How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups

Difficulties faced by intensive care nurses in caring for patients with delirium: A cross-sectional, multicentre study

BACKGROUND

Intensive care nurses experience many difficulties in caring for patients with delirium. Thus, it is valuable to conduct in-depth research on the factors that influence the difficulties faced by intensive care nurses in caring for those with delirium as doing so can result in tangible improvements in patient outcomes.

OBJECTIVES

The objective of this study was to explore the difficulties faced by intensive care nurses in caring for patients with delirium in light of the demographic, clinical, and professional and management characteristics of nurses.

METHODS

A cross-sectional study involving 360 intensive care nurses from eight general hospitals in Taizhou, Zhejiang Province, China. The participants completed questionnaires assessing the level of difficulty they faced in caring for patients with delirium and their level of delirium-related knowledge.

RESULTS

The highest overall mean scores on the difficulty scale subscales were observed for ensuring safety (2.92 ± 0.30), dealing with stress and distress (2.80 ± 0.37), and lack of resources (2.85 ± 0.41). The main factors influencing nurses' difficulty in caring for these patients were title, status as a critical care specialist nurse, training regarding delirium, a standardised delirium management process, the knowledge level regarding delirium, the total number of years working in the intensive care unit, and work communication ability. Likewise, most of these characteristics made it difficult for the nurses to use delirium screening tools.

CONCLUSIONS

This study provides insights into factors influencing the difficulties faced by intensive care nurses in caring for patients with delirium and in using delirium screening tools. Our findings suggested that nursing managers could develop targeted improvement strategies and provide more resources to support nurses, thereby improving the quality of delirium care and patient outcomes by using the results from this study. These findings can also provide evidence to support intervention studies in the future.

Nurse anesthetists' perceptions and experiences of managing emergence delirium: A qualitative study

BACKGROUND

This study employs a descriptive phenomenological approach to investigate the challenges anesthesia nurses face in managing emergence delirium (ED), a common and complex postoperative complication in the post-anesthesia care unit. The role of nurses in managing ED is critical, yet research on their understanding and management strategies for ED is lacking.

AIM

To investigate anesthetic nurses' cognition and management experiences of ED in hopes of developing a standardized management protocol.

METHODS

This study employed a descriptive phenomenological approach from qualitative research methodologies. Purposeful sampling was utilized to select 12 anesthetic nurses from a tertiary hospital in Shanghai as research subjects. Semi-structured interviews were conducted, and the data were organized and analyzed using Colaizzi's seven-step analysis method, from which the final themes were extracted.

RESULTS

After analyzing the interview content, four main themes and eight subthemes were distilled: Inefficient cognition hinders the identification of ED (conceptual ambiguity, empirical identification), managing diversity and challenges (patient-centered safe care, low level of medical-nursing collaboration), work responsibilities and pressure coexist (heavy work responsibilities, occupational risks and stress), demand for high-quality management (expecting the construction of predictive assessment tools and prevention strategies, and pursuing standardized management processes to enhance management effectiveness).

CONCLUSION

Nursing managers should prioritize the needs and suggestions of nurses in order to enhance their nursing capabilities and provide guidance for standardized management processes.

Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery : A Nationwide Cohort Study

BACKGROUND

Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time.

OBJECTIVE

To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery.

DESIGN

Retrospective cohort study.

SETTING

U.S. hospitals in the Premier Healthcare Database.

PATIENTS

17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018.

INTERVENTIONS

Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg).

MEASUREMENTS

The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting.

RESULTS

The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group.

LIMITATION

Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment.

CONCLUSION

These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug.

PRIMARY FUNDING SOURCE

National Institute on Aging.

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.

Barriers and facilitators of early mobilisation for intensive care unit delirium: perspectives from patients, family members and carers. A qualitative study protocol

Background/Aims

One-third of patients develop delirium following admission to an intensive care unit. Intensive care unit delirium is associated with poor patient outcomes, including long-term disability and high mortality. Early mobilisation contributes towards the prevention and reduction of intensive care unit delirium. However, the implementation of early mobilisation is infrequent. The aim of this protocol is to explore participants' experiences of the barriers to, and facilitators of, early mobilisation in the adult intensive care unit specific to people experiencing delirium.

Methods

Three moderators will carry out up to six focus groups including up to five participants in each group. Focus group discussions will be used to explore the experiences of patients, carers and family members using Microsoft Teams. Participants will be recruited from the charity ICUsteps using a purposive sampling technique.

Results

Discussions will be audio-recorded and simultaneously transcribed verbatim using the otter.ai programme. Member check approval will be sought to ensure accuracy of data. Framework analysis using a thematic methodology will identify themes in the data.

Conclusions

It is anticipated that the findings of this study will contribute towards further understanding the implementation of early mobilisation in order to improve measures for prevention and management of delirium in the adult intensive care unit.

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.

Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review

BACKGROUND

Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role.

OBJECTIVES

The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU.

METHODS

A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715.

RESULTS

Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues.

CONCLUSIONS

This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.

EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC): a protocol for an interprofessional mixed-method study

INTRODUCTION

Agitation and violent behaviours are common conditions developed by patients with acute traumatic brain injury (TBI) in intensive care units (ICUs). Healthcare professionals caring for these patients have various tools to manage these behaviours, but lack of a formal protocol to assess and manage them makes caring for these patients a challenge. Moreover, safety may often be compromised for both ICU professionals and patients encountering such situations. The EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC) study aims to explore the experiences and attitudes of ICU nurses and other ICU healthcare professionals on the management of agitated behaviours in patients with acute TBI.

METHODS AND ANALYSIS

EXSTATIC is a multicenter mixed methods convergent study exploring experiences and attitudes of ICU healthcare professionals caring of agitated patients with TBI. The study includes three qualitative methods (observation, semistructured interviews and focus groups) and one quantitative method (retrospective cohort). The integration of the different methods will be done using sequential steps of the research and by the integration of results for each step. Qualitative data will be evaluated following a thematic analysis derived from a grounded theory approach. Quantitative data will be analysed using descriptive statistics. Qualitative and quantitative results will be combined in a convergent interactive interpretative design. Gender and race perspective will be integrated in collection, analysis and interpretation of data.

ETHICS AND DISSEMINATION

This study has been approved by the Centre intégré universitaire de santé et de services sociaux du nord de l'île de Montréal (CIUSSS-NÎM) Research Ethics Board. The findings will be disseminated locally with ICU staff and health managers, international peer-reviewed journals, a PhD dissertation, and national and international conferences. The knowledge derived from this study is key in the development of clinical protocols to manage agitation and related behaviours in patients with TBI and designing further interventional studies targeting this specific problematic.

TRIAL REGISTRATION NUMBER

NCT04741399.

Nursing Insights on Delirium in the Intensive Care Unit: A Quality Improvement Study

Delirium is a common complication of critical illness. As frontline providers, nurses (registered nurses) are uniquely positioned to inform interventions to improve intensive care unit (ICU) patient outcomes. This article reports a study of attitudes and knowledge about ICU delirium assessment at an urban academic medical center. Findings suggest a knowledge deficit regarding the spectrum of delirium. ICU nurses also identified that a lack of effective collaboration within the treatment team was the biggest barrier to effective care for the patient with hypoactive delirium. The study findings indicate that both educational and management initiatives are needed to improve clinical practices for patients with manifestations of hypoactive and hyperactive delirium.

The multidisciplinary team perspectives on agitation management in critical care: A qualitative study

BACKGROUND

People who are experiencing a period of critical illness frequently experience severe agitation. The presence of agitation can pose risks to the patient, family, and clinical team.

AIMS AND OBJECTIVES

To capture the views and opinions of critical care multidisciplinary teams concerning the approaches in the management of agitation, and to understand and identify the perceived risks and benefits of current management strategies.

DESIGN

A descriptive qualitative design.

METHODS

Data were gathered using semi-structured interviews with multidisciplinary teams from adult critical care units from one region in the United Kingdom.

FINDINGS

A total of 19 participants participated between February to September 2017. There were two group interviews (GIs) (n = 12, GI 1 n = 8, GI 2 n = 4) and seven one-to-one interviews, across four hospital organisations with one participant working via an agency. The mean length (± SD) of each interview, one to one or group, was 58.86 minutes (5.81 minutes). Three major themes were generated about the complex clinical decision-making required to manage an agitated patient. These themes represented: the burden of care, continuity of clinical decision-making, and uncertainty and indecision experienced by participants.

CONCLUSION

Participants described caring for an agitated patient as challenging and stressful. Staff sought clarification on what level of restrictive practice is allowed. Feelings of anxiety and stress generated by the decisions made may have an impact on staff, particularly those who are more inexperienced, which in the longer term could lead to fatigue or moral distress.

RELEVANCE TO CLINICAL PRACTICE

The study has emphasised the challenges faced by multidisciplinary teams and how decision-making may impact on individuals within the team.

Assessing the uncertainty of treatment outcomes in a previous systematic review of venous leg ulcer randomized controlled trials: Additional secondary analysis

In this secondary analysis of a previous systematic review, we assessed randomized controlled trials evaluating treatments of venous leg ulcers in terms of factors that affect risk of bias at the study level and thus uncertainty of outcomes obtained from the interventions. Articles that assessed the wound bed condition in venous leg ulcers and that were published in English between 1998 and May 22, 2018 were previously searched in PubMed, Embase, CINAHL, CENTRAL, Scopus, Science Direct, and Web of Science. Duplicates and retracted articles were excluded. The following data were extracted to assess the risk of bias: treatment groups; primary and secondary endpoints that were statistically tested between groups, including their results and p values; whether blinding of patients and assessors was done; whether allocation concealment was adequate; whether an intention‐to‐treat analysis was conducted; whether an appropriate power calculation was correctly done; and whether an appropriate multiplicity adjustment was made, as necessary. Pre‐ and post‐study power calculations were made. The step‐up Hochberg procedure adjusted for multiplicity. Results were analysed for all studies, pre‐2013 studies, and 2013/post‐2013 studies. We included 142 randomized controlled trials that evaluated 14,141 patients. Most studies lacked blinding (72.5–77.5%) and allocation concealment (88.7%). Only 49.3% of trials provided a power calculation, with 27.5% having an appropriate calculation correctly done. Adequate statistical power of the primary endpoint was found in 27.2% of trials. The lack of multiplicity adjustment in 98.6% of studies affected the uncertainty of outcomes in 20% of studies, with the majority of the secondary endpoints (67.7%) in those studies becoming non‐significant after multiplicity adjustment. Recent studies tended to weakly demonstrate improved certainty of outcomes. Venous leg ulcer randomized controlled trials have a high degree of uncertainty associated with treatment outcomes. Greater attention to trial design and conduct is needed to improve the evidence base.

Non-pharmacologic interventions for the prevention of delirium in the intensive care unit: An integrative review

BACKGROUND

Delirium in the intensive care unit (ICU) is associated with increased mortality, longer hospital stays, and increased odds of institutionalization after discharge. Delirium is a significant complication that occurs frequently in ICU yet lacks a standardized treatment protocol. Because of the limited effective pharmacologic treatments available for the management of delirium, non-pharmacologic interventions such as early mobilization, earplugs and blinds at night, music and natural sunlight during the day, continuous reorientation, and increased visitation and family participation are essential to integrate into the treatment plan for the management of delirium in the ICU.

AIM

To summarize evidence on the use of non-pharmacologic interventions for the reduction in incidence and duration of delirium in ICU patients and to integrate qualitative studies that explore the perception of delirium in the ICU from staff and patients' families to support the use of non-pharmacologic interventions.

METHODS

For this integrative review, electronic databases PubMed, EMBASE, and Google Scholar were searched using the guidance of a librarian and second reviewer to find qualitative and quantitative studies that were published after 2005 and involved adult patients in the ICU.

CONCLUSION

Eight quantitative articles and four qualitative articles were chosen to be included in this review. All eight quantitative studies provide significant evidence (P < .05) for the efficacy of their interventions to provide benefit to at least one delirium-related outcome. The four qualitative research studies reviewed provide insight on delirium in the ICU from staff and patients' families who share a desire for the use of effective non-pharmacologic interventions.

RELEVANCE TO CLINICAL PRACTICE

Non-pharmacologic interventions used for patients in the ICU may be efficacious in reducing the incidence and duration of delirium in adults. Non-pharmacologic interventions are feasible and supported by ICU staff and patients' families and should be considered in the care of the critically ill patient.

The training needs of Korean intensive care unit nurses regarding delirium

OBJECTIVES

The aim of this study was to investigate high-priority training needs by analysing the perceived importance and self-reported performance of nurses' delirium care competency.

DESIGN

A cross-sectional survey with a convenience sample of 255 Korean intensive care units nurses.

SETTING

Intensive care units in the Republic of Korea.

MAIN OUTCOME MEASURES

Intensive care unit nurses' delirium care competency.

RESULTS

Exploratory factor analysis of the Nurse Delirium Care Competency Scale showed a six-factor structure, which accounted for 67.51% of the variance in nurses' delirium care competency: management algorithm, prevention, communication, nursing management, assessment, and collaboration. The self-reported performance scores of all six factors were significantly lower than their perceived importance scores. The delirium assessment factor was identified as a high training priority on the importance-performance matrix for new graduate nurses.

CONCLUSION

Training programmes should be developed considering the six delirium care competency factors identified in this study. Further, nurse educators must adopt active educational modalities such as case-based small group learning and simulation-based learning to improve nurse competency in recognising and managing delirium.

Nurses' knowledge and attitudes regarding physical restraint in Turkish intensive care units

BACKGROUND

Physical restraint is still widely used despite studies supporting a reduction in its use. The development of guidelines to reduce the use of PR first requires the identification of factors related to the use of alternative methods.

AIM

This study aimed to determine factors associated with the use of alternatives to physical restraint (PR) in intensive care units.

DESIGN

This was a cross-sectional descriptive study.

METHODS

Data were collected from adult intensive care units of three hospitals in Turkey using the Physical Restraint Knowledge, Attitude and Practice Scale and a questionnaire including open-ended questions.

RESULTS

Overall, 202 nurses (80% response rate) completed the questionnaire. Nurses' knowledge, attitude, and practice scores regarding PR were 6.89 ± 1.79, 29.85 ± 4.93, and 36.76 ± 3.36, respectively. PR was reported to be necessary for patients at risk of self-harm, with dangerous behaviours, and who were trying to remove their catheters. Most nurses (64.9%) stated that they needed a written doctor's order. Analysis of free-text responses showed that patient disorientation (because of delirium, sedation, or agitation), nurses' workload, and lack of training regarding restraint were the primary reasons why nurses could not use alternatives. The main alternatives suggested by nurses were categorized as sedation, communication, and environmental regulation. Logistic regression analysis identified training (P = .009), working unit (P = .001), and nurses' practice score to use PR (P = .004) as independent risk factors for not using alternative methods of PR.

CONCLUSIONS

The results of this study revealed a moderate level of knowledge, attitude, and practice among nurses regarding the use of PR. Thus, education of nurses about the prevention of delirium and alternatives to PR according to the characteristics of their units is required.

RELEVANCE TO CLINICAL PRACTICE

Clinical guidelines and in-service training need to be developed to increase the use of alternatives to PR and delirium management.

Enabling interprofessional collaboration in delirium management / Interprofessionelle Zusammenarbeit im Delir-Management gestalten

Introduction

Interprofessional collaboration (IPC) is dependent on different expectations and communication styles. IPC is a meaningful approach to accomplish treatment goals, especially in patients with delirium. Delirium affects approximately 50 % of patients older than 65 years in acute care settings. The constant attention and effort needed to care for patients suffering from delirium is challenging and cannot be provided by one profession alone. Instead, there is a need for IPC.

Aim

This study aims to analyse the structure of IPC in the treatment of patients suffering from delirium.

Method

Data was collected by conducting three group interviews and six individual interviews with members of different professions in an acute care hospital, and analysed by Charmaz's (2014) grounded theory approach.

Results

A model called enabling IPC in delirium management was developed. This model shows how mutual respect and appreciation, being in dialog and dealing with challenges in IPC interact with each other and also affect each other. Mutual respect and appreciation are common baseline values that have a pivotal effect on the dialog between professions and the management of IPC challenges. Being in dialog and dealing with challenges in IPC are essential values for enabling IPC, as well as mutual respect and appreciation.

Conclusion

Mutual respect and appreciation is fundamental for enabling IPC in the treatment of patients suffering from delirium. Interprofessional education, structured interprofessional care conferences and standardised communication can offer opportunities to foster mutual respect and appreciation which, in turn enable IPC.

Qualitative descriptive study to explore nurses' perceptions and experience on pain, agitation and delirium management in a community intensive care unit

OBJECTIVES

The purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically ill patients.

DESIGN

A qualitative descriptive study.

SETTING

This study took place in a community hospital ICU located in a medium size Canadian city.

PARTICIPANTS

Purposeful sampling was conducted. Participants included full-time nurses working in the ICU. Forty-six ICU nurses participated.

METHODS

A total of five focus group sessions were held to collect data. There were one to three separate groups in each focus group session, with no more than seven participants in each group. There were 10 separate groups in total. A semistructured question guide was used. Thematic analysis method was adopted to analyse the data, and to search for emergent themes and patterns.

RESULTS

Three main themes emerged: (1) the professional perspectives on patient wakefulness state, (2) the professional perspectives on PAD management of critically ill patients and (3) the factors impacting PAD management. Nurses have different opinions on the optimal level of patient sedation and felt that many factors, including environmental, healthcare teams, patients and family members, can influence PAD management. This potentially leads to inconsistent PAD management in critically ill patients. The nurses also believed that PAD management requires a multidisciplinary approach including healthcare teams and patients' families.

CONCLUSIONS

Many external and internal factors contribute to the complexity of PAD management including the attitudes of nursing staff towards PAD. The themes emerged from this study suggested the need of a multifaceted and multidisciplinary quality improvement programme to optimise the management of PAD in the ICU.

Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in a Canadian community intensive care unit: a quality improvement study protocol

BACKGROUND

Pain and agitation are closely linked to the development of delirium, which affects 60%-87% of critically ill patients. Delirium is associated with increased mortality and morbidity. Clinical guidelines that suggest routine assessment, treatment and prevention of pain, agitation and delirium (PAD) is crucial to improving patient outcomes. However, the adoption of and adherence to PAD guidelines remain suboptimal, especially in community hospitals. The aim of this quality improvement study is to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community intensive care unit (ICU).

METHODS

This is a quality improvement, uncontrolled, before-and-after study of a multifaceted and multidisciplinary intervention targeting nurses (educational modules, visual reminders), family members (interviews, educational pamphlets and an educational video), physicians (multidisciplinary round script) and the multidisciplinary team as a whole (delirium poster). We will collect data every day for 6 weeks before implementing the intervention. Data collection will include clinical information and information on process of care. We will then implement the intervention. Four weeks after, we will collect data daily for 6 weeks to evaluate the effect of the intervention. On the basis of the volume of the ICU, we expect to enroll approximately 280 patients. We have obtained local ethics approval from the Hamilton Integrated Research Ethics Board (HiREB 18-040-C).

INTERPRETATION

The results of this quality improvement study will provide information on adherence to PAD guidelines in a Canadian community ICU setting. They will also supply information on the feasibility of implementing multifaceted and multidisciplinary PAD interventions in community ICUs.

‘I hope you get normal again’: an explorative study on how delirious octogenarian patients experience their interactions with healthcare professionals and relatives after aortic valve therapy

Background:

Delirium affects nearly half of octogenarian patients after aortic valve replacement, resulting in impaired cognition, reduced awareness and hallucinations. Although healthcare professionals and relatives are often present during episodes, the nature of interactions with them is scarcely studied, and little is known about their long-term experiences.

Purpose:

The purpose of this study was to explore and describe how octogenarian patients with post-aortic valve replacement delirium experience interactions with healthcare professionals and relatives within the first year and four years later.

Method:

An explorative design with qualitative content analysis was used. Delirium was assessed for five consecutive days after aortic valve replacement using the Confusion Assessment Method. Delirious patients ( n=10) were interviewed 6–12 months post-discharge and four years later ( n=5). We used an inductive approach to identify themes in transcribed interviews.

Findings:

An overarching theme emerged: ‘ Healthcare professionals’ and relatives’ responses made a considerable impact on the delirium experience postoperatively and in a long-term’. Three sub-themes described the patients’ experiences: ‘ the need for close supportive care’, ‘ disrespectful behaviour created a barrier’ and ‘ insensitive comments made lasting impressions’. Having healthcare professionals and relatives nearby made the patients feel secure, while lack of attention elevated patients’ emotional distress. Four years later, patients clearly recalled negative comments and unsupportive actions in their delirious state.

Conclusions:

Healthcare professionals and relatives have an essential role in the aortic valve replacement recovery process. Inconsiderate behaviour directed at older patients in delirium elevates distress and has long-term implications. Supportive care focused on maintaining the patients’ dignity and integrity is vital.

Management of Pediatric Delirium in Pediatric Cardiac Intensive Care Patients: An International Survey of Current Practices

OBJECTIVES

The purpose of this study was to describe how pediatric cardiac intensive care clinicians assess and manage delirium in patients following cardiac surgery.

DESIGN

Descriptive self-report survey.

SETTING

A web-based survey of pediatric cardiac intensive care clinicians who are members of the Pediatric Cardiac Intensive Care Society.

PATIENT OR SUBJECTS

Pediatric cardiac intensive care clinicians (physicians and nurses).

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

One-hundred seventy-three clinicians practicing in 71 different institutions located in 13 countries completed the survey. Respondents described their clinical impression of the occurrence of delirium to be approximately 25%. Most respondents (75%) reported that their ICU does not routinely screen for delirium. Over half of the respondents (61%) have never attended a lecture on delirium. The majority of respondents (86%) were not satisfied with current delirium screening, diagnosis, and management practices. Promotion of day/night cycle, exposure to natural light, deintensification of care, sleep hygiene, and reorientation to prevent or manage delirium were among nonpharmacologic interventions reported along with the use of anxiolytic, antipsychotic, and medications for insomnia.

CONCLUSIONS

Clinicians responding to the survey reported a range of delirium assessment and management practices in postoperative pediatric cardiac surgery patients. Study results highlight the need for improvement in delirium education for pediatric cardiac intensive care clinicians as well as the need for systematic evaluation of current delirium assessment and management practices.

The Effects of a Delirium Notification Program on the Clinical Outcomes of the Intensive Care Unit: A Preliminary Pilot Study

Background

Delirium is common among intensive care unit (ICU) patients, so recent clinical guidelines recommended routine delirium monitoring in the ICU. But, its effect on the patient’s clinical outcome is still controversial. In particular, the effect of systems that inform the primary physician of the results of monitoring is largely unknown.

Methods

The delirium notification program using bedside signs and electronic chart notifications was applied to the pre-existing delirium monitoring protocol. Every patient was routinely evaluated for delirium, pain, and anxiety using validated tools. Clinical outcomes, including duration of delirium, ICU stay, and mortality were reviewed and compared for 3 months before and after the program implementation.

Results

There was no significant difference between the two periods of delirium, ICU stay, and mortality. However, anxiety, an important prognostic factor in the ICU survivor’s mental health, was significantly reduced and pain tended to decrease.

Conclusions

Increasing the physician’s awareness of the patient’s mental state by using a notification program could reduce the anxiety of ICU patients even though it may not reduce delirium. The results suggested that the method of delivering the results of monitoring was also an important factor in the success of the delirium monitoring program.

Do systematic reviews address community healthcare professionals' wound care uncertainties? Results from evidence mapping in wound care

Background

Complex wounds such as leg and foot ulcers are common, resource intensive and have negative impacts on patients’ wellbeing. Evidence-based decision-making, substantiated by high quality evidence such as from systematic reviews, is widely advocated for improving patient care and healthcare efficiency. Consequently, we set out to classify and map the extent to which up-to-date systematic reviews containing robust evidence exist for wound care uncertainties prioritised by community-based healthcare professionals.

Methods

We asked healthcare professionals to prioritise uncertainties based on complex wound care decisions, and then classified 28 uncertainties according to the type and level of decision. For each uncertainty, we searched for relevant systematic reviews. Two independent reviewers screened abstracts and full texts of reviews against the following criteria: meeting an a priori definition of a systematic review, sufficiently addressing the uncertainty, published during or after 2012, and identifying high quality research evidence.

Results

The most common uncertainty type was ‘interventions’ 24/28 (85%); the majority concerned wound level decisions 15/28 (53%) however, service delivery level decisions (10/28) were given highest priority. Overall, we found 162 potentially relevant reviews of which 57 (35%) were not systematic reviews. Of 106 systematic reviews, only 28 were relevant to an uncertainty and 18 of these were published within the preceding five years; none identified high quality research evidence.

Conclusions

Despite the growing volume of published primary research, healthcare professionals delivering wound care have important clinical uncertainties which are not addressed by up-to-date systematic reviews containing high certainty evidence. These are high priority topics requiring new research and systematic reviews which are regularly updated. To reduce clinical and research waste, we recommend systematic reviewers and researchers make greater efforts to ensure that research addresses important clinical uncertainties and is of sufficient rigour to inform practice.

Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium

Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.

Nurses' and physicians' perceptions of Confusion Assessment Method for the intensive care unit for delirium detection: focus group study

BACKGROUND

Delirium in the intensive care unit (ICU) has received more attention in the past decade. Early detection, prevention and treatment of delirium are important, and the most commonly used tool for delirium assessment is the Confusion Assessment Method for the ICU (CAM-ICU).

AIM

The aim of this study was to identify nurses' and physicians' perceived professional barriers to using the CAM-ICU in Danish ICUs.

METHODS

This study uses a qualitative explorative multicentre design using focus groups and a semi-structured interview guide. Five focus groups with nurses (n = 20) and four with physicians (n = 14) were conducted. Strategic sampling was used to include participants with varying CAM-ICU experience at units, with variable implementation of the tool.

RESULTS

Using a hermeneutical approach, three main themes and nine sub-themes emerged. The main themes were (1) Professional role issues: CAM-ICU screening affected nursing care, clinical judgment and professional integrity; (2) Instrument reliability: nurses and physicians expressed concerns about CAM-ICU assessment in non-sedated patients, patients with multi-organ failure or patients influenced by residual sedatives/opioids; and (3) Clinical consequence: after CAM-ICU assessment, physicians lacked evidence-based treatment options, and nurses lacked physician acknowledgment and guidelines for disclosing CAM-ICU results to patients.

CONCLUSION

In this study, ICU nurses and physicians raised a number of concerns regarding the use of the CAM-ICU for delirium detection. It might be necessary to revalidate the instrument as ICU care has changed in recent years, with lighter sedation and early mobilization of patients. We recommend that nurses and physicians receive more training in the use of the CAM-ICU to address some of the issues identified in our study.

RELEVANCE TO CLINICAL PRACTICE

There is a need for ongoing training and clearer guidelines on how to proceed with the delirium screening of non-sedated patients.