Acute cognitive disturbances are common in patients hospitalized in wards and ICUs and can lead to adverse patient outcomes if not properly assessed and managed. Nurse educators need to develop and implement a training program based on the needs assessment and priorities identified in this study so that ICU and ward nurses can obtain the optimal level of delirium care competency.

Development and Validation of an ICU Delirium Playbook for Provider Education

Although delirium detection and prevention practices are recommended in critical care guidelines, there remains a persistent lack of effective delirium education for ICU providers. To address this knowledge-practice gap, we developed an "ICU Delirium Playbook" to educate providers on delirium detection (using the Confusion Assessment Method for the ICU) and prevention.

DESIGN

Building on our previous ICU Delirium Video Series, our interdisciplinary team developed a corresponding quiz to form a digital "ICU Delirium Playbook." Playbook content validity was evaluated by delirium experts, and face validity by an ICU nurse focus group. Additionally, focus group participants completed the quiz before and after video viewing. Remaining focus group concerns were evaluated in semi-structured follow-up interviews.

SETTING

Online validation survey, virtual focus group, and virtual interviews.

SUBJECTS

The validation group included six delirium experts in the fields of critical care, geriatrics, nursing, and ICU education. The face validation group included nine ICU nurses, three of whom participated in the semi-structured feedback interviews.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The 44-question quiz had excellent content validity (average scale-level content validity index [S-CVI] of individual items = 0.99, universal agreement S-CVI = 0.93, agreement κ ≥ 0.75, and clarity p ≥ 0.8). The focus group participants completed the Playbook in an average (sd) time of 53 (14) minutes, demonstrating significant improvements in pre-post quiz scores (74% vs 86%; p = 0.0009). Verbal feedback highlighted the conciseness, utility, and relevance of the Playbook, with all participants agreeing to deploy the digital education module in their ICUs.

CONCLUSIONS

The ICU Delirium Playbook is a novel, first-of-its-kind asynchronous digital education tool aimed to standardize delirium detection and prevention practices. After a rigorous content and face validation process, the Playbook is now available for widespread use.

Knowledge, attitude, and practice regarding postoperative delirium among cardiac surgery nurses: A cross-sectional multi-centre study

AIMS AND OBJECTIVES

To examine knowledge, attitude, and practice regarding postoperative delirium and the relationships among cardiac surgery nurses in China.

BACKGROUND

Postoperative delirium is a prevalent and devastating complication following cardiac surgery. Nurses play a part in multi-disciplinary collaboration for preventing and managing postoperative delirium, of whom knowledge, attitude, and practice are essential.

DESIGN

A cross-sectional multi-centre study.

METHODS

Nurses from cardiac surgery wards and intensive care units of five tertiary hospitals in Wuhan, Hubei Province, China were enrolled. Data were gathered online using a self-administered questionnaire. Student's t-test, or analysis of variance, or non-parametric tests were performed to compare differences across groups. Bootstrapping mediation analysis was conducted to examine the relationship between knowledge, attitude, and practice. The STROBE checklist was used for the reporting of this study.

RESULTS

Of 429 nurses, a moderate level of knowledge and high levels of attitude and practice regarding postoperative delirium were revealed. Nurses with higher education, higher academic title, 5-10 years of practice in nursing and cardiac surgery nursing exhibited increased knowledge. With advanced age, practice in a specialised hospital, and training experience, nurses reported a better degree of practice. Attitude played a full mediating effect in the relationship between knowledge and practice, accounting for 81.82% of the total effects.

CONCLUSIONS

Knowledge, attitude, and practice regarding postoperative delirium are promising among Chinese cardiac surgery nurses, with knowledge of screening tools and perioperative nonpharmacological interventions and practice of screening in need of enhancement. Attitudes act as an intermediary between knowledge and practice regarding postoperative delirium.

RELEVANCE TO CLINICAL PRACTICE

Innovative and stratified in-service education is warranted to address knowledge enhancement. Meanwhile, organisations are suggested to make efforts to foster nurses' positive attitudes, particularly in creating a favourable culture and developing institutional protocols for postoperative delirium management to improve practice.

NO PATIENT OR PUBLIC CONTRIBUTION

This study is focused on cardiac surgery nurses' knowledge, attitude, and practice regarding postoperative delirium, and the research questions and design are from clinical nursing practice, literature review, and expert panel review, in which the patient or public is temporarily not involved.

Clinical application of 'Sophia Observation withdrawal Symptoms-Paediatric Delirium' screening tool in Danish version: A feasibility study

AIMS AND OBJECTIVES

The aims of the present study were investigating the feasibility of: (1) using the Danish version of Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) screening tool in clinical practice and (2) comparing SOS-PD performance to a child psychiatrist's assessment using the diagnostic criteria as a reference standard.

BACKGROUND

Critically ill children risk developing delirium potentially causing discomfort and suffering. Intensive care delirium has a fluctuating course complicating detection. Systematic screening during and after intensive care is central to manage paediatric delirium.

DESIGN AND METHODS

We used a descriptive and comparative design. First aim: Bedside nurses were asked to evaluate their experience of using the SOS-PD. Second aim: We compared the SOS-PD performance with the child psychiatrist assessment in 50 children aged 4 weeks to 18 years.

RESULTS

Nurses found the Danish version of the SOS-PD applicable and easy to use. Of the 50 children included, 13 were diagnosed with delirium by the child psychiatrist. Consistency was found between the SOS-PD score and the child psychiatrist's assessment (88%). We found three false-negative and three false-positive SOS-PD cases. The false-negative cases could be explained by the differences in time periods for the assessments. SOS-PD assessments covered the past 4 h, whereas the psychiatric assessments covered the past 24 h. We assume the false-positive cases represent an acceptable inconsistency between the two assessment methods.

CONCLUSIONS

The Danish version of the SOS-PD appeared suitable for identifying paediatric delirium. Our results emphasised the importance of assessment at least once during each nursing shift to ensure delirium detection around the clock due to the fluctuating course of delirium.

RELEVANCE TO CLINICAL PRACTICE

Implementing the Danish SOS-PD may increase awareness of this critical disorder by improving systematic identification of paediatric delirium in clinical practice paving the way for improved delirium prevention and management.

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis

Background

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.

Objective

The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.

Design

The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.

Settings

Surgical wards, surgical intensive care units, and post-anaesthesia care units.

Data sources

A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.

Participants

Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.

Methods

In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.

Results

The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care.

Conclusions

In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

Knowledge, attitudes and practices of ICU nurses regarding subsyndromal delirium among 20 hospitals in China: a descriptive cross-sectional survey

OBJECTIVES

This study sought to investigate nurses' knowledge, attitudes and practices, and analyse the influencing factors for subsyndromal delirium (SSD).

DESIGN

A descriptive cross-sectional survey.

SETTING

E-questionnaires were distributed to intensive care unit (ICU) nurses from 20 tertiary-grade, A-class hospitals in Henan Province, China.

PARTICIPANTS

A total of 740 ICU nurses participated in the questionnaire survey.

MAIN OUTCOME MEASURES

Each dimension score is converted to a percentage scale. A score of ≤60% on each dimension of the questionnaire was considered a negative score, <80% was considered a intermediate score and ≥80% was considered an excellent score.

RESULTS

A total of 733 questionnaires were included in the study. More than half of the nurses were at the intermediate level, and a few nurses were at the excellent level. Nurses self-assessed their level of knowledge was intermediate. In the attitudes dimension, nurses' attitudes were negative. The results of the practical dimension showed that most nurses could carry out the clinical practice. Multiple linear regression analysis showed that educational level and received SSD training were influencing factors.

CONCLUSIONS

ICU nursing staff overestimated their knowledge of SSD and showed a negative attitude towards it. Various forms of education and training are necessary.

Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis

Background

Postoperative delirium (POD) is an acute brain dysfunction that is frequently observed in patients undergoing cardiac surgery. Increasing evidence indicates POD is related to higher mortality among cardiac surgical patients, but the results remain controversial. Moreover, a quantitative evaluation of the influence of POD on hospital days, intensive care unit (ICU) time, and mechanical ventilation (MV) time has not been performed.

Objective

This study aimed to evaluate the correlation between POD and outcomes in patients undergoing cardiac surgery by a systematic review and meta-analysis.

Materials and methods

A total of 7 electronic databases (Cochrane Library, PubMed, EMBASE, CINAHL Complete, MEDLINE, Wan-fang database, and China National Knowledge Infrastructure) were searched from January 1980 to July 20, 2021, with language restrictions to English and Chinese, to estimate the impact of the POD on outcome in patients who underwent cardiac surgery. The meta-analysis was registered with PROSPERO (Registration: CRD42021228767).

Results

Forty-two eligible studies with 19785 patients were identified. 3368 (17.0%) patients were in the delirium group and 16417 (83%) were in the non-delirium group. The meta-analysis showed that compared to patients without POD, patients with POD had 2.77-fold higher mortality (OR = 2.77, 95% CI 1.86-4.11, P < 0.001), 5.70-fold higher MV (>24h) rate (OR = 5.70, 95% CI 2.93-11.09, P < 0.001); and longer MV time (SMD = 0.83, 95% CI 0.57-1.09, P < 0.001), ICU time (SMD = 0.91, 95% CI 0.60-1.22, P < 0.001), hospital days (SMD = 0.62, 95% CI 0.48-0.76, P < 0.001).

Conclusion

The synthesized evidence suggests that POD is causally related to the increased risk of mortality, prolonged length of ICU and hospital stay, and a longer duration of MV time. Future research should focus on the interventions for POD, to reduce the incidence.

Systematic review registration

[www.crd.york.ac.uk/PROSPERO], identifier [CRD42021228767].

Implementation of music in colorectal perioperative standard care-barriers and facilitators among patients and healthcare professionals

AIM

Perioperative anxiety and pain are still prevalent among patients undergoing surgery. Inflammatory bowel disease and colorectal cancer patients are known to have higher anxiety rates than the general population. Perioperatively applied music intervention has been proven to be effective in reducing perioperative anxiety and pain, resulting in a decrease of intra-operative sedative use, postoperative opioid requirement and neurohormonal stress response. IMPROVE evaluates the adherence to music intervention in colorectal perioperative standard care during systematic implementation.

METHOD

The Consolidated Framework for Implementation Research (CFIR) was used for implementation in three steps. This study addresses the first step in which barriers and facilitators for implementing perioperative music were identified by surveying patients who underwent colorectal surgery and healthcare professionals involved in perioperative care. Also, perioperative anxiety scores were assessed and data on perioperative pain was collected from the patients' medical records.

RESULTS

Fifty patients and 69 professionals (response rate 68.3%) were surveyed. For patients, all domains of the CFIR were facilitating implementation. The median reported preoperative and postoperative anxiety scores were 4.5 (1.0-7.0) and 3.0 (1.0-5.75) respectively. The median postoperative pain score on the first postoperative day was 2.8 (2.0-3.7). Also, for professionals most domains were facilitating, except for some factors related to work climate and culture among nurses.

CONCLUSIONS

In this study it was identified that facilitating factors for implementing music in standard perioperative care were more prominent in both patients and healthcare professionals and therefore successful implementation is probable. Also, this study provides a guideline for assessing facilitators and barriers in other settings.

Recognizing Intensive Care Unit Delirium: Are Critical Care Nurses Ready?

BACKGROUND

Delirium remains significantly undetected in the intensive care unit (ICU). Little is known regarding the level of delirium care knowledge among critical care nurses in Taiwan.

PURPOSE

This study was designed to investigate the level of knowledge about delirium care among critical care nurses using a multiple-choice question quiz.

METHODS

A descriptive, cross-sectional approach was used, and data were collected using a web-based survey. The demographic characteristics including age, years worked as critical care nurse, gender, advanced ICU training, educational level, and type of ICU, along with a delirium care knowledge quiz, were collected. The quiz consisted of 16 items measuring (a) symptoms, types, and outcomes; (b) high-risk groups; (c) predisposing and precipitating factors; and (d) assessment and detection of delirium. Data were collected between October 6 and November 16, 2020.

RESULTS

In total, 324 critical care nurses completed the survey. The rate of correct response on the delirium care quiz for each domain was measured: (a) symptoms, types, and outcomes: 67.1%; (b) high-risk groups: 76.2%; (c) predisposing and precipitating factors: 78.9%; and (d) assessment and detection: 41.5%. The item with the lowest correct response rate was related to the interpretation of delirium assessments.

CONCLUSION/IMPLICATIONS FOR PRACTICE

The findings of this study suggest that future studies and education should focus on the use and interpretation of the assessment using a valid delirium assessment tool to improve the ability of critical care nurses to detect delirium in ICU settings.

Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

BACKGROUND

Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.

OBJECTIVES

The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.

METHODS

We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test-retest reliability.

RESULTS

Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68-.87) and test-retest reliability (intraclass correlation coefficients = .46-.62) were confirmed.

CONCLUSION

We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

Delirium on stroke units: a prospective, multicentric quality-improvement project

Background

Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management.

Methods

Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others.

Results

Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved.

Conclusions

Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke.

Registry

DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11000-6.

Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka

Background

Delirium is a common, underdiagnosed, and undertreated condition that increases morbidity and mortality in ICU patients which has an incidence up to 80%. Barriers that hinder optimum care of delirium include inadequate knowledge, poor attitudes, and low perceived importance of delirium care.

Aim

To assess attitudes, knowledge, and current practices related to delirium care among medical professionals working in intensive care units (ICUs) in all teaching hospitals in Central Province, Sri Lanka, as there are no Sri Lankan studies on this regard.

Method

A descriptive cross-sectional study was carried out among all medical professionals working in nine ICUs in all (n = 5) teaching hospitals in Central Province. Data were collected using a pretested self-administered questionnaire. Responses to questions were compared between postgraduate trainee medical officers (PG-MOs) and non-postgraduate-trainee medical officers (non-PG-MOs).

Results

Eighty-eight questionnaires were analyzed. More than 80% of PGs and non-PG-MOs regarded ICU delirium as significant problem that should be screened and prevented. Forty-one percent stated confidence in diagnosing delirium. However, more than 75% of non-PG-MOs failed to recognize features of hypoactive delirium. Only 30–50% subjects in incorporated preventive methods in usual practice and more than 60% non-PG-MOs had poor knowledge and experience on delirium screening. More than 80% of the participants did not routinely screen their patients. More than 90% non-PG-MOs (p <0.05) had no recent educational exposure.

Conclusion

A positive attitude toward the importance of management of delirium was observed. However, there is a discrepancy between the perceived importance and the current practice related to screening and prevention. Participants, especially non-PG-MOs, lacked knowledge on delirium screening, diagnosis, and identification of risk factors, probably related to a lack of educational exposure.

How to cite this article

Arachchi TMJ, Pinto V. Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka. Indian J Crit Care Med 2021;25(12):1413–1420.

Knowledge, attitude, and practice toward delirium and subtype assessment among Chinese clinical nurses and determinant factors: A multicentre cross-section study

BACKGROUND

Delirium, a confused transient state of consciousness, can be divided into hyperactive, hypoactive, mixed, and no motor subtypes, according to different clinical manifestations. Several studies have investigated delirium subtypes in the knowledge dimension, but few studies have investigated delirium subtype in the attitude and practice dimensions. The barriers, knowledge sources, and practice details regarding subtype assessment are unclear.

OBJECTIVES

This study had three objectives. First, we planned to investigate the KAP status regarding delirium and subtypes for nurses. Second, we wanted to identify factors affecting clinical nurses' KAP scores. Third, this study expected to explore more details regarding delirium and subtypes assessment, including assessment barriers, assessment instruments, and knowledge sources.

METHODS

This multicentre cross-section study was conducted in 10 tertiary hospitals in three provinces, China, from January to April 2022. We investigated 477 nurses from six departments with a high prevalence. The self-developed KAP questionnaire regarding delirium and subtypes assessment had four parts: knowledge, attitude, practice, and source. Its reliability and validity were verified effectively by 2-round Delphi expert consultation.

RESULTS

A total of 477 nurses from the general intensive care unit (ICU), specialty ICU, orthopedics, thoracic surgery, operating room, and geriatrics were 28.3, 22.4, 22.2, 10.5, and 5.2%, respectively. The total KAP score regarding delirium and subtypes assessment was 60.01 ± 6.98, and the scoring rate was 73.18%. The scoring rate for knowledge, attitude, and practice was 58.55, 83.94, and 51.70%, respectively. More than half (54.1%) were unaware of the delirium subtypes assessment instruments. A total of 451 (94.6%) participants recognized the importance of nursing work for delirium prevention. A total of 250 (52.4%) nurses occasionally or sometimes assessed delirium subtypes, and 143 (30.0%) never assessed for delirium subtypes. We found that age, department, technical title, familiarity with delirium, familiarity with delirium subtypes, delirium training, and subtype training affected the total KAP scores. ICU nurses achieved the highest scores.

CONCLUSION

Chinese nurses' KAP status regarding delirium and subtypes assessment were barely acceptable, and the attitude score was positive, but knowledge and practice needed improvement. Meanwhile, the department was one of the significant KAP factors, and ICU nurses did better in delirium and subtype assessment in knowledge and practice dimension than other departments. Systematic and scientific training processes including subtype content and assessment tools are required. Experience still drives nurses' assessments of delirium and subtype. Adding the delirium assessment into routine tasks should be considered.

Managing agitation secondary to hyperactive delirium in deteriorating patients

Delirium is an under-recognised condition which adversely affects deteriorating patients. Delirium can be an acute or long-term condition and is associated with increased morbidity and mortality, and extended length of hospital stay. The management of delirium is often reactive rather than proactive, which can lead to the inappropriate use of chemical and physical restraint to control agitation secondary to hyperactive delirium. Caring for patients with delirium presents physical and emotional challenges for nurses, who are sometimes inclined to use restraint, which should be a last resort. This article describes the challenges of caring for patients with delirium, presents the risk factors for and assessment of delirium, and describes the management of agitation secondary to hyperactive delirium. Support and education for nurses caring for patients with delirium is essential to ensure optimal patient care and avoid staff burnout.

Delirium in Intensive Care Units: Perceptions of Physicians and Nurses

Delirium is an indicator of morbidity and mortality in intensive care unit (ICU) patients. It can lead to negative outcomes and longer hospital stays, thus increasing hospital costs. Despite national recommendations for daily assessment of delirium, it remains underdiagnosed. Many studies point to a lack of knowledge among health care professionals to accurately detect and manage ICU delirium. The aim of our study was to assess the knowledge, attitudes, and practices of Palestinian health care professionals regarding ICU delirium. The results of a cross-section observational study revealed that delirium appears to be often underrecognized or misdiagnosed in ICUs in Palestine. Therefore, it is critical to further educate the medical and nursing teams and to promote the use of validated tools that can aid in the assessment of this condition. In this way, the length of hospital stays and related health care costs can be reduced.

Delirium and long term cognition in critically ill patients

Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.

Evaluation of an Educational Intervention Utilizing Nurse "Champions" and Nurses' Documentation of Intensive Care Unit Delirium

BACKGROUND

Delirium is a common, underdetected problem that has short- and long-term negative sequelae for critically ill patients. Prompt and accurate delirium identification by nurses can ensure early intervention and treatment to help minimize adverse outcomes.

OBJECTIVES

To evaluate the relationship between an educational program and the accuracy of registered nurses' (RNs') documentation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a delirium screening tool.

METHODS

In a medical ICU at a tertiary academic medical center from September 2015 to March 2016, RNs were reinstructed on use of the CAM-ICU. Registered nurse assessment data were collected retrospectively for 12 months before and after intervention and were compared against the CAM-ICU algorithm using χ analysis.

RESULTS

A total of 10 736 RN assessments in 1020 patients preintervention and 11 068 in 951 patients postintervention were evaluated. Overall RN accuracy improved from 78% to 80% (P = .054). The algorithm determined delirium to be present in 32% versus 30% of all patients preintervention and postintervention, respectively; there was no difference in rate of nurse detection of delirium preintervention and postintervention (54% vs 55%, not statistically significant). The percentage of "inappropriate unable to assess" ratings by nurses decreased from 42% to 37% postintervention (P < .05).

CONCLUSIONS

After a comprehensive training initiative, there was no significant improvement in CAM-ICU documentation and no improvements in patient delirium identification. Future quality improvement efforts should target reducing the number of assessments that RNs judge to be "unable to assess." Clinical practice must evolve to routinely incorporate RN delirium assessments into the patient's plan of care.

Prevention and Management of Delirium in the Intensive Care Unit

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

Prospective multicentre multifaceted before-after implementation study of ICU delirium guidelines: a process evaluation

Objective

We aimed to explore: the exposure of healthcare workers to a delirium guidelines implementation programme; effects on guideline adherence at intensive care unit (ICU) level; impact on knowledge and barriers, and experiences with the implementation.

Design

A mixed-methods process evaluation of a prospective multicentre implementation study.

Setting

Six ICUs.

Participants

4449 adult ICU patients and 500 ICU professionals approximately.

Intervention

A tailored implementation programme.

Main outcome measure

Adherence to delirium guidelines recommendations at ICU level before, during and after implementation; knowledge and perceived barriers; and experiences with the implementation.

Results

Five of six ICUs were exposed to all implementation strategies as planned. More than 85% followed the required e-learnings; 92% of the nurses attended the clinical classroom lessons; five ICUs used all available implementation strategies and perceived to have implemented all guideline recommendations (>90%). Adherence to predefined performance indicators (PIs) at ICU level was only above the preset target (>85%) for delirium screening. For all other PIs, the inter-ICU variability was between 34% and 72%. The implementation of delirium guidelines was feasible and successful in resolving the majority of barriers found before the implementation. The improvement was well sustained 6 months after full guideline implementation. Knowledge about delirium was improved (from 61% to 65%). The implementation programme was experienced as very successful.

Conclusions

Multifaceted implementation can improve and sustain adherence to delirium guidelines, is feasible and can largely be performed as planned. However, variability in delirium guideline adherence at individual ICUs remains a challenge, indicating the need for more tailoring at centre level.

ICU Delirium-Prediction Models: A Systematic Review

Supplemental Digital Content is available in the text.

Objective:

Summarize performance and development of ICU delirium-prediction models published within the past 5 years.

Data Sources:

Systematic electronic searches were conducted in April 2019 using PubMed, Embase, Cochrane Central, Web of Science, and Cumulative Index to Nursing and Allied Health Literature to identify peer-reviewed studies.

Study Selection:

Eligible studies were published in English during the past 5 years that specifically addressed the development, validation, or recalibration of delirium-prediction models in adult ICU populations.

Data Extraction:

Screened citations were extracted independently by three investigators with a 42% overlap to verify consistency using the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies.

Data Synthesis:

Eighteen studies featuring 23 distinct prediction models were included. Model performance varied greatly, as assessed by area under the receiver operating characteristic curve (0.62–0.94), specificity (0.50–0.97), and sensitivity (0.45–0.96). Most models used data collected from a single time point or window to predict the occurrence of delirium at any point during hospital or ICU admission, and lacked mechanisms for providing pragmatic, actionable predictions to clinicians.

Conclusions:

Although most ICU delirium-prediction models have relatively good performance, they have limited applicability to clinical practice. Most models were static, making predictions based on data collected at a single time-point, failing to account for fluctuating conditions during ICU admission. Further research is needed to create clinically relevant dynamic delirium-prediction models that can adapt to changes in individual patient physiology over time and deliver actionable predictions to clinicians.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

The influence of a serious game's narrative on students' attitudes and learning experiences regarding delirium: an interview study

BACKGROUND

Delirium is a neuropsychiatric syndrome that affects patients' attention and awareness as a result of a physical condition. In recent years, persistent gaps in delirium education have led to suboptimal delirium care. Still, little is known about what are the most important aspects of effective delirium education. Serious games are both entertainment and an interactive, safe learning environment where players can experiment and create new knowledge. They have the potential to contribute to improved delirium education. We used a video-based serious games' narrative to explore aspects essential to enhance students' attitudes and learning experiences regarding delirium.

METHODS

We created a semi-structured interview guide and interviewed seven nursing and nine medical students about their attitudes and learning experiences, after they had played the game. A qualitative descriptive design and inductive content analysis with constant comparison were used.

RESULTS

The patient's and nurse's perspective, interactivity to experiment, realistic views on care options, and feedback on care actions were important for enhancing students' attitudes and learning experiences regarding delirium. Students felt these aspects encouraged them to get actively involved in and experiment with the study material, which in turn led to enhanced reflection on delirium care and education. Our findings highlight the importance of a more patient-oriented focus to delirium education to drive attitudinal change. Students' learning experiences were further enhanced through their affective responses provoked by the perspectives, interactivity, realism, and feedback.

CONCLUSIONS

Students considered the characters' perspectives, interactivity, realism, and feedback important aspects of the game to enhance their attitudes towards delirious patients and enrich their learning experiences. A patient-oriented narrative provides a clinically relevant experience in which reflection plays an important role. The serious game also serves as medium to actively experiment with care solutions to create better understanding of how healthcare professionals can influence a delirious patient's experience.

Implementation of strategies to prevent and treat postoperative delirium in the post-anesthesia caring unit : A German survey of current practice

Postoperative delirium is associated with worse outcome. The aim of this study was to understand present strategies for delirium screening and therapy in German Post-Anesthesia-Caring-Units (PACU). We designed a German-wide web-based questionnaire which was sent to 922 chairmen of anesthesiologic departments and to 726 anesthetists working in ambulatory surgery. The response rate was 30% for hospital anesthesiologists. 10% (95%-confidence interval: 8–12) of the anesthesiologists applied a standardised screening for delirium. Even though not on a regular basis, in 44% (41–47) of the hospitals, a recommended and validated screening was used, the Nursing Delirium Screening Scale (NuDesc) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). If delirium was likely to occur, 46% (43–50) of the patients were examined using a delirium tool. 20% (17–23) of the patients were screened in intensive care units. For the treatment of delirium, alpha-2-agonists (83%, 80–85) were used most frequently for vegetative symptoms, benzodiazepines for anxiety in 71% (68–74), typical neuroleptics in 77% (71–82%) of patients with psychotic symptoms and in 20% (15–25) in patients with hypoactive delirium. 45% (39–51) of the respondents suggested no therapy for this entity. Monitoring of delirium is not established as a standard procedure in German PACUs. However, symptom-oriented therapy for postoperative delirium corresponds with current guidelines.

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

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

[Study protocol to improve the quality of delirium management in intensive care]

BACKGROUND

Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far.

HYPOTHESIS

In cardiac surgery ICU patients, standardized delirium management will lead after a 4‑week introduction, compared to nonstandardized treatment, to a reduction of delirium duration.

METHODS

Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients.

INCLUSION CRITERIA

(a) ≥18 years, (b) consent for research with their data.

EXCLUSION CRITERIA

(a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics.

OBJECTIVES

The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.

Critical care nurses' perception of care coordination competency for management of mechanically ventilated patients

AIMS AND OBJECTIVES

To evaluate nurses' care coordination competency for mechanically ventilated patients in intensive care units (ICUs) of Saudi Arabia (SA).

BACKGROUND

ICUs are increasingly using multidisciplinary approach to provide critical care. Functionality gaps remain within these teams preventing optimum performance, including a lack of adequate care coordination in the management of mechanically ventilated (MV) patients.

DESIGN

A cross-sectional survey of ICU nurses working across 20 hospitals in SA.

METHODS

The Nurses' Care Coordination Competency Scale (NCCCS) survey for MV patients was administered to all the nurses to assess their care coordination competence. The data were analysed using Student's t test, ANOVA and linear regression. Reporting of this research follows STROBE guidelines.

RESULTS

A total of 254 nurses participated in the survey. The overall NCCCS mean score was 3.94 (±0.69) out of a 5-point scale. Also, the "promoting team cohesion factor (Factor 1)" had a mean score of 3.90 (±0.77), the "understanding care coordination needs factor (Factor II)" had a mean score of 4.00 (±0.77), the "aggregating and disseminating information factor (Factor III)" had a mean score of 4.05 (±0.76), and the "devising and clearly articulating the care vision factor (Factor IV)" had a mean score of 3.78 (±0.87). The mean overall NCCCS score was 4.10 among Indians, 3.98 among Filipinos and 3.81 among Saudi nationals.

CONCLUSION

There were a high overall score and subscale scores of nurses' care coordination competence for mechanically ventilated patients, but few gaps were identified in some of the items.

RELEVANCE TO CLINICAL PRACTICE

The results provide information on the status and gaps in ICU nurses' care coordination competencies to address the needs of mechanically ventilated critically ill patients. The NCCCS can be utilised as an educational tool for nurses who are new to the ICU work environment.

Iranian Nurses Perception and Practices for Delirium Assessment in Intensive Care Units

Introduction

Delirium is a fluctuating cognitive disorder that occurs in admitted patients, especially in patients who are in intensive care units. Nurses due to persistent contact with patients and direct observation of their mental changes play an essential role in delirium evaluation. Early detection of delirium, identification of risk factors, and its prevention methods are critical to reducing complications, mortality, and treatment costs. This study aimed to determine the perception and the practices of nurses in intensive care units to assess delirium and its barriers.

Study design

A cross-sectional study.

Materials and methods

All nurses working in the intensive care unit (neurology, trauma, surgery, general, and heart) of educational hospitals in Kerman, Iran, were the study population. The data gathering tool was a questionnaire consisting of four sections: demographic information, nurses’ perception, practices, and perceived barriers in delirium assessment.

Results

The total score of nurses’ perception in delirium assessment was 19.47 ± 3.36, which was higher than the medium score of the questionnaire (estimated score = 16). In all, 45.5% of nurses reported having delirium treatment protocol in their units, and 12.1% of the nurses considered delirium as a priority of evaluating the patient's condition. The most important barrier to delirium assessment was the difficulty of assessing delirium in intubated patients. There was no association between nurses’ perception and practices (p value > 0.05).

Conclusion

Designing and implementing educational programs for improving nurses’ practices in this field is necessary.

Clinical significance

Healthcare providers, especially nurses, should be aware of the delirium assessment of the ICU patients to provide better care.

How to cite this article

Biyabanaki F, Arab M, Dehghan M. Iranian Nurses Perception and Practices for Delirium Assessment in Intensive Care Units. Indian J Crit Care Med 2020;24(10):955–959.

Development of a Tool for the Assessment of Nurses' Attitudes Toward Delirium

BACKGROUND AND PURPOSE

The prevalence of delirium during hospitalization is high in older patients and there is evidence of staff regarding them as unpopular or a burden. This study aims to develop an instrument examining nurses' attitudes toward patients with delirium.

METHODS

Stages included (a) content identification, (b) content development, (c) content critique, (e) pilot study with a test-retest reliability, (f) field study consisting of psychometric testing of the internal consistency and construct validity.

RESULTS

The Cronbach's alpha was 0.89 and the stability reliability was acceptable. The factor analysis resulted in three factors explaining a total of 56.5% of the variance. hese factors are "beliefs," "behavior," and "emotions," explaining 37.025%, 12.792%, and 5.652% of variance.

CONCLUSIONS

The Attitude Tool of Delirium (ATOD) is a reliable and valid instrument for the assessment of attitudes toward delirium.

Incidence, risk factors, and cumulative risk of delirium among ICU patients: A case-control study

Objectives

Delirium is a common acute cognitive impairment syndrome among intensive care unit (ICU) patients. This study was aimed to investigate the incidence, risk factors, and cumulative risk of delirium among ICU patients.

Methods

A case-control study including clinical records of 452 patients were retrospectively analyzed. Delirium was assessed using the Confusion Assessment Method for the ICU and Richmond Agitation–Sedation Scale.

Results

We found that 163 out of the 452 patients (36.1%) had delirium. Multivariate analysis showed that use of sedatives, length of ICU hospitalization, and physical restraint were independent risk factors for delirium. The additive effect of all three factors resulted to an odds ratio of 30.950.

Conclusion

The incidence of delirium remained high. Thus, nurses shall strengthen the monitoring of delirium, regularly access the patient's level of calmness, and limit the use of physical restraint.

Reliability and accuracy of delirium assessments among investigators at multiple international centres

INTRODUCTION

Delirium is a common, serious postoperative complication. For clinical studies to generate valid findings, delirium assessments must be standardised and administered accurately by independent researchers. The Confusion Assessment Method (CAM) is a widely used delirium assessment tool. The objective was to determine whether implementing a standardised CAM training protocol for researchers at multiple international sites yields reliable inter-rater assessment and accurate delirium diagnosis.

METHODS

Patients consented to video recordings of CAM delirium assessments for research purposes. Raters underwent structured training in CAM administration. Training entailed didactic education, role-playing with intensive feedback, apprenticeship with experienced researchers and group discussions of complex cases. Raters independently viewed and scored nine video-recorded CAM interviews. Inter-rater reliability was determined using Fleiss kappa. Accuracy was judged by comparing raters' scores with those of an expert delirium researcher.

RESULTS

Twenty-seven raters from eight international research centres completed the study and achieved almost perfect agreement for overall delirium diagnosis, kappa=0.88 (95% CI 0.85 to 0.92). Agreement of the four core CAM features ranged from fair to substantial. The sensitivity and specificity for identifying delirium were 72% (95% CI 60% to 81%) and 99% (95% CI 96% to 100%), considering an expert rater's scores as the reference standard (delirious, n=3; non-delirious, n=6). Delirium severity ratings were tightly clustered, with most scores within 5% of the median.

CONCLUSION

Our results demonstrate that, with appropriate training and ongoing scoring discussions, researchers at multiple sites can reliably detect delirium in postsurgical patients. These results support the premise that methodologically rigorous multi-centre studies can yield standardised and accurate determinations of delirium.

e-Screening revolution: A novel approach to developing a delirium screening tool in the intensive care unit

OBJECTIVES

Delirium is common in the intensive care unit (ICU), often affecting older patients. A bedside electronic tool has the potential to revolutionise delirium screening. Our group describe a novel approach to the design and development of delirium screening questions for the express purpose of use within an electronic device. Preliminary results are presented.

METHODS

Our group designed a series of tests which targeted the clinical criteria for delirium according to Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) criteria against predefined requirements, including applicability to older patients.

RESULTS

Candidate questions, including tests of attention and awareness, were devised and then refined by an expert multidisciplinary group, including geriatricians. A scoring scheme was constructed, with testing to failure an indicator of delirium. The device was tested in healthy controls, aged 20-80 years, who were recorded as being without delirium.

CONCLUSION

e-Screening for delirium requires a novel approach to instrument design but may revolutionise recognition of delirium in ICU.

Postoperative Delirium After Esophagectomy: The Efficacy of Continual Monitoring Using the NEECHAM Confusion Scale

Abstract Background

Although a majority of nurses understand that delirium is a major issue in perioperative care, professional barriers to routine monitoring using delirium assessment tools exist. The aim of this study was to assess the effectiveness of continual monitoring of postoperative delirium in patients that have undergone esophagectomy using the Neelon and Champagne (NEECHAM) Confusion Scale (NCS).

Methods

Demographic data and case histories were obtained from medical records. We conducted NCS scoring for 1 week after surgery and verified the daily changes in scores. Patients were classified into normal, neurocognitive-change, and complication groups for the analysis of the influence of preoperative neurocognitive changes and postoperative complications.

Results

Data from 19 patients were analyzed. NCS scores decreased sharply on the first day and then significantly recovered each day. The normal group exhibited a steady recovery process, but the other groups deviated from this progression. The incidence of delirium was highest on the first day. The incidence in the normal group decreased each day, but other groups developed delirium for an extended time. In the NCS subscale score analyses, the information processing score was low in the neurocognitive-change group. The complication group exhibited delayed recovery of the physiologic control score.

Conclusions

We observed the recovery process of mental function after esophagectomy as well as the impact of preoperative neurocognitive changes and postoperative complications. Continual monitoring of postoperative mental function may predict postoperative delirium. For early detection and prevention of delirium, nurses should monitor postoperative mental function via daily observation.

Implementing a Multicomponent Intervention to Prevent Delirium Among Critically Ill Patients

BACKGROUND

Delirium is common among the critically ill. Nonpharmacologic interventions are reportedly effective in reducing incident delirium, but limited data specific to this population exist.

OBJECTIVES

To assess the efficacy and describe the implementation strategy of a multicomponent intervention to prevent delirium in an intensive care unit.

METHODS

A before-and-after study was conducted in an intensive care unit between May 2014 through August 2015. Adult participants were enrolled consecutively, excluding only those who refused to participate. Tailored interventions took available evidence into consideration. Components included early mobilization, physical therapy, reorientation, cognitive stimulation, drug reviews, environmental stimulation, avoidance of sensory deprivation, pain control, restraint use avoidance, and family participation. Incident delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Multivariate logistic regression was used to control for confounders.

RESULTS

The study included 227 patients (54.7% male; mean [SD] age, 63.3 [18.3] years). Our strategy significantly reduced delirium (from 38% to 24%; relative risk, 0.62; 95% CI, 0.40–0.94; P = .02), an association that remained significant after adjusting for confounders. Adherence rates were more than 85% in all intervention domains (except daily reorientation) that were overseen by health care providers.

CONCLUSIONs

The strategy was successful in reducing delirium. Self-removals of invasive implements decreased, an observation that has not been previously described. No difference in mortality rate was seen, as has been reported in other studies. Early participation of the whole team, shared leadership, and the provision of concrete tasks were key to the success of this multicomponent intervention.

Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review

BACKGROUND

Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation.

METHODS

We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved.

RESULTS

Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination).

CONCLUSIONS

We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.