Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management

Nurses' perceptions of patient pain, delirium, and sedation assessments in the intensive care unit: A qualitative study

BACKGROUND

Pain, delirium, and sedation should be assessed routinely using validated assessment scales. Inappropriately managed pain, delirium, and sedation in critically ill patients can have serious consequences regarding mortality, morbidity, and increased healthcare costs. Despite the benefits of a bundled approach to pain, delirium, and sedation assessments, few studies have explored nurses' perceptions of using validated scales for such assessments. Furthermore, no studies have examined nurses' perceptions of undertaking these assessments as a bundled approach.

OBJECTIVES

The objective of this study was to explore nurses' knowledge, perceptions, attitudes, and experiences regarding the use of validated pain, delirium, and sedation assessment tools as a bundled approach in the intensive care unit (ICU).

METHODS

A qualitative exploratory descriptive design was adopted. We conducted four focus groups and 10 individual interviews with 23 nurses from a 26-bed adult ICU at an Australian metropolitan tertiary teaching hospital. Data were analysed using thematic analysis techniques.

FINDINGS

Four themes were identified: (i) factors impacting nurses' ability to undertake pain, delirium, and sedation assessments in the ICU; (ii) use, misuse, and nonuse of tools and use of alternative strategies to assess pain, delirium, and sedation; (iii) implementing assessment tools; and (iv) consequences of suboptimal pain, delirium, and sedation assessments. A gap was found in nurses' use of validated scales to assess pain, delirium, and sedation as a bundled approach, and they were not familiar with using a bundled approach to assessment.

CONCLUSION

The practice gap could be addressed using a carefully planned implementation strategy. Strategies could include a policy and protocol for assessing pain, delirium, and sedation in the ICU, engagement of change champions to facilitate uptake of the strategy, reminder and feedback systems, further in-service education, and ongoing workplace training for nurses.

A qualitative study of geriatric specialist nurses' experiences to navigate delirium in the elderly

BACKGROUND

The experiences and perceptions of geriatric specialist nurses are pivotal to understanding the complexities of managing delirium and to developing effective nursing interventions. This qualitative study aims to explore these experiences and perceptions to inform the enhancement of clinical geriatric nursing and care practices.

METHODS

Utilizing a qualitative exploratory design, this research engaged a convenience sample of geriatric specialist nurses at a tertiary hospital in Shanghai, China through focus groups and semi-structured interviews. Data were rigorously analyzed using Colaizzi's phenomenological method, which facilitated the identification of themes that emerged from the narratives of the geriatric specialist nurses.

RESULTS

The thematic analysis yielded three major themes that encapsulate the nurses' experiences and perceptions. Theme 1: Understanding of Delirium, highlighted the nurses' awareness of the condition's significance, yet it was often deprioritized due to the pressing demands of managing more acute and immediately life-threatening conditions. Theme 2: Barriers in Application, brought to light the multifaceted challenges faced by nurses, including language barriers, the frequency and consistency of delirium assessments, the social determinants of health, and the nurses' own competencies in assessment. Theme 3: Evolution of Nursing Approaches, detailed the adaptive strategies employed by nurses, such as managing nursing adverse events, improving communication with patients' families, and adopting a proactive stance towards long-term patient outcomes.

CONCLUSIONS

The findings suggest that while geriatric specialist nurses recognize the importance of delirium assessment, there are several barriers to effective application. The study underscores the imperative for the advancement of more refined delirium assessment and care protocols, tailored to address the unique requirements of geriatric nursing care.

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.

A family intervention to prevent postoperative delirium in patients undergoing cardiac valve surgery: A randomized controlled study

BACKGROUND

Multiple guidelines recommend that families be involved in the care of ICU patients, which has been widely used in ICU delirium management in recent years. Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with poor outcomes; however, the effects of family intervention on this group are rarely studied.

OBJECTIVES

This study aimed to investigate the effects of family intervention on the incidence of POD and the ICU prognoses of patients undergoing cardiac valve surgery.

METHODS

This was a two-group, single-blind, randomized controlled trial involving 80 patients undergoing cardiac valve surgery, with 40 patients in each group. The control group received routine ICU visits, and the experimental group implemented a family intervention that instructed family caregivers to participate in delirium management during ICU visits. The occurrence of POD, ICU stay, mechanical ventilation time of patients; as well as the anxiety, depression, and satisfaction levels of family caregivers were compared between the two groups.

RESULTS

The incidence of POD and ICU stay of patients were significantly lower in the experimental group compared to the control group (P < 0.05). The anxiety and depression incidence of family caregivers in the experimental group was lower than those of the control group (P < 0.05), and satisfaction scores were higher than those of the control group (P < 0.05).

CONCLUSIONS

Family intervention has the potential to reduce the incidence of POD in patients undergoing cardiac valve surgery, shorten ICU stays, reduce the incidence of anxiety and depression in family caregivers, and improve their satisfaction. These findings suggest that family intervention could be incorporated into routine nursing practice.

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.

Risk factors for delirium after surgery for craniocerebral injury in the neurosurgical intensive care unit

BACKGROUND

Postoperative delirium is common in patients who undergo neurosurgery for craniocerebral injury. However, there is no specific medical test to predict postoperative delirium to date.

AIM

To explore risk factors for postoperative delirium in patients with craniocerebral injury in the neurosurgery intensive care unit (ICU).

METHODS

A retrospective analysis was performed in 120 patients with craniocerebral injury admitted to Hainan People’s Hospital/Hainan Hospital Affiliated to Hainan Medical University, The First Affiliated Hospital of Hainan Medical University, and The Second Affiliated Hospital of Hainan Medical University between January 2018 and January 2020. The patients were categorized into groups based on whether delirium occurred. Of them, 25 patients with delirium were included in the delirium group, and 95 patients without delirium were included in the observation group. Logistic regression analysis was used to explore the association between sex, age, educational level, Glasgow coma scale (GCS), complications (with or without concussion, cerebral contusion, hypoxemia and ventricular compression) and site of injury and delirium.

RESULTS

The GCS score above 8 and concomitant disease of cerebral concussion, cerebral contusion, hypoxemia and ventricular compression, and damage to the frontal lobe were associated with delirium in patients admitted to neurosurgical intensive care unit (ICU) (all P < 0.05). However, age, sex, administration more than three medicines, and educational level were not significantly associated with the onset of delirium in patients with craniocerebral injury in the neurosurgical ICU (P < 0.05). Multivariate logistic regression analysis showed that GCS score above 8, cerebral concussion, cerebral contusion, hypoxemia, ventricle compression, and frontal lobe disorders were independent risk factors for delirium in patients with craniocerebral injury in the neurosurgical ICU (P < 0.05).

CONCLUSION

GCS score, concussive concussion, cerebral contusion, hypoxemia, ventricle compression, and damage to frontal lobe are risk factors of postoperative delirium.

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.

Factors Influencing CAM-ICU Documentation and Inappropriate "Unable to Assess" Responses

BACKGROUND

Detecting delirium with standardized assessment tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is important, but such detection is frequently hampered by poor documentation and inappropriate "unable to assess" responses (in noncomatose patients).

OBJECTIVE

To identify patient, clinical, and workplace factors that may impede or facilitate appropriate delirium assessment through use of the CAM-ICU, specifically documentation and inappropriate "unable to assess" responses.

METHODS

An electronic health record-based data set was used to quantify CAM-ICU documentation and inappropriate "unable to assess" responses during 24 months. Associated patient (eg, age), clinical (eg, diagnosis), and workplace (eg, geographic location within the ICU, shift) factors were evaluated with multivariable regression.

RESULTS

Of 28 586 CAM-ICU documentation opportunities, 66% were documented; 16% of documentations in alert or lightly sedated patients had inappropriate "unable to assess" responses. Night shift was associated with lower CAM-ICU documentation rates (P = .001), whereas physical restraints and location on side B (rather than side A) of the ICU were associated with higher documentation rates (P < .05 for both). Age older than 80 years, non-White race, intubation, and physical restraints were associated with more inappropriate "unable to assess" responses (all P < .05), as was infusion of propofol, midazolam, dexmedetomidine, or fentanyl (all P < .05).

CONCLUSION

Data from electronic health records can identify patient, clinical, and workplace factors associated with CAM-ICU documentation and inappropriate "unable to assess" responses, which can help target quality improvement efforts related to delirium assessment.

Improving Pediatric Delirium Assessment Documentation and Implementation of a Nonpharmacologic Delirium Management Bundle in the Cardiovascular Intensive Care Unit

BACKGROUND

Pediatric delirium is common, associated with negative patient outcomes, and infrequently assessed in the ICU. Locally, pediatric delirium assessments in the cardiac PICU were infrequently documented resulting in an initiative to increase assessment documentation and implement a nurse-driven management protocol, the Bundle to Eliminate Delirium (BED).

METHODS

This was a nurse-driven, quality improvement project in an eleven-bed cardiac PICU at a large academic health care facility. A pre- and postimplementation survey evaluating delirium management perceptions, knowledge, and assessment barriers was emailed to 113 nurses. Nurses received education about general delirium principles and assessment followed by weekly emails that included delirium assessment documentation rates and targeted education. Subsequently, BED education was provided via email followed by BED implementation, inclusion of BED completion rates in weekly emails, and observational audits of BED implementation.

FINDINGS

1522 delirium assessment opportunities were evaluated. Assessment documentation increased by 33%. Nurses reported greater confidence in their ability to manage delirium (P < .05 for numerous aspects of delirium care) and were less likely to report 'positive delirium assessments not acted upon' as a barrier to delirium assessment. BED implementation was inconsistent.

DISCUSSION

Nursing education and feedback can increase delirium assessment rates and confidence in management but the impact of BED on these outcomes is not clear.

APPLICATION TO PRACTICE

Improvement in pediatric delirium care may be obtained through a nurse-driven quality improvement project but an interprofessional approach is needed for optimal management. More studies are needed to identify effective pediatric delirium management strategies such as the BED.

Using Concept Unique Identifiers to Filter Electronic Health Records for Delirium Cases

Delirium, an acute mental status change associated with inattention, confusion, hypervigilance, or somnolence due to a medical cause, is considered a medical emergency. Unfortunately, screening and diagnosis of delirium in acute care are often inadequate. It is estimated that 60% of delirium cases are not identified, and in claims data, they are underreported. Using information technology, we investigated whether concept unique identifiers from the Unified Language Medical System Metathesaurus could be used as a method to filter electronic health records for possible delirium cases. This article provides the reader with an overview of delirium, the Unified Language Medical System Metathesaurus, and our method for retrospectively filtering electronic health records for delirium cases from our clinical research database. Using a retrospective observational approach, we randomly selected 150 electronic health records with narrative notes containing a delirium concept unique identifier. One hundred records were used for training and 50 were used for validation and interrater reliability. Our results validate electronic health record-selected concept unique identifiers and provide insights into their use. Refinement and application of this method on a larger scale can provide an initial filter for identifying patients with delirium from the electronic health record.

Use of Tailored Feedback Improves Accuracy of Delirium Documentation in the Burn ICU: Results of a Performance Improvement Initiative

One of the most widely used tools for delirium assessment in burn intensive care units is the Confusion Assessment Method for the Intensive Care Unit delirium assessment tool. However, some nurses struggle with inaccurate delirium documentation. This performance improvement project was undertaken to assess the impact that routine chart audits with tailored feedback would have on documentation accuracy. An a priori goal of at least 90% documentation accuracy was set by burn leadership at our academic, American Burn Association-verified burn center. For the precorrectional feedback time period, nursing delirium documentation was reviewed for accuracy by the nurse educator. In the postcorrectional feedback time period, an intervention was started, in which the educator sent tailored feedback to nurses with inaccurate delirium documentation. A Poisson regression with robust standard errors was used to compare the proportions of correct delirium documentation for the precorrectional feedback and postcorrectional feedback time periods. The overall rates of correct delirium documentation in the precorrectional feedback time period were 49.15% (SD = 31.86), 95% CI: 36.43 to 66.31. A significant increase was seen in the rates of correct delirium documentation for the postcorrectional feedback time period (91.47% [SD = 8.28], 95% CI: 87.45 to 95.67), P = .0001. In the 4 months prior to starting corrective feedback, zero out of five (0%) audits reached the 90% goal of accurate delirium documentation. In the 8 months in which corrective feedback was being given, 9 out of 15 (60%) audits reached the compliance goal set by leadership. Using corrective feedback improves the accuracy of nursing delirium documentation.

The experience of intensive care nurses caring for patients with delirium: A phenomenological study

OBJECTIVES

The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses' experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients.

RESEARCH METHODOLOGY

This study utilised an interpretive phenomenological approach as described by van Manen.

SETTING

Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada.

FINDINGS

The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You.

CONCLUSION

The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience.

The Effects of Delirium Prevention Guidelines on Elderly Stroke Patients

This study aimed to evaluate the effectiveness of the delirium prevention interventions recommended by the Delirium Prevention Guidelines for Elderly Stroke Patients (DPGESP). The DPGESP comprises nine dimensions with 28 interventions, including risk factor assessment, orientation disorder prevention, sleeping pattern maintenance, sensory interventions, constipation, dehydration, hypoxia and infection prevention, pain management, and appropriate nutrition maintenance. This quasi-experimental study used a nonequivalent control group and a pretest–posttest design. The experimental and control groups each included 54 patients, and the participants were elderly patients who were admitted to the stroke unit. The study outcomes were the delirium incidence and severity, stroke impact, and length of hospitalization. Posttest values for delirium incidence, severity, stroke impact, and length of hospitalization were significantly improved in the experimental group. Implementation of the DPGESP had beneficial effects on the delirium incidence and severity, stroke impact, and length of hospitalization among elderly patients admitted to a stroke unit.

Symptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research

BACKGROUND

Symptom assessment in critically ill patients is challenging because many cannot provide a self-report.

OBJECTIVES

To describe the state of the science on symptom communication and the assessment of selected physical symptoms in non-vocal ICU patients.

METHODS

This paper summarizes a 2014 American Thoracic Society Annual International Conference symposium presenting current evidence on symptom communication, delirium, and the assessment of common physical symptoms (i.e., dyspnea, pain, weakness, and fatigue) experienced by non-vocal ICU patients.

RESULTS

Symptom assessment begins with accurate assessment, which includes an evaluation of delirium, and assistance in symptom communication. Simple self-report measures (e.g., 0-10 numeric rating scale), observational measures (e.g., Respiratory Distress Observation Scale and Critical-Care Pain Observation Tool), or objective measures (e.g., manual muscle testing and hand dynamometry) have demonstrated utility among this population.

CONCLUSION

Optimizing symptom assessment with valid and reliable instruments with minimum patient burden is necessary to advance clinical practice and research in this field.