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Azamfirei R, Behrens D, Padilla S, Madden K, Goldberg S, Geno M, Manning MJ, Piole M, Madsen E, Maue D, Abu-Sultaneh S, Awojoodu R, Wang NY, Needham DM, Neufeld K, Kudchadkar SR. Delirium Screening in Critically Ill Children: Secondary Analysis of the Multicenter PICU Up! Pilot Trial Dataset, 2019-2020. Pediatr Crit Care Med 2024; 25:880-888. [PMID: 38832837 PMCID: PMC11449648 DOI: 10.1097/pcc.0000000000003555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices. DESIGN A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168). SETTING Six PICUs in the United States. PATIENTS One thousand sixty-four patients who were admitted to a PICU for 3 or more days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1064 patients, 74% (95% CI, 71-76%) underwent delirium screening at least once during their PICU stay. On 57% of the 8965 eligible patient days, screening was conducted. The overall prevalence of delirium was 46% across all screened days, and 64% of screened patients experienced delirium at some point during their PICU stay. Factors associated with greater adjusted odds ratio (aOR) of increased daily delirium screening included PICU stay longer than 15 days compared with 1-3 days (aOR 3.36 [95% CI, 2.62-4.30]), invasive mechanical ventilation as opposed to room air (aOR 1.67 [95% CI, 1.32-2.12]), dexmedetomidine infusions (aOR 1.23 [95% CI, 1.04-1.44]) and propofol infusions (aOR 1.55 [95% CI, 1.08-2.23]). Conversely, decreased aOR of daily delirium screening was associated with female gender (aOR 0.78 [95% CI, 0.63-0.96]), and the administration of continuous infusions of opioids (aOR 0.75 [95% CI, 0.63-0.90]) or ketamine (aOR 0.48 [95% CI, 0.29-0.79]). Neither patient age, the presence of family or physical restraints, or benzodiazepine infusions were associated with daily delirium screening rates. CONCLUSIONS In the 2019-2020 PICU UP! cohort, across six PICUs, delirium screening occurred on only 57% of days, despite the presence of established practices. Female gender, patients in the early stages of their PICU stay, and patients not receiving mechanical ventilation were associated with lower odds of daily delirium screening. Our results highlight the need for structured quality improvement processes to both standardize and increase the frequency of delirium screening.
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Affiliation(s)
- Razvan Azamfirei
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Targu Mures, Romania
| | - Deanna Behrens
- Advocate Children’s Hospital, Pediatric Critical Care, Park Ridge, IL, USA
| | - Sofia Padilla
- Advocate Children’s Hospital, Pediatric Critical Care, Park Ridge, IL, USA
| | - Kate Madden
- Boston Children’s Hospital, Anesthesiology, Critical Care and Pain Medicine, Boston, MA, USA
| | | | - Megan Geno
- Boston Children’s Hospital, Physical Therapy and Occupational Therapy Services, Boston, MA, USA
| | | | - Michelle Piole
- SSM Health Cardinal Glennon Children’s Hospital, Pediatrics, Critical Care, St. Louis, MO, USA
| | - Erik Madsen
- SSM Health Cardinal Glennon Children’s Hospital, Pediatrics, Critical Care, St. Louis, MO, USA
| | - Danielle Maue
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ronke Awojoodu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nae-Yuh Wang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA, and Departments of Biostatistics and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dale M. Needham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA, and Departments of Biostatistics and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Outcomes after Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karin Neufeld
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Outcomes after Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Meghani S, Timmins F. Intensive care nurses' perceptions and awareness of delirium and delirium prevention guidelines. Nurs Crit Care 2024; 29:943-952. [PMID: 38634180 DOI: 10.1111/nicc.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/19/2024]
Abstract
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.
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Affiliation(s)
- Salima Meghani
- Department of Pulmonary Hypertension, Mater Hospital, Dublin, Ireland
| | - Fiona Timmins
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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3
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den Boogaard MV, Leenders M, Pop-Purceleanu M, Tilburgs B. Performance and validation of two ICU delirium assessment and severity tools; a prospective observational study. Intensive Crit Care Nurs 2024; 83:103627. [PMID: 38301387 DOI: 10.1016/j.iccn.2024.103627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND The clinical statistical performance of the Confusion Assessment Method Intensive Care Unit (CAM-ICU, including CAM-ICU-7) and Intensive Care Delirium Screening Checklist (ICDSC) have rarely been studied. Additionally, delirium severity is often not measured due to a lack of validation of delirium assessment tools. OBJECTIVE The aim was to determine the statistical performance of both delirium assessment tools in daily practice, and the correlation with the gold standard Delirium Rating Scale (DRS)-R98, for delirium severity. RESEARCH METHOD CAM-ICU-7 and ICDSC, performed by nurses were compared with the DRS-R98 assessed by delirium experts, twice weekly. Within a time-window of one hour all assessments were independently performed. DESIGN A prospective observational study performed between October and December 2020. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive value of both tools was determined. The correlation between DRS-R98 and CAM-ICU-7 and ICDSC was used for validation of delirium severity. RESULTS In total, 104 CAM-ICU-7 and 105 ICDSC assessments in 86 patients were compared with the DRS-R98. For the CAM-ICU-7 and ICDSC, respectively, the sensitivity was 90% and 95%, the specificity was 92.4% and 92.3%. The positive predictive value was 0.76 and 0.80, and negative predictive value was 0.77 and 0.97. Correlation of the CAM-ICU-7 score and ICDSC score with the DRS-R98 score was 0.74 (95% CI 0.64-0.81) and 0.70 (95%CI 0.59-0.79; both p < 0.001), respectively. CONCLUSION Both CAM-ICU-7 and ICDSC demonstrated good statistical performance and correlated well with the delirium severity tool DRS-R98. IMPLICATIONS FOR CLINICAL PRACTICE Nurses can either use the CAM-ICU(-7) or the ICDSC in their practice, both are accurate in delirium diagnosis. Total CAM-ICU-7 and ICDSC score reflects delirium severity well; the higher the score, the more severe the delirium. This enables nurses to gauge the impact of their interventions and enhance the well-being of patients experiencing delirium by minimizing distressing occurrences.
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Affiliation(s)
- Mark van den Boogaard
- Radboud University Medical Center, Department Intensive Care, Nijmegen, the Netherlands.
| | - Margot Leenders
- Radboud University Medical Center, Department Intensive Care, Nijmegen, the Netherlands
| | - Monica Pop-Purceleanu
- Radboud University Medical Center, Department of Psychiatrie, Nijmegen, the Netherlands
| | - Bram Tilburgs
- Radboud University Medical Center, Department Intensive Care, Nijmegen, the Netherlands
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4
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Correya A, Rawson H, Ockerby C, Hutchinson AM. Nurses' perceptions of patient pain, delirium, and sedation assessments in the intensive care unit: A qualitative study. Aust Crit Care 2024:S1036-7314(24)00112-7. [PMID: 38960745 DOI: 10.1016/j.aucc.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 05/18/2024] [Accepted: 05/28/2024] [Indexed: 07/05/2024] Open
Abstract
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.
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Affiliation(s)
- Anu Correya
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, 3220, VIC, Australia
| | - Helen Rawson
- School of Nursing and Midwifery, Monash University, 35 Rainforest Walk, Clayton, 3800, VIC, Australia
| | - Cherene Ockerby
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, 3220, VIC, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, 3220, VIC, Australia; Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 1 Gheringhap Street, Geelong, 3220, VIC, Australia.
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5
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Nydahl P, Liu K, Bellelli G, Benbenishty J, van den Boogaard M, Caplan G, Chung CR, Elhadi M, Gurjar M, Heras-La Calle G, Hoffmann M, Jeitziner MM, Krewulak K, Mailhot T, Morandi A, Nawa RK, Oh ES, Collet MO, Paulino MC, Lindroth H, von Haken R. A world-wide study on delirium assessments and presence of protocols. Age Ageing 2024; 53:afae129. [PMID: 38952186 DOI: 10.1093/ageing/afae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/26/2024] [Indexed: 07/03/2024] Open
Abstract
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.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
- Institute for Molecular Bioscience (IMB), The University of Queensland, 306 Carmody Rd, St Lucia QLD, 4067, Queensland, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
- Acute Geriatric Unit, IRCCS San Gerardo Foundation, Via Pergolesi 33, 20900 Monza, Italy
| | - Julie Benbenishty
- Hebrew University Faculty of Medicine School of Nursing, PO Box 12272, Jerusalem 91120, Israel
| | - Mark van den Boogaard
- Department Intensive Care, Radboud University Medical Center, 10 Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital Sydney, 320-346 Barker St, Randwick NSW 2031, Sydney, Australia
- University of New South Wales, Gate 9, High St, The Chancellery Kensington, 2052, NSW Sydney, Australia
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro Gangnam-gu. Seoul, Korea 06351, South Korea
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, University Road, Al-Furnaje Tripoli, PO Box 13932, Tripoli, Libya
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow-226014, Uttar Pradesh, India
| | - Gabi Heras-La Calle
- Director of the International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI), Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Magdalena Hoffmann
- Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
- Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 1, Postfach, 4001 Basel, Switzerland
| | - Karla Krewulak
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada
| | - Tanya Mailhot
- Montreal Heart Institute Research Center, Faculty of Nursing, Université de Montréal, 680 Sherbrooke West, Montreal QC, H3A 2M7, Canada
| | - Alessandro Morandi
- Intermediate Care and Rehabilitation, Azienda Speciale Cremona Solidale, Via Brescia 207, 26100 Cremona, Italy
- Parc Sanitari Per Vergili, Val d'Hebron Institute of Research, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ricardo Kenji Nawa
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP 05652-900, Brazil
| | - Esther S Oh
- Departments of Medicine, Psychiatry and Behavioral Sciences, and Pathology, Johns Hopkins University School of Medicine, 733 N. Broadway, MD 21205 Baltimore, ML, USA
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Maria Carolina Paulino
- Department of Intensive Care, Hospital da Luz Lisboa, 1150-082 Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, 1150-199 Lisbon, Portugal
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1500-650 Lisbon, Portugal
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
- Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 W 10th St, Indianapolis, IN 46202, USA
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Fuentes AL, Makhija H, Fine JM, Alicea Reyes P, Diaz De Leon B, Sanchez-Azofra A, Rodriguez-Flores L, Weston J, Marquine MJ, Hu E, Espinosa-Meza R, Serafin Higuera IR, Vacas Jacques P, Pollack D, Novelli F, Ely EW, Malhotra A, Needham DM, Martin JL, Kamdar BB, Arroyo-Novoa CM, Figueroa-Ramos MI. Spanish Translation and Cultural Adaptation of the Intensive Care Unit Delirium Playbook. ATS Sch 2024; 5:259-273. [PMID: 38957494 PMCID: PMC11215996 DOI: 10.34197/ats-scholar.2023-0114oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/13/2023] [Indexed: 07/04/2024] Open
Abstract
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.
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Affiliation(s)
| | - Hirsh Makhija
- Division of Pulmonary, Critical Care and Sleep Medicine and
| | | | | | | | | | | | - Julia Weston
- Department of Medicine, University of California, San Diego School of Medicine, La Jolla, California
| | - María J. Marquine
- Division of Geriatrics, Department of Medicine, and
- Department of Psychiatry, Duke University, Durham, North Carolina
| | | | | | | | - Paulino Vacas Jacques
- Departamento de Medicina y Psicología, Universidad Autonoma de Baja California, Baja California, Mexico
| | - Daniel Pollack
- Nursing Education & Development Research Department, and
- Critical Care Unit, University of California, San Diego Health, San Diego, California
| | - Francesca Novelli
- Nursing Education & Development Research Department, and
- Critical Care Unit, University of California, San Diego Health, San Diego, California
- School of Nursing, Oregon Health and Science University, Ashland, Oregon
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction and Survivorship Center and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine and
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery Group
- Division of Pulmonary & Critical Care Medicine, and
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Jennifer L. Martin
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California
- University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California; and
| | - Biren B. Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine and
- Veterans Affairs San Diego Healthcare, La Jolla, California
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Zhang S, Ji M, Cui W, Wei J, Ding S, Wu Y. Impact of delirium intervention on cognitive load among nurses in the intensive care unit: A multi-centre cluster randomized controlled trial. Int J Nurs Pract 2024; 30:e13200. [PMID: 37680110 DOI: 10.1111/ijn.13200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND High cognitive load in nurses is a common problem in the intensive care unit (ICU). However, it remains unclear what different types of cognitive load the ICU nurses have experienced during the implementation of delirium interventions. AIM To describe the characteristics and explore the effect of implementing a delirium intervention on the cognitive load of nurses working in the ICU. METHODS A cluster-randomized controlled clinical trial was conducted. Six ICUs were randomized in a 1:1 ratio, and eligible nurses from these units provided either a delirium bundle intervention in addition to usual care (27 nurses) or usual care alone. An instrument was used to measure different types of cognitive load (MDT-CL), assessing intrinsic, extraneous and germane cognitive load. The repeated measures analysis of variance was used to detect between-group differences. RESULTS Among these nurses, significant between-group differences were identified in terms of their overall (P < 0.001), intrinsic (P < 0.001) and extraneous (P < 0.001) cognitive load. There was no significant change observed in the germane cognitive load (P = 0.489) in the delirium intervention group. CONCLUSION It is important to understand how the implementation of a delirium intervention affects different types of cognitive load in nurses, in order that tailored strategies can be applied to reduce cognitive load in ICU nurses.
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Affiliation(s)
- Shan Zhang
- School of Nursing, Capital Medical University, Beijing, China
| | - Meihua Ji
- School of Nursing, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Wei Cui
- School of Nursing, Capital Medical University, Beijing, China
| | - Jun Wei
- Respiratory Intensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shu Ding
- Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ying Wu
- School of Nursing, Capital Medical University, Beijing, China
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8
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Zhang S, Cui W, Wu Y, Ji M. Description of an individualised delirium intervention in intensive care units for critically ill patients delivered by an artificial intelligence-assisted system: using the TIDieR checklist. J Res Nurs 2024; 29:112-124. [PMID: 39070574 PMCID: PMC11271677 DOI: 10.1177/17449871231219124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
Background Delirium is a preventable and reversible complication for intensive care unit (ICU) patients, which can be linked to negative outcomes. Early intervention to cope with the risk factors of delirium is necessary. Yet no specific description of the Artificial Intelligence Assisted Prevention and Management for Delirium (AI-AntiDelirium) following the Template for Intervention Description and Replication (TIDieR) checklist was reported. This is the first study to describe a detailed process for the development of an evidence-based delirium intervention. Aims To describe an individualised delirium intervention which is delivered by an artificial intelligence-assisted system in the ICU for critically ill patients. Methods and results The TIDieR checklist improved the description of ICU delirium interventions, including several key features for improved implementation of the intervention. This descriptive research describes the AI-assisted ICU delirium interventions for improving cognitive load and adherence of nurses and reducing ICU delirium incidence. Following the TIDieR checklist, we standardised the flow chart of ICU delirium assessment tools; formed an evaluation sheet of ICU delirium risk factors; and translated the evidence-based ABCDEF bundle intervention into practice. Therefore, nurses and researchers would benefit from replicating the interventions for clinical use or experimental research. Conclusions The TIDieR checklist provided a systematic approach for reporting the complex ICU delirium interventions delivered in a clinical interventional trial, which contributes to the nursing practice policy for the standardisation of interventions.
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Affiliation(s)
- Shan Zhang
- Associate Professor, School of Nursing, Capital Medical University, China
| | - Wei Cui
- Registered Nurse, School of Nursing, Capital Medical University, China
| | - Ying Wu
- Professor, School of Nursing, Capital Medical University, China
| | - Meihua Ji
- Associate Professor, School of Nursing, Capital Medical University, China
- Associate Professor, Advanced Innovation Center for Human Brain Protection, Capital Medical University, China
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Balsalobre-Martínez P, Montosa-García R, Marín-Yago A, Baeza-Mirete M, Muñoz-Rubio GM, Rojo-Rojo A. Challenges of the Implementation of a Delirium Rate Scale in a Pediatric Intensive Care Unit: A Qualitative Approach. Healthcare (Basel) 2023; 12:52. [PMID: 38200958 PMCID: PMC10779040 DOI: 10.3390/healthcare12010052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Delirium in the pediatric population admitted to intensive care is a worrying reality due to its potential complications and the increase in associated costs. This study aims to explore the experiences of nursing staff of a Pediatric Intensive Care Unit after 15 months of starting a program to fight against childhood delirium in their unit. METHODOLOGY A qualitative study was conducted through semi-structured interviews with Pediatric Intensive Care Unit (PICU) Key Informants. The Standards for Reporting Qualitative Research (SRQR) and the consolidated criteria for Reporting Qualitative Research (COREQ) were followed as quality measures for the study. Seven nurses (33% of the eligible population) from the PICU of a referral hospital were interviewed. Text transcripts were analyzed using the Interpretative Description and Qualitative Content Analysis method. RESULTS The interviewees indicated not identifying delirium as an important reality; with great deficiencies observed in what is related to the identification of delirium; identifying CAPD as an unreliable tool in their unit; and not sharing therapeutic objectives in this respect with the medical staff. CONCLUSIONS The nursing staff presented a series of negative attitudes towards the phenomena of delirium in their unit, with gaps in training and in clinical management, and the diagnostic tool used, and did not see it as a priority objective of the unit, partly due to a resistance to change and a latent interprofessional communication conflict. A change at the formative, attitudinal, and relational levels is urgently needed for the success of the program and the well-being of the children in the unit.
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Affiliation(s)
| | - Raquel Montosa-García
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Healthcare System, 30120 Murcia, Spain (A.M.-Y.)
| | - Ana Marín-Yago
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Healthcare System, 30120 Murcia, Spain (A.M.-Y.)
| | - Manuel Baeza-Mirete
- Faculty of Nursing, Catholic University of Murcia (UCAM), 30107 Murcia, Spain
| | - Gloria María Muñoz-Rubio
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Health System, 30120 Murcia, Spain
| | - Andrés Rojo-Rojo
- Faculty of Nursing, Catholic University of Murcia (UCAM), 30107 Murcia, Spain
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Casamento A, Neto AS, Lawrence M, Chudleigh L, Browne E, Taplin C, Eastwood GM, Bellomo R. Delirium in ventilated patients receiving fentanyl and morphine for Analgosedation: Findings from the ANALGESIC trial. J Crit Care 2023; 77:154343. [PMID: 37235918 DOI: 10.1016/j.jcrc.2023.154343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/30/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE The differential effect of fentanyl vs. morphine analgosedation on the development of hospital inpatient delirium in patients receiving mechanical ventilation is unknown. We aimed to compare the incidence of coding for delirium and antipsychotic medication use in patients treated with fentanyl vs. morphine in the ANALGESIC trial. MATERIALS AND METHODS We obtained data from a cluster randomized, cluster crossover trial of fentanyl vs. morphine for analgosedation on antipsychotic use and coding diagnosis of delirium and compared these outcomes according to treatment allocation. We assessed the relationship between opioid choice and dose, hospital inpatient delirium, and outcomes. RESULTS Among 681 patients enrolled in the ANALGESIC trial, 160/344 (46.5%) in the fentanyl group vs. 132/337 (39.1%) in the morphine group (absolute difference 7.34% [95% CI -0.9 to 14.78]; RR: 1.19 [95%CI 1.00 to 1.41]; p = 0.053) developed hospital inpatient delirium. Antipsychotic use was linearly related to opioid dose. Antipsychotic use was not associated with increased mortality. CONCLUSIONS Fentanyl is associated with a higher incidence of hospital inpatient delirium when used for analgosedation compared with morphine, and the dose of opioid is linearly related to the need for antipsychotic medication administration. The role of analgosedation in promoting delirium requires further investigation.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Laura Chudleigh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Emma Browne
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia.
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Baluku Murungi E, Niyonzima V, Atuhaire E, Nantume S, Beebwa E. Improving Nurses Knowledge and Practices of Delirium Assessment at Mbarara Regional Referral Hospital: A Quasi Experimental Study. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2023; 14:313-322. [PMID: 37020902 PMCID: PMC10069436 DOI: 10.2147/amep.s398606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/21/2023] [Indexed: 06/19/2023]
Abstract
Background Despite the recommendations for delirium assessment in clinical settings, it stills remain a serious clinical problem associated with prolonged mechanical ventilation, stress on the patient and family, and mortality. There is paucity of data regarding delirium assessment and prevention in developing world. The Confusion Assessment Method for Intensive Care Unit (CAM-ICU) was developed to aid in the assessment of delirium. There is no documented assessment of delirium and prevention in Uganda. This study evaluated the effect of an educational intervention on nurses' knowledge and practices of delirium assessment using the CAM-ICU tool. Methods We used a quasi-experimental and recruited a convenience sample of 29 nurses from ICU and ER. The assessment before and after the interventions was conducted using a self-completed questionnaire from October 2020 to January 2021. The interventions were delivered through face-to-face presentations, demonstrations, watching videos, and hands on practice. Data were entered into excel, cleaned and exported to Stata version 14. Median and interquartile ranges were used for continuous variables, and frequencies and percentages for categorical variables. The mean knowledge score was calculated before and after the intervention. A paired t-test was used to compare Pre- and Post-test knowledge and practice scores at P <0.05. Results Majority (62%) were female, 48% were Diploma holders, median age was 30 (IQR = 28-32) years and median years of experience 3.5 (IQR = 3-4). The Mean knowledge scores was 10.7 (SD = 2.36) pretest and 19 (0.94) posttest. The mean practice score was 2 (SD = 0.83) pretest and 6 (0.35) posttest. There were significant differences in mean knowledge and practice scores before and after intervention mean of (t (28) =17.32, p < 0.001) and (t (28) = 25.04, p<0.001), respectively. Conclusion Educational intervention Improved nurses' knowledge and practice of delirium assessment. Continuous nursing education could improve nurses' knowledge of delirium assessment and thus quality of patient care.
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Affiliation(s)
- Eric Baluku Murungi
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Vallence Niyonzima
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Evas Atuhaire
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Susan Nantume
- Masaka School of Comprehensive Nursing, Masaka City, Uganda
| | - Esther Beebwa
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara City, Uganda
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12
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Lange S, Mȩdrzycka-Da̧browska W, Tomaszek L, Wujtewicz M, Krupa S. Nurses' knowledge, barriers and practice in the care of patients with delirium in the intensive care unit in Poland-A cross-sectional study. Front Public Health 2023; 11:1119526. [PMID: 36935691 PMCID: PMC10020524 DOI: 10.3389/fpubh.2023.1119526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Background Delirium is a cognitive disorder that occurs with high frequency in patients in intensive care units and affects patient outcomes. Despite recommendations for monitoring and assessing delirium in the ICU, studies show that it is still not routinely assessed and often remains undiagnosed or misinterpreted as dementia or depression. Aim The aim of this study was (1) to assess nurses' knowledge and clinical practices regarding delirium, (2) to identify the factors associated with nurses' knowledge, and (3) to define barriers to effective control of delirium. Methods A cross-sectional study was conducted among 371 ICU nurses in Poland. Results 53.1% of nurses had never been educated on delirium control resulting in a deficit in knowledge of delirium symptoms, risk factors and complications associated with delirium in ICU patients. Master's degree in nursing (vs. Registered nurses + Bachelor's), female gender, and working in university hospital (vs. other) were positively correlated with nurse's knowledge, while age had a negative impact on knowledge. Delirium is a marginalized state in ICU patients, only 16.4% of nurses assessed delirium routinely and 35.8% assessed delirium occasionally, rarely using validated scales. Barriers to effective delirium control were primarily the lack of a requirement to assess delirium, the difficulty of assessing delirium in intubated patients and nurses' lack of confidence in their ability to use delirium assessment tools. Conclusions There is an urgent need to educate nurses about delirium and to make delirium assessment obligatory in clinical practice. The area of change should also include a hospital policy on delirium monitoring and management. The study was registered on ClinicalTrials.gov (NCT05384964).
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Affiliation(s)
- Sandra Lange
- Department of Internal and Pediatric Nursing, Faculty of Health Sciences, Medical University of Gdańsk, Gdańsk, Poland
- *Correspondence: Sandra Lange
| | - Wioletta Mȩdrzycka-Da̧browska
- Department of Anaesthesiology Nursing and Intensive Care, Faculty of Health Sciences, Medical University of Gdansk, Gdańsk, Poland
| | - Lucyna Tomaszek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój, Poland
| | - Magdalena Wujtewicz
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Sabina Krupa
- Institute of Health Sciences, College of Medical Sciences of the University of Rzeszow, Rzeszow, Poland
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13
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Liu S, Schlesinger JJ, McCoy AB, Reese TJ, Steitz B, Russo E, Koh B, Wright A. New onset delirium prediction using machine learning and long short-term memory (LSTM) in electronic health record. J Am Med Inform Assoc 2022; 30:120-131. [PMID: 36303456 PMCID: PMC9748586 DOI: 10.1093/jamia/ocac210] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/09/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To develop and test an accurate deep learning model for predicting new onset delirium in hospitalized adult patients. METHODS Using electronic health record (EHR) data extracted from a large academic medical center, we developed a model combining long short-term memory (LSTM) and machine learning to predict new onset delirium and compared its performance with machine-learning-only models (logistic regression, random forest, support vector machine, neural network, and LightGBM). The labels of models were confusion assessment method (CAM) assessments. We evaluated models on a hold-out dataset. We calculated Shapley additive explanations (SHAP) measures to gauge the feature impact on the model. RESULTS A total of 331 489 CAM assessments with 896 features from 34 035 patients were included. The LightGBM model achieved the best performance (AUC 0.927 [0.924, 0.929] and F1 0.626 [0.618, 0.634]) among the machine learning models. When combined with the LSTM model, the final model's performance improved significantly (P = .001) with AUC 0.952 [0.950, 0.955] and F1 0.759 [0.755, 0.765]. The precision value of the combined model improved from 0.497 to 0.751 with a fixed recall of 0.8. Using the mean absolute SHAP values, we identified the top 20 features, including age, heart rate, Richmond Agitation-Sedation Scale score, Morse fall risk score, pulse, respiratory rate, and level of care. CONCLUSION Leveraging LSTM to capture temporal trends and combining it with the LightGBM model can significantly improve the prediction of new onset delirium, providing an algorithmic basis for the subsequent development of clinical decision support tools for proactive delirium interventions.
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Affiliation(s)
- Siru Liu
- Corresponding Author: Siru Liu, PhD, Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave #1475, Nashville, TN 37212, USA;
| | - Joseph J Schlesinger
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Steitz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elise Russo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian Koh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units. Aust Crit Care 2022:S1036-7314(22)00043-1. [PMID: 35595665 DOI: 10.1016/j.aucc.2022.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/02/2022] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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15
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Yaghoubi E, Shariat SV, Rashedi V, Ghanbari Jolfaei A. Repetitive Transcranial Magnetic Stimulation in Delirium: A Double-blind, Randomized, Sham-controlled, Pilot Study. Basic Clin Neurosci 2022; 13:237-246. [PMID: 36425946 PMCID: PMC9682314 DOI: 10.32598/bcn.2022.1830.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/20/2020] [Accepted: 11/14/2020] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Delirium is a fatal but potentially reversible disorder of the central nervous system that imposes high costs on health systems. This study aims to evaluate the effect of intermittent theta-burst stimulation on the severity and course of delirium disorder. METHODS This is a double-blind, randomized, sham-controlled pilot study. The study participants were randomly allocated into the active (active intermittent theta-burst stimulation) and sham groups. The severity of delirium was assessed 15 minutes before the intervention and 15 minutes after that by the Neelon and Champagne (NEECHAM) confusion scale. RESULTS In the active group, total and subscale scores of NEECHAM significantly decreased after intervention (P<0.05). Although no statistical difference was found in the control group regarding the subscale scores of NEECHAM, the difference in the total scores before and after the sham intervention was statistically significant. CONCLUSION Carrying one session of repetitive transcranial magnetic stimulation on the left dorsolateral prefrontal cortex can reduce the delirium severity in a short period, although it will not decrease the number of delirium cases three days after the intervention. HIGHLIGHTS Delirium is a CNS disorder;Delirium treatment is based on pharmacological and non-pharmacological;rTMS is quasi-modern treatment of neurocognitive disorders. PLAIN LANGUAGE SUMMARY Delirium is fatal but reversible disorder. regarding the restrictions of routine treatments of delirium and by considering the cognition disturbances as the core symptom of delirium, and the positive effect of rTMS on cognition functions. we hypothesized that rTMS could be effective in the treatment of delirium.
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Affiliation(s)
- Emad Yaghoubi
- Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Vahid Shariat
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Vahid Rashedi
- School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran
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Krupa S, Friganović A, Oomen B, Benko S, Mędrzycka-Dąbrowska W. Nurses' Knowledge about Delirium in the Group of Intensive Care Units Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:2758. [PMID: 35270453 PMCID: PMC8909941 DOI: 10.3390/ijerph19052758] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/17/2022] [Accepted: 02/25/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Intensive Care Unit (ICU) delirium is a nonspecific, potentially preventable, and often reversible disorder of impaired cognition, which results from various causes in ICU patients. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. DESIGN In this study, authors used the exploratory and descriptive study method. METHOD The study was conducted in a group of 45 nurses of the cardiac intensive care unit. The department has 16 intensive care stations and is intended for patients after cardiac surgery who require intensive care in the postoperative period. RESULTS During the analysis the interviews, five Collective Subject Discourses were distinguished: signs and symptoms, physical restraint, use of sedatives, environment, and lack of education. CONCLUSION Nurses have no knowledge of the factors contributing to the development of delirium, are unable to communicate with such patients and, most of all, do not know the consequences of the actions taken.
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Affiliation(s)
- Sabina Krupa
- Institute of Health Sciences, College of Medical Sciences of the University of Rzeszow, Poland St. Warzywna 1A, 35-310 Rzeszow, Poland;
| | - Adriano Friganović
- Department of Anesthesiology and Intensive Medicine, University Hospital Centre Zagreb, Kišpatićeva ul. 12, 10000 Zagreb, Croatia
- Department of Nursing, University of Applied Health Sciences, Mlinarska cesta 38, 10000 Zagreb, Croatia;
| | - Ber Oomen
- ESNO, European Specialist Nurses Organization, Pontanuslaan 12, 6821 HR Arnhem, The Netherlands;
| | - Snježana Benko
- Special Hospital for Lung Disease, Rockefellerova 3, 10000 Zagreb, Croatia;
- Faculty of Health Studies, International University of Rijeka, 51000 Rijek, Croatia
| | - Wioletta Mędrzycka-Dąbrowska
- Department of Anaesthesiology Nursing & Intensive Care, Faculty of Health Sciences, Medical University of Gdansk, Dębinki 7, 80-211 Gdańsk, Poland
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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 2022; 25:1413-1420. [PMID: 35027803 PMCID: PMC8693102 DOI: 10.5005/jp-journals-10071-24040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Tilani M Jayasinghe Arachchi
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Vasanthi Pinto
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Ma Z, Camargo Penuela M, Law M, Joshi D, Chung HO, Lam JNH, Tsang JL. Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project. BMJ Open Qual 2021; 10:bmjoq-2020-001305. [PMID: 34887298 PMCID: PMC8663072 DOI: 10.1136/bmjoq-2020-001305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 11/23/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Clinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project. METHODS A ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods. RESULTS Data on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses. DISCUSSION The implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.
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Affiliation(s)
- Zechen Ma
- Niagara Regional Campus, McMaster University Michael G DeGroote School of Medicine, St. Catharines, Ontario, Canada
| | - Mercedes Camargo Penuela
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada.,Department of Health Science, Brock University, Saint Catharines, Ontario, Canada
| | - Madelyn Law
- Department of Health Science, Brock University, Saint Catharines, Ontario, Canada
| | - Divya Joshi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Han-Oh Chung
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada.,Medicine/Critical Care, McMaster University Department of Medicine, Hamilton, Ontario, Canada
| | - Joyce Nga Hei Lam
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada
| | - Jennifer Ly Tsang
- Medicine/Critical Care, McMaster University Department of Medicine, Hamilton, Ontario, Canada .,Medicine/Critical Care, Niagara Health, St. Catharines, Ontario, Canada
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19
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Back JS, Jin T, Jin H, Lee SM. Patient Factors That Influence Reliable Delirium Assessments in a Medical Intensive Care Unit During the Routine Clinical Practice. Clin Nurs Res 2021; 32:742-751. [PMID: 34889155 DOI: 10.1177/10547738211058983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to determine patient and therapeutic characteristics of patients in the medical intensive care unit (MICU) that contribute to inconsistent results of delirium assessments performed during routine clinical practice. Therefore, electronic health records were reviewed and compared with secondary data collected from the same medical ICU patients who were assessed using the Confusion Assessment Method in the ICU (CAM-ICU). Of 5,241 cases involving 762 patients, 827 (15.78%) cases showed disagreement between assessments. Continuous renal replacement therapy, physical restraint use, and altered mental status were factors that increased the likelihood of inconsistencies between assessments. A significant positive correlation was found between the CAM-ICU disagreement rate and the total number of assessments per month. To maximize the reliability of delirium assessments, individual-targeted approaches considering the patient's level of consciousness and type of treatment implemented are required, along with ensuring a stable, and regulated working environment and customized educational programs.
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Affiliation(s)
- Ji-Sun Back
- The Catholic University of Korea, Seoul, Republic of Korea
| | - Taixian Jin
- The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Sun-Mi Lee
- The Catholic University of Korea, Seoul, Republic of Korea
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Yang EJ, Hahm BJ, Shim EJ. Screening and Assessment Tools for Measuring Delirium in Patients with Cancer in Hospice and Palliative Care: A Systematic Review. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:214-225. [PMID: 37674643 PMCID: PMC10180070 DOI: 10.14475/jhpc.2021.24.4.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 09/08/2023]
Abstract
Purpose This study reviewed screening and assessment tools that are used to measure delirium in patients with cancer in hospice and palliative care settings and examined their psychometric properties. Methods Four databases were searched for studies using related search terms (delirium, tools, palliative care, cancer, and others). The inclusion criteria were a) studies that included screening/assessment tools for measuring delirium in cancer patients receiving hospice/palliative care, and b) studies published in English or Korean. The exclusion criteria were a) studies that were conducted in an intensive care setting, and b) case studies, qualitative studies, systematic reviews, or meta-analyses. Results Out of the 81 studies identified, only 10 examined the psychometric properties of tools for measuring delirium, and 8 tools were ultimately identified. The psychometric properties of the Memorial Delirium Assessment Scale (MDAS) were the most frequently examined (n=5), and the MDAS showed good reliability, concurrent validity, and diagnostic accuracy. The Delirium Rating Scale had good reliability and diagnostic accuracy. The Delirium Rating Scale-Revised 98 also showed good reliability and structural validity, but its diagnostic performance was not examined in hospice/palliative care settings. The Nursing Delirium Screening Scale showed relatively low diagnostic accuracy. Conclusion The MDAS showed evidence of being a valid assessment tool for assessing delirium in patients with cancer in palliative care. Few studies examined the diagnostic performance of delirium tools. Therefore, further studies are needed to examine the diagnostic performance of screening/assessment tools for the optimal detection of delirium in patients with cancer in hospice/palliative care.
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Affiliation(s)
- Eun Jung Yang
- Department of Psychology, Pusan National University, Busan, Korea
| | - Bong-Jin Hahm
- Department of Psychiatry and Behavioral Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Jung Shim
- Department of Psychology, Pusan National University, Busan, Korea
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21
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Family intervention for delirium for patients in the intensive care unit: A systematic meta-analysis. J Clin Neurosci 2021; 96:114-119. [PMID: 34838428 DOI: 10.1016/j.jocn.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/24/2022]
Abstract
Delirium is one of the common manifestations of acute brain dysfunction in critically ill patients. We aimed to evaluate the effect of family intervention on reducing the delirium incidence in patients hospitalized in the intensive care unit (ICU). We searched electronic databases for randomized clinical trials, cohort, and before-and-after studies up to September 2021 using the MeSH terms ("family" OR "family caregiver") AND ("delirium"). A total of 6 studies including 4199 patients were analyzed. Compared to the control group, the risk of delirium was 24% lower in the family intervention group (OR 0·76 [0·67-0·86], P = 0.20, I2 = 31%). Pooled data from two trials showed that family intervention was associated with fewer delirium days (SMD: -1.13, 95% CI: -1.91 to -0.34; P = 0.08; I2 = 67%;). However, there were no significant differences between the two groups in the length of ICU stay, mechanical ventilation duration, and mortality (ICU stay days: MD: -0.62 days; 95% CI: -1.49 to 0.24; P = 0.14; I2 = 72%; mechanical ventilation days: MD: -0.48 days; 95% CI: -2.10 to 1.13; P = 0.56; I2 = 0%; mortality: OR: 0.68, 95% CI: 0.22 to 2.09; P = 0.08; I2 = 67%). Current evidence supports the use of family intervention in reducing the delirium risk and delirium days in hospitalized ICU patients. However, its effects on reducing ICU stay length, ventilation duration, and mortality require further study. Future research should consider identifying the specific family intervention strategies and their duration.
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Awan OM, Buhr RG, Kamdar BB. Factors Influencing CAM-ICU Documentation and Inappropriate "Unable to Assess" Responses. Am J Crit Care 2021; 30:e99-e107. [PMID: 34719712 DOI: 10.4037/ajcc2021599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Omar M. Awan
- Omar M. Awan is a staff physician, Pulmonary Section, Department of Medicine, Washington DC Veterans Affairs Medical Center; and an associate professor, Division of Pulmonary, Critical Care, and Sleep Medicine, The George Washington University, Washington, DC
| | - Russell G. Buhr
- Russell G. Buhr is an assistant professor, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, and the Center for the Study of Healthcare Innovation, Implementation, and Policy, Health Services Research and Development, Greater Los Angeles Veterans Affairs Healthcare System, California
| | - Biren B. Kamdar
- Biren B. Kamdar is an associate professor, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego School of Medicine, La Jolla, California
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Salameh B, Al Razeeni DM, Mansor K, Abdallah JM, Ayed A, Salem H. Delirium in Intensive Care Units: Perceptions of Physicians and Nurses. Crit Care Nurs Q 2021; 44:393-402. [PMID: 34437318 DOI: 10.1097/cnq.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Basma Salameh
- Department of Nursing, Arab American University, Jenin, Palestine (Drs Salameh and Ayed); Palestinian Ministry of Health-ICU Department, Rafedia Hospital, Nablus, Palestine (Dr Razeeni and Mr Mansor); An-najah National University, Nablus, Palestine (Dr Abdallah); and Kindred Hospital, Denver, Colorado (Ms Salem)
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Krupa S, Dorota O, Friganovic A, Mędrzycka-Dąbrowska W, Jurek K. The Polish Version of the Nursing Delirium Screening Scale (NuDESC PL)-Experience of Using in Nursing Practice in Cardiac Surgery Intensive Care Unit. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910108. [PMID: 34639408 PMCID: PMC8507661 DOI: 10.3390/ijerph181910108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
Introduction: Delirium is a common complication of patients hospitalized in Intensive care units (ICU). The risk of delirium is estimated at approximately 80% in intensive care units. In the case of cardiac surgery ICU, the risk of delirium increases due to the type of procedures performed with the use of extracorporeal circulation. The aim of this study was to provide an official translation and evaluation of Nursing Delirium Screening Scale (NuDESC) into Polish. The NuDESC scale is a scale used by nurses around the world to detect delirium at an early stage in treatment. Methods: The method used in the study was the NuDESC tool, which was translated into Polish. The study was conducted by Cardiac ICU nurses during day shift (at 8 a.m.), night shift (at 8 p.m.) and in other situations where the patients showed delirium-like symptoms. Results: Statistically significant differences were observed between the first and second day in the studied group of patients in the case of illusions/hallucinations. Delirium occurred more frequently during the night, but statistical significance was demonstrated for both daytime and nighttime shifts. It was not demonstrated in relation to the NuDESC scale in the case of insomnia disorders. The diagnosis of delirium and disorientation was the most common diagnosis observed in patients on the first day of their stay in the ICU, followed by problems with communication. Delirium occurred on the first day, mainly at night. On the second day, delirium was much less frequent during the night; the biggest problem was disorientation and problems with communication. Conclusion: This study contributed to the development of the Polish version of the scale (NuDESC PL) which is now used as the Polish screening tool for delirium detection. The availability of an easy-to-use nurse-based delirium instrument is a prerequisite for widespread implementation.
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Affiliation(s)
- Sabina Krupa
- Institute of Health Sciences, College of Medical Sciences of the University of Rzeszow, Poland St. Warzywna 1A, 35-310 Rzeszow, Poland; (S.K.); (O.D.)
| | - Ozga Dorota
- Institute of Health Sciences, College of Medical Sciences of the University of Rzeszow, Poland St. Warzywna 1A, 35-310 Rzeszow, Poland; (S.K.); (O.D.)
| | - Adriano Friganovic
- Department of Anesthesiology and Intensive Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
- Department of Nursing, University of Applied Health Sciences, Mlinarska Cesta 38, 10000 Zagreb, Croatia
| | - Wioletta Mędrzycka-Dąbrowska
- Department of Anaesthesiology Nursing & Intensive Care, Faculty of Health Sciences, Medical University of Gdansk, 80-211 Gdansk, Poland
- Correspondence:
| | - Krzysztof Jurek
- The Institute of Sociological Sciences, The John Paul II Catholic University of Lublin, 20-950 Lublin, Poland;
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Sinvani L, Delle Site C, Laumenede T, Patel V, Ardito S, Ilyas A, Hertz C, Wolf-Klein G, Pekmezaris R, Hajizadeh N, Thomas L. Improving delirium detection in intensive care units: Multicomponent education and training program. J Am Geriatr Soc 2021; 69:3249-3257. [PMID: 34402046 DOI: 10.1111/jgs.17419] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Delirium is a common, devastating, and underrecognized syndrome in the intensive care unit (ICU). The study aimed to describe and evaluate a multicomponent education and training program utilizing a "Train-The-Trainer" (TTT) model, to improve delirium detection across a large health system. METHODS Fourteen ICUs across nine hospitals participated in a multicomponent delirium program consisting of a 1-day workshop that included: (1) patient testimonials, (2) small group discussions, (3) didactics, and (4) role-playing. Additionally, four ICUs received direct observation/training via telehealth (tele-delirium training). The Kirkpatrick model was used for program evaluation in a pre/post-test design. RESULTS A 1-day delirium workshop was held at two time points and included 73 ICU nurses. Of the 65 nurses completing the post-workshop satisfaction survey, most (46.2) had >10 years of clinical experience, and no or minimal delirium training (69.2%). All nurses (100%) identified lack of knowledge as a barrier to delirium detection, while time constraints and lack of importance accounted for only 25%. Overall, nurses rated the workshop positively (excellent 66.7%, and very good 23.3%), and likely to change practice (definitely 73.3% and very likely 15.0%). All validated Confusion Assessment Method for the ICU (CAM-ICU) cases demonstrated improvement in number of correct responses. Delirium detection across the health system improved from 9.1% at baseline to 21.2% in ICUs that participated in the workshop and 30.1% in those ICUs that also participated in the tele-delirium training (p = 0.005). CONCLUSION A multicomponent delirium education and training program using a TTT model was rated positively, improved CAM-ICU knowledge, and increased delirium detection.
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Affiliation(s)
- Liron Sinvani
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA.,Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, New York, USA.,Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, New York, USA
| | | | - Tara Laumenede
- Patient Care Services, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Vidhi Patel
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Suzanne Ardito
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Anum Ilyas
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Craig Hertz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA.,Tele-Intensive Care Unit (eICU), Division of TeleHealth, Northwell Health, New Hyde Park, New York, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Northwell Health, Manhasset, New York, USA
| | - Gisele Wolf-Klein
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Renee Pekmezaris
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Negin Hajizadeh
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Northwell Health, Manhasset, New York, USA
| | - Lily Thomas
- Institute for Nursing, Northwell Health, New Hyde Park, New York, USA
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Nursing Insights on Delirium in the Intensive Care Unit: A Quality Improvement Study. Crit Care Nurs Q 2021; 44:277-286. [PMID: 33595974 DOI: 10.1097/cnq.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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27
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Asmar IT, Yaseen KS, Jaghama MK, Khawaja YF, Alwredat AA, Sadaqa MH. Awareness of Delirium by ICU Nurses. Crit Care Nurs Q 2021; 44:263-267. [PMID: 33595972 DOI: 10.1097/cnq.0000000000000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Delirium is a critical issue in the intensive care unit (ICU), and the correct diagnosis and treatment of this disorder by the ICU team are doubtful on many occasions due to a lack of information. This research is intended to test the awareness and control of ICU delirium by the ICU nurses. A nonexperimental, quantitative, descriptive, cross-sectional study was conducted using a previously adopted and translated to Arabic and validated questionnaire. The sample include nurses who work in ICUs of 10 Palestinian hospitals (private and public) located in the West Bank and Jerusalem participated in this study; each gave consent to be part of this study. Approval was received from the Palestinian Ministry of Health and the Ethical Committee at Birzeit University. Version 19 of the Social Sciences Statistical Package (SPSS) software was used to analyze the data. The results showed that ICU nurses hold moderate to low levels of knowledge and lack of adequate clinical experience to handle delirium. Delirium is a common complication in the ICU that increases morbidity and mortality and increases the length of ICU stay, therefore the cost of health care rise and the quality of life is decreased. In clinical practice, there are no assessment guidelines and protocols for patients with delirium.
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Affiliation(s)
- Imad T Asmar
- Department of Nursing, Birzeit University, Ramallah, Palestine
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28
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Parker AM, Aldabain L, Akhlaghi N, Glover M, Yost S, Velaetis M, Lavezza A, Mantheiy E, Albert K, Needham DM. Cognitive Stimulation in an Intensive Care Unit: A Qualitative Evaluation of Barriers to and Facilitators of Implementation. Crit Care Nurse 2021; 41:51-60. [PMID: 33791762 DOI: 10.4037/ccn2021551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium in the intensive care unit is associated with poor patient outcomes. Recent studies support nonpharmacological therapy, including cognitive stimulation, to address delirium. Understanding barriers to cognitive stimulation implemented by nurses during clinical care is essential to translating evidence into practice. OBJECTIVE To use qualitative methods through a structured quality improvement project to understand nurses' perceived barriers to implementing a cognitive stimulation intervention in a medical intensive care unit. METHODS Data were collected through semistructured interviews with nurses in a medical intensive care unit. Data were categorized into themes by using thematic analysis and the Consolidated Framework for Implementation Research. During cognitive stimulation, nurses reviewed with patients a workbook of evidence-based tasks (focused on math, alertness, motor skills, visual perception, memory, problem-solving, and language). RESULTS The 23 nurses identified 62 barriers to and 26 facilitators of cognitive stimulation. These data were summarized into 12 barrier and 9 facilitator themes corresponding to the following Consolidated Framework for Implementation Research domains: Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals. Nurses also identified several facilitators within the Process domain. Patient-specific variables, including sedation, were the most frequently reported barriers. Other barriers included cognitive stimulation not being prioritized, nursing staff-related issues, documentation burden, and a lack of understanding of, or appreciation for, the evidence supporting cognitive stimulation. CONCLUSIONS Implementation of cognitive stimulation requires a multidisciplinary approach to address perceived barriers arising from the organization, context, and individuals associated with the intervention, as well as the intervention itself.
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Affiliation(s)
- Ann M Parker
- Ann M. Parker is an assistant professor, Division of Pulmonary and Critical Care Medicine, and a member of the Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Louay Aldabain
- Louay Aldabain is an internal medicine resident, Medstar Health, Baltimore, Maryland
| | - Narges Akhlaghi
- Narges Akhlaghi is a postdoctoral research fellow, Division of Pulmonary and Critical Care Medicine, and a member of the OACIS Research Group, Johns Hopkins University
| | - Mary Glover
- Mary Glover is a lead clinical nurse in the medical intensive care unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stephanie Yost
- Stephanie Yost is a bedside nurse in the intensive care unit, University of Vermont Medical Center in Burlington, Vermont
| | - Michael Velaetis
- Michael Velaetis is a critical care physician assistant in the medical intensive care unit, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
| | - Annette Lavezza
- Annette Lavezza is the acute care therapy manager, Johns Hopkins Hospital, and a member of the OACIS Research Group, Johns Hopkins University
| | - Earl Mantheiy
- Earl Mantheiy is a senior clinical program coordinator, Critical Care Physical Medicine and Rehabilitation Program, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine
| | - Kelsey Albert
- Kelsey Albert is a research program assistant, Critical Care Physical Medicine and Rehabilitation Program, and a member of the OACIS Research Group, Johns Hopkins University
| | - Dale M Needham
- Dale M. Needham is a professor, Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, School of Nursing, and a member of the OACIS Research Group, Johns Hopkins University
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Evaluation of an Educational Intervention Utilizing Nurse "Champions" and Nurses' Documentation of Intensive Care Unit Delirium. Dimens Crit Care Nurs 2021; 39:155-162. [PMID: 32251164 DOI: 10.1097/dcc.0000000000000416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Henao Castaño ÁM, Baquero Lizarazo AC, Gonzalez Pabon N, Burgos Tulcán GF, Lozano Gonzalez L. Enfermería en la monitorización del delirium en cuidado intensivo adulto: una revisión de alcance. INVESTIGACIÓN EN ENFERMERÍA: IMAGEN Y DESARROLLO 2021. [DOI: 10.11144/javeriana.ie22.emdc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Introducción. El delirium es una alteración cognitiva secundaria a una situación clínica aguda que puede estar presente en el paciente crítico, y la enfermería juega un rol protagónico en la prevención, monitoreo y tratamiento no farmacológico del delirium en el paciente en unidad de cuidado intensivo. Objetivo. Identificar las investigaciones actuales que describen las estrategias que utilizan las enfermeras para la monitorización del delirium en la unidad de cuidado intensivo adulto. Método. Revisión de alcance, utilizando la pregunta orientadora ¿qué estrategias utiliza enfermería en la monitorización del delirium en la unidad de cuidado intensivo?, estudios obtenidos en las bases de datos PubMed, Biblioteca Virtual en Salud, Science Direct y Cochrane. Se realizó una revisión crítica con el instrumento CASPe, los datos se extrajeron, y se llevaron a cabo registros en tablas de gráficos elaboradas para condensar la información. Resultados. Trece estudios se consideraron relevantes y fueron analizados. Las estrategias de monitorización del delirium empleadas por enfermería son, principalmente, el juicio clínico, la observación de la agitación y, en menor medida, el empleo de instrumentos validados para la detección. Conclusión. La enfermería requiere comprender mejor el delirium, y para esto la educación es vital para mejorar su conocimiento, y aumentar la autoconfianza y competencia en la evaluación a través del uso correcto de instrumentos.
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Nurses' Attitude, Behavior, and Knowledge Regarding Protective Lung Strategies of Mechanically Ventilated Patients. Crit Care Nurs Q 2021; 43:274-285. [PMID: 32433068 DOI: 10.1097/cnq.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The management of critically ill patients is complicated and often involves complex devices including mechanical ventilators (MVs), which may be associated with many complications. Protective lung strategies (PLSs) are used to prevent complications associated with MVs, but nurses may not possess adequate knowledge to optimize the efficacy of PLSs. This article reports findings from what is thought to be the first study in Palestine that explores critical care nurses' knowledge about PLSs. The purpose of this study was to assess the critical care nurses' attitude, behavior, and knowledge regarding PLSs of mechanically ventilated patients. This descriptive, cross-sectional study was conducted at both public and private hospitals in Palestine. The sample included nurses who worked in intensive care units and cardiac care units and utilized a previously developed and validated questionnaire. The result of the study concludes that the majority of the Palestinian critical care nurses agree with the utilization or application of PLSs but have a severe lack of knowledge about the strategies. This highlights the need to provide additional educational programs related to the optimum use of mechanical ventilation.
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Roberson SW, Patel MB, Dabrowski W, Ely EW, Pakulski C, Kotfis K. Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice. Curr Neuropharmacol 2021; 19:1519-1544. [PMID: 33463474 PMCID: PMC8762177 DOI: 10.2174/1570159x19666210119153839] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 11/22/2022] Open
Abstract
Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.
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Affiliation(s)
| | | | | | | | | | - Katarzyna Kotfis
- Address correspondence to this author at the Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland; E-mail:
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Öztürk Birge A, Tel Aydın H, Salman F. The development of a delirium knowledge test for intensive care nurses: A validity and reliability study. Intensive Crit Care Nurs 2020; 61:102900. [DOI: 10.1016/j.iccn.2020.102900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 05/13/2020] [Accepted: 05/31/2020] [Indexed: 10/23/2022]
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Leigh V, Stern C, Elliott R, Tufanaru C. Effectiveness and harms of pharmacological interventions for the treatment of delirium in adults in intensive care units after cardiac surgery: a systematic review. ACTA ACUST UNITED AC 2020; 17:2020-2074. [PMID: 31449136 DOI: 10.11124/jbisrir-d-18-00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The objective of this review was to synthesize the best available evidence on the effectiveness and harms of pharmacological interventions for the treatment of delirium in adult patients in the intensive care unit (ICU) after cardiac surgery. INTRODUCTION Patients who undergo cardiac surgery are at high risk of delirium (incidence: 50-90%). Delirium has deleterious effects, increasing the risk of death and adversely affecting recovery. Clinical interventional trials have been conducted to prevent and treat postoperative delirium pharmacologically including antipsychotics and sedatives. These trials have provided some evidence about efficacy and influenced clinical decision making. However, much reporting is incomplete and provides biased assessments of efficacy; benefits are emphasized while harms are inadequately reported. INCLUSION CRITERIA Participants were ≥ 16 years, any sex or ethnicity, who were treated postoperatively in a cardiothoracic ICU following cardiac surgery and were identified as having delirium. Any pharmacological intervention for the treatment of delirium was included, regardless of drug classification, dosage, intensity or frequency of administration. Outcomes of interest of this review were: mortality, duration and severity of delirium, use of physical restraints, quality of life, family members' satisfaction with delirium management, duration/severity of the aggressive episode, associated falls, severity of accidental self-harm, pharmacological harms, harms related to over-sedation, ICU length of stay, hospital length of stay (post ICU), total hospital length of stay, need for additional intervention medication and need for rescue medication. Randomized controlled trials were considered first and in their absence, non-randomized controlled trials and quasi-experimental would have been considered, followed by analytical observational studies. METHODS A search was conducted in PubMed, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, Epistemonikos, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, Clinical Trials in New Zealand, and ProQuest Dissertations and Theses to locate both published and unpublished studies. There was no date limit for the search. A hand search for primary studies published between January 1, 2012 and November 17, 2018 in relevant journals was also conducted. Only studies published in English were considered for inclusion. Two reviewers independently assessed the methodological quality using standardized critical appraisal instruments from JBI and McMaster University. Quantitative data were extracted using the standardized JBI data extraction tool. A meta-analysis was not performed, as there was too much clinical and methodological heterogeneity in the included studies. Results have been presented in a narrative form. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment of outcomes has been reported. RESULTS Three RCTs investigating morphine versus haloperidol (n = 53), ondansetron versus haloperidol (n = 72), and dexmedetomidine versus midazolam (n = 80) were included. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Overall, the methodological quality of these studies was found to be low. Additionally, this review found reporting of harms to be inadequate and superficial for all three studies and did not meet the required standards for harms reporting, as defined by the CONSORT statement extension for harms. CONCLUSIONS It was not possible to draw any valid conclusions regarding the effectiveness of morphine vs haloperidol, ondansetron vs haloperidol or dexmedetomidine vs midazolam in treating delirium after cardiac surgery. This is due to the low number of studies, the poor methodological quality in conducting and reporting and the heterogeneity between the studies.
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Affiliation(s)
- Vivienne Leigh
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia.,Adelaide Nursing School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Cindy Stern
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Rosalind Elliott
- The Malcolm Fisher Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia.,Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, Australia.,Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Catalin Tufanaru
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Ho MH, Chen KH, Montayre J, Liu MF, Chang CC, Traynor V, Shen Hsiao ST, Chang HC(R, Chiu HY. Diagnostic test accuracy meta-analysis of PRE-DELIRIC (PREdiction of DELIRium in ICu patients): A delirium prediction model in intensive care practice. Intensive Crit Care Nurs 2020; 57:102784. [DOI: 10.1016/j.iccn.2019.102784] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/09/2019] [Accepted: 12/04/2019] [Indexed: 11/27/2022]
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Biyabanaki F, Arab M, Dehghan M. Iranian Nurses Perception and Practices for Delirium Assessment in Intensive Care Units. Indian J Crit Care Med 2020; 24:955-959. [PMID: 33281321 PMCID: PMC7689114 DOI: 10.5005/jp-journals-10071-23502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Mansour Arab
- Medical Surgical Department, Faculty of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
| | - Mahlagha Dehghan
- Nursing Research Center, Critical Care Department, Nursing and Midwifery School, Kerman University of Medical Sciences, Kerman, Iran
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Teece A, Baker J, Smith H. Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit. J Clin Nurs 2019; 29:5-19. [DOI: 10.1111/jocn.15052] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/05/2019] [Accepted: 08/24/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Angela Teece
- School of Healthcare University of Leeds Leeds UK
| | - John Baker
- School of Healthcare University of Leeds Leeds UK
| | - Helen Smith
- School of Healthcare University of Leeds Leeds UK
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Collet M, Thomsen T, Egerod I. Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation. Aust Crit Care 2019; 32:299-305. [DOI: 10.1016/j.aucc.2018.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/01/2018] [Accepted: 07/08/2018] [Indexed: 02/01/2023] Open
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Penuela MC, Law M, Chung HO, Faught BE, Tsang JLY. 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. CMAJ Open 2019; 7:E430-E434. [PMID: 31243059 PMCID: PMC6597341 DOI: 10.9778/cmajo.20190015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Mercedes Camargo Penuela
- Department of Health Sciences (Camargo Penuela, Law, Faught), Brock University; Niagara Health (Camargo Penuela, Chung, Tsang), St. Catharines, Ont.; Department of Medicine (Chung, Tsang), McMaster University, Hamilton, Ont.; Niagara Regional Campus (Chung, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont
| | - Madelyn Law
- Department of Health Sciences (Camargo Penuela, Law, Faught), Brock University; Niagara Health (Camargo Penuela, Chung, Tsang), St. Catharines, Ont.; Department of Medicine (Chung, Tsang), McMaster University, Hamilton, Ont.; Niagara Regional Campus (Chung, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont
| | - Han-Oh Chung
- Department of Health Sciences (Camargo Penuela, Law, Faught), Brock University; Niagara Health (Camargo Penuela, Chung, Tsang), St. Catharines, Ont.; Department of Medicine (Chung, Tsang), McMaster University, Hamilton, Ont.; Niagara Regional Campus (Chung, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont
| | - Brent E Faught
- Department of Health Sciences (Camargo Penuela, Law, Faught), Brock University; Niagara Health (Camargo Penuela, Chung, Tsang), St. Catharines, Ont.; Department of Medicine (Chung, Tsang), McMaster University, Hamilton, Ont.; Niagara Regional Campus (Chung, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont
| | - Jennifer L Y Tsang
- Department of Health Sciences (Camargo Penuela, Law, Faught), Brock University; Niagara Health (Camargo Penuela, Chung, Tsang), St. Catharines, Ont.; Department of Medicine (Chung, Tsang), McMaster University, Hamilton, Ont.; Niagara Regional Campus (Chung, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.
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Woelfel JM, Vacchiano CA, West C, Titch JF. Nursing Perceptions and Workload Impact of a Standardized Emergence Delirium Assessment Scale in a Postanesthesia Care Unit. J Perianesth Nurs 2019; 34:729-738. [PMID: 30827789 DOI: 10.1016/j.jopan.2018.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 10/03/2018] [Accepted: 11/14/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Emergence delirium (EDL) is a psychomotor behavioral phenomenon that occurs immediately after emergence from general anesthesia. EDL is nearly 1.5 times more common among military than nonmilitary patients. Indirect delirium scales have precluded understanding of EDL in military patients. This quality improvement project assesses the feasibility of adopting a population-specific scale, the Emergence Delirium in the Wounded Warrior (ED-WW) Tool. DESIGN Pre-post implementation design. METHODS Postanesthesia care unit (PACU) nurses were surveyed on the clinical utility of the ED-WW Tool and its impact on their workload. The incidence of EDL behaviors in a Veterans Administration PACU was also recorded using the ED-WW Tool. FINDINGS PACU nurses agreed the ED-WW Tool was of clinical value to military patients and had a very low workload impact. Twenty-one percent of patients demonstrated at least one behavior associated with EDL. CONCLUSIONS ED-WW Tool adoption is clinically feasible and recommended for practice.
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Rohlik GM, Fryer KR, Tripathi S, Duncan JM, Coon HL, Padhya DR, Kahoud RJ. Overcoming Barriers to Delirium Screening in the Pediatric Intensive Care Unit. Crit Care Nurse 2018; 38:57-67. [PMID: 30068721 DOI: 10.4037/ccn2018227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is associated with poor outcomes in adults but is less extensively studied in children. OBJECTIVES To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion. METHODS A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case-control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed. RESULTS Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and "busy patient." Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9-12] vs 12 [10-13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001). CONCLUSIONS Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.
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Affiliation(s)
- Gina M Rohlik
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota. .,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota. .,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois. .,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center. .,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center. .,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center. .,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction.
| | - Karen R Fryer
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota.,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois.,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center.,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction
| | - Sandeep Tripathi
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota.,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois.,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center.,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction
| | - Julie M Duncan
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota.,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois.,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center.,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction
| | - Heather L Coon
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota.,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois.,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center.,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction
| | - Dipti R Padhya
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota.,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois.,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center.,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction
| | - Robert J Kahoud
- Gina M. Rohlik is a certified clinical nurse specialist in the pediatric intensive care unit, Mayo Clinic Children's Center, Rochester, Minnesota, and an instructor in nursing at the Mayo Clinic School of Medicine, Rochester, Minnesota.,Karen R. Fryer is a nurse and quality specialist in the Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.,Sandeep Tripathi is an attending physician in the pediatric critical care unit at Children's Hospital of Illinois, Peoria, Illinois, and an assistant professor of pediatrics at the University of Illinois College of Medicine, Peoria, Illinois.,Julie M. Duncan is a nurse and quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Heather L. Coon is a nurse and former quality coach in the pediatric intensive care unit, Mayo Clinic Children's Center.,Dipti R. Padhya is a pediatric critical care fellow in the pediatric intensive care unit, Mayo Clinic Children's Center.,Robert J. Kahoud is a pediatric intensivist and physician scientist, Mayo Clinic Children's Center, and an assistant professor of neurology and pediatrics, Mayo Clinic School of Medicine, with special interest in acute brain dysfunction
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Herling SF, Greve IE, Vasilevskis EE, Egerod I, Bekker Mortensen C, Møller AM, Svenningsen H, Thomsen T. Interventions for preventing intensive care unit delirium in adults. Cochrane Database Syst Rev 2018; 11:CD009783. [PMID: 30484283 PMCID: PMC6373634 DOI: 10.1002/14651858.cd009783.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delirium is defined as a disturbance in attention, awareness and cognition with reduced ability to direct, focus, sustain and shift attention, and reduced orientation to the environment. Critically ill patients in the intensive care unit (ICU) frequently develop ICU delirium. It can profoundly affect both them and their families because it is associated with increased mortality, longer duration of mechanical ventilation, longer hospital and ICU stay and long-term cognitive impairment. It also results in increased costs for society. OBJECTIVES To assess existing evidence for the effect of preventive interventions on ICU delirium, in-hospital mortality, the number of delirium- and coma-free days, ventilator-free days, length of stay in the ICU and cognitive impairment. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, Latin American Caribbean Health Sciences Literature, CINAHL from 1980 to 11 April 2018 without any language limits. We adapted the MEDLINE search for searching the other databases. Furthermore, we checked references, searched citations and contacted study authors to identify additional studies. We also checked the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and CenterWatch.com (all on 24 April 2018). SELECTION CRITERIA We included randomized controlled trials (RCTs) of adult medical or surgical ICU patients receiving any intervention for preventing ICU delirium. The control could be standard ICU care, placebo or both. We assessed the quality of evidence with GRADE. DATA COLLECTION AND ANALYSIS We checked titles and abstracts to exclude obviously irrelevant studies and obtained full reports on potentially relevant ones. Two review authors independently extracted data. If possible we conducted meta-analyses, otherwise we synthesized data narratively. MAIN RESULTS The electronic search yielded 8746 records. We included 12 RCTs (3885 participants) comparing usual care with the following interventions: commonly used drugs (four studies); sedation regimens (four studies); physical therapy or cognitive therapy, or both (one study); environmental interventions (two studies); and preventive nursing care (one study). We found 15 ongoing studies and five studies awaiting classification. The participants were 48 to 70 years old; 48% to 74% were male; the mean acute physiology and chronic health evaluation (APACHE II) score was 14 to 28 (range 0 to 71; higher scores correspond to more severe disease and a higher risk of death). With the exception of one study, all participants were mechanically ventilated in medical or surgical ICUs or mixed. The studies were overall at low risk of bias. Six studies were at high risk of detection bias due to lack of blinding of outcome assessors. We report results for the two most commonly explored approaches to delirium prevention: pharmacologic and a non-pharmacologic intervention.Haloperidol versus placebo (two RCTs, 1580 participants)The event rate of ICU delirium was measured in one study including 1439 participants. No difference was identified between groups, (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.87 to 1.17) (moderate-quality evidence). Haloperidol versus placebo neither reduced or increased in-hospital mortality, (RR 0.98, 95% CI 0.80 to 1.22; 2 studies; 1580 participants (moderate-quality evidence)); the number of delirium- and coma-free days, (mean difference (MD) -0.60, 95% CI -1.37 to 0.17; 2 studies, 1580 participants (moderate-quality of evidence)); number of ventilator-free days (mean 23.8 (MD -0.30, 95% CI -0.93 to 0.33) 1 study; 1439 participants, (high-quality evidence)); length of ICU stay, (MD 0.18, 95% CI -0.60 to 0.97); 2 studies, 1580 participants; high-quality evidence). None of the studies measured cognitive impairment. In one study there were three serious adverse events in the intervention group and five in the placebo group; in the other there were five serious adverse events and three patients died, one in each group. None of the serious adverse events were judged to be related to interventions received (moderate-quality evidence).Physical and cognitive therapy interventions (one study, 65 participants)The study did not measure the event rate of ICU delirium. A physical and cognitive therapy intervention versus standard care neither reduced nor increased in-hospital mortality, (RR 0.94, 95% CI 0.40 to 2.20, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of delirium- and coma-free days, (MD -2.8, 95% CI -10.1 to 4.6, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of ventilator-free days (within the first 28/30 days) was median 27.4 (IQR 0 to 29.2) and 25 (IQR 0 to 28.9); 1 study, 65 participants; very low-quality evidence, length of ICU stay, (MD 1.23, 95% CI -0.68 to 3.14, I² = 0; 1 study, 65 participants; very low-quality evidence); cognitive impairment measured by the MMSE: Mini-Mental State Examination with higher scores indicating better function, (MD 0.97, 95% CI -0.19 to 2.13, I² = 0; 1 study, 30 participants; very low-quality evidence); or measured by the Dysexecutive questionnaire (DEX) with lower scores indicating better function (MD -8.76, 95% CI -19.06 to 1.54, I² = 0; 1 study, 30 participants; very low-quality evidence). One patient experienced acute back pain accompanied by hypotensive urgency during physical therapy. AUTHORS' CONCLUSIONS There is probably little or no difference between haloperidol and placebo for preventing ICU delirium but further studies are needed to increase our confidence in the findings. There is insufficient evidence to determine the effects of physical and cognitive intervention on delirium. The effects of other pharmacological interventions, sedation, environmental, and preventive nursing interventions are unclear and warrant further investigation in large multicentre studies. Five studies are awaiting classification and we identified 15 ongoing studies, evaluating pharmacological interventions, sedation regimens, physical and occupational therapy combined or separately, and environmental interventions, that may alter the conclusions of the review in future.
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Affiliation(s)
- Suzanne Forsyth Herling
- Rigshospitalet, University of CopenhagenThe Neuroscience CentreBlegdamsvej 9CopenhagenDenmark2100
- Herlev and Gentofte Hospital, University of CopenhagenDepartment of AnaesthesiaHerlev Ringvej 75HerlevDenmark2730
| | - Ingrid E Greve
- Bispebjerg and Frederiksberg Hospitals, University of CopenhagenDepartment of Anaesthesia and Intensive careCopenhagenDenmark
| | - Eduard E Vasilevskis
- Division of General Internal Medicine and Public Health, Vanderbilt University and theTennessee Valley Geriatric Research, Education and Clinical Center (GRECC)Department of Medicine1215 21st Ave. S.6005 Medical Center East, NTNashvilleTNUSA37232‐8300
| | - Ingrid Egerod
- Rigshospitalet, University of CopenhagenIntensive Care Unit 4131Blegdamsvej 9Copenhagen ØDenmark2100
| | - Camilla Bekker Mortensen
- Zealand University HospitalIntensive Care Unit, Department of AnaesthesiologyLykkebækvej 1KøgeDenmark4600
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenDepartment of AnaesthesiaHerlev Ringvej 75HerlevDenmark2730
- Herlev and Gentofte Hospital, University of CopenhagenCochrane AnaesthesiaHerlev RingvejHerlev Ringvej 75HerlevDenmark2730
- Herlev and Gentofte Hospital, University of CopenhagenCochrane Emergency and Critical CareHerlev Ringvej 75HerlevDenmark2730
| | - Helle Svenningsen
- VIA University CollegeFaculty of Health SciencesAarhus NDenmarkDK‐8200
| | - Thordis Thomsen
- Rigshospitalet, The Abdominal CentreDepartment of Nursing ResearchBlegdamsvej 9CopenhagenDenmark2200
- University of CopenhagenDepartment of Clinical MedicineCopenhagenDenmark
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Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs 2018; 27:2109-2119. [PMID: 29603815 DOI: 10.1111/jocn.14365] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2018] [Indexed: 01/10/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the relationship of delirium and risk factors for cardiology intensive care unit (ICU) patients with the nursing workload. BACKGROUND Delirium is a common syndrome in patients with cardiac problems. The risk factors causing delirium and the presence and type of delirium affect the nurse workload and patient care quality adversely. DESIGN This cross-sectional study was conducted with 133 patients staying at the cardiology ICU of a university hospital between 5 January-31 March 2017. METHOD The study data were collected using the Patient Information Form, Delirium Risk Factors' Form and Therapeutic Intervention Scoring System-28 (TISS-28) scale to identify the nurse workload. The statistical analysis of the data was performed using frequency, chi-square, Mann-Whitney U, correlation and regression analyses. RESULTS It was found that patients who developed delirium were 65 years or older, they had more nasogastric/total parenteral nutrition (NG/TPN), benzodiazepine and physical restraints in comparison with those with no delirium development, and that the prevalence of hypoxia and hypoalbuminemia were higher in these patients. The mean TISS-28 score was higher in patients with delirium, compared with those without delirium. There was a positive correlation between the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and the mean TISS-28 score of the patients. The mean TISS-28 score was found to significantly increase with being at the age of 65 and above and the administration of mechanical ventilation. The patients with delirium required a mean of 60-min additional care. CONCLUSIONS Our study results suggest that the presence of delirium and the delirium risk factors, irrespective of delirium, increase the nurse workload. RELEVANCE TO CLINICAL PRACTICE An effective management of delirium risk factors can improve the patient care quality by reducing delirium occurrence and nurse workload.
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Affiliation(s)
| | - Tülin Bedük
- Ankara University Faculty of Health Sciences, Ankara, Turkey
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Steinseth EB, Høye S, Hov R. Use of the CAM-ICU during daily sedation stops in mechanically ventilated patients as assessed and experienced by intensive care nurses – A mixed-methods study. Intensive Crit Care Nurs 2018; 47:23-29. [DOI: 10.1016/j.iccn.2018.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/12/2018] [Indexed: 11/29/2022]
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Ramoo V, Abu H, Rai V, Surat Singh SK, Baharudin AA, Danaee M, Thinagaran RRR. Educational intervention on delirium assessment using confusion assessment method-ICU (CAM-ICU) in a general intensive care unit. J Clin Nurs 2018; 27:4028-4039. [PMID: 29775510 DOI: 10.1111/jocn.14525] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 03/27/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives. BACKGROUND Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools. DESIGN This study, performed in Malaysia, used a single-group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment. METHODS Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and postintervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance. RESULTS There were significant differences in the knowledge scores pre- and postintervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision-making" and "difficult to interpret delirium in intubated patients". CONCLUSIONS Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and interprofessional involvements are essential for a successful implementation of intensive care unit delirium assessment practice. RELEVANCE TO CLINICAL PRACTICE This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings.
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Affiliation(s)
- Vimala Ramoo
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Harlinna Abu
- Kulliyyah of Nursing, International Islamic University Malaysia, Pahang, Malaysia
| | - Vineya Rai
- KPJ Tawakkal Specialist Hospital, Kuala Lumpur, Malaysia
| | | | | | - Mahmoud Danaee
- Academic Enhancement and Leadership Development Centre (ADeC), Level 14, Wisma R& D, University of Malaya, Kuala Lumpur, Malaysia
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Stewart C, Bench S. Evaluating the implementation of confusion assessment method-intensive care unit using a quality improvement approach. Nurs Crit Care 2018; 23:172-178. [PMID: 29766622 DOI: 10.1111/nicc.12354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/22/2018] [Accepted: 03/21/2018] [Indexed: 02/01/2023]
Abstract
Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post-implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.
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Affiliation(s)
- C Stewart
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - S Bench
- School of Health and Social Care, London South Bank University, London, UK
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Barnes‐Daly MA, Pun BT, Harmon LA, Byrum DG, Kumar VK, Devlin JW, Stollings JL, Puntillo KA, Engel HJ, Posa PJ, Barr J, Schweickert WD, Esbrook CL, Hargett KD, Carson SS, Aldrich JM, Ely EW, Balas MC. Improving Health Care for Critically Ill Patients Using an Evidence‐Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation. Worldviews Evid Based Nurs 2018; 15:206-216. [DOI: 10.1111/wvn.12290] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Brenda T. Pun
- Clinical Program ManagerVanderbilt University Medical Center Nashville TN USA
| | - Lori A. Harmon
- Director QualitySociety of Critical Care Medicine Mount Prospect IL USA
| | - Diane G. Byrum
- Quality Implementation ConsultantInnovative Solutions for HealthCare Education LLC Chicago IL USA
| | - Vishakha K. Kumar
- Senior Manager, ResearchSociety of Critical Care Medicine Mount Prospect IL USA
| | - John W. Devlin
- Professor of Pharmacy, School of Pharmacy, Northeastern University, and Scientific Staff, Division of Pulmonary and Critical Care MedicineTufts Medical Center Boston MA USA
| | - Joanna L. Stollings
- Medical Intensive Care Unit Clinical Pharmacy Specialist and Pharmacist ICU Recovery Center, Department of Pharmaceutical ServicesVanderbilt University Medical Center Nashville TN USA
| | - Kathleen A. Puntillo
- Professor EmeritaSchool of Nursing, University of California San Francisco San Francisco, CA USA
| | - Heidi J. Engel
- Clinical Specialist, Department of Rehabilitative ServicesUniversity of California San Francisco CA USA
| | - Patricia J. Posa
- Quality Excellence LeaderSaint Joseph Mercy Health System Ann Arbor MI USA
| | - Juliana Barr
- Associate Professor, Department of Anesthesiology, Perioperative, and Pain MedicineStanford University School of Medicine Stanford CA USA
- Staff Anesthesiologist and Intensivist at the VA, Anesthesiology ServiceVA Palo Alto Health Care System Palo Alto CA USA
| | - William D. Schweickert
- Director, Medical Critical Care Operations, Division of Pulmonary, Allergy and Critical CarePerelman School of Medicine at the University of Pennsylvania Philadelphia PA USA
| | - Cheryl L. Esbrook
- Program Coordinator of Occupational Therapy Professional DevelopmentUniversity of Chicago Medicine Chicago IL USA
| | - Ken D. Hargett
- Director, Respiratory Care ServicesHouston Methodist Hospital Houston TX USA
| | - Shannon S. Carson
- Professor of Medicine and Division Chief, Pulmonary Diseases & Critical Care MedicineUniversity of North Carolina‐Chapel Hill Chapel Hill NC USA
| | - J. Matthew Aldrich
- Medical Director, Critical Care Medicine, Associate Clinical Professor, Anesthesia and Perioperative CareUniversity of San Francisco‐California Medical Center San Francisco CA USA
| | - E. Wesley Ely
- Professor of Medicine, Department of Medicine, Pulmonary and Critical Care and Health Services Research CenterVanderbilt University School of Medicine and The Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC) Nashville TN USA
| | - Michele C. Balas
- Associate Professor, College of Nursing, Center of Excellence in Critical and Complex CareThe Ohio State University and Nurse Scientist, The Ohio State University Wexner Medical Center Columbus OH USA
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Efficacy of Liaison Education and Environmental Changes on Delirium Incidence in ICU. ARCHIVES OF NEUROSCIENCE 2018. [DOI: 10.5812/archneurosci.56019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Smith JM, Van Aman MN, Schneiderhahn ME, Edelman R, Ercole PM. Assessment of Delirium in Intensive Care Unit Patients: Educational Strategies. J Contin Educ Nurs 2018; 48:239-244. [PMID: 28459497 DOI: 10.3928/00220124-20170418-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 12/06/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently. METHOD A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU. RESULTS Participants (N = 34) showed a significant increase (p < .001) in confidence in their ability to assess and manage delirium following the multimodal education. No statistical change in knowledge of delirium existed following the education. CONCLUSION A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244.
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