• Implementation of a Delirium Assessment Tool

      Van Allen, Jaime; Bullock, Lynn (2022-05)
      Problem: Delirium in hospitalized older adult patients is associated with significant adverse outcomes such as re-hospitalization, extended length of stay, functional decline, and increased morbidity and mortality rates. In non-intensive care unit (ICU) patients, the incidence of delirium is estimated to affect between 10% to 50%. Purpose: The purpose of this Quality Improvement (QI) project is to provide bedside nurses education on delirium and implement a bedside delirium assessment tool to assist in early identification. Providing care that is proactive and focused on prevention, as opposed to reactive and focused on treating identified conditions, is known to have better patient outcomes. Methods: A 24-bed medical surgical unit was selected to participate in the delirium assessment intervention. Patients aged 65 years and older and not on hospice or palliative care were the target intervention population. To achieve the project objective, staff reviewed an education module focusing on delirium and the selected bedside tool called the 4AT Rapid Clinical Test for Delirium. After participating in a pre-learning module with a pre- post-test, nurses then began completing the assessment tool on the designated population once per shift. When a completed assessment reflected possible delirium, the assigned provider was notified. Results: Upon completion of the education module the post-education survey reflected an increase in knowledge by 9.15%. The assessment tool had an implementation rate of 62.35% on day shift and 10.57% on night shift. Out of 552 completed assessments, eighty-three identified possible delirium (15.04%). Conclusions: The QI project demonstrated the effectiveness of providing delirium education to bedside nurses and the successful implementation of a brief assessment tool to identify patients at a risk for delirium.
    • Implementation of Delirium Screening in Thoracic and Surgical Intermediate Care Units

      Faherty, Karen M.; Jackson-Parkin, Maranda (2022-05)
      Problem: Delirium is a disorder experienced by 13-50% of patients over the age of 50 during their hospital stay. The thoracic and surgical intermediate care units (TIMC and SIMC) at a large, teaching hospital care for many elderly patients at high-risk of delirium, but unit-level chart audits revealed a 0-5% incidence of detected delirium. Current practice did not include delirium screening, which placed patients at higher risk for undetected delirium. Unrecognized and untreated delirium may lead to longer hospital stays, higher risks of falls, and longer duration of delirium episodes. Purpose: The purpose of this quality improvement project was to implement delirium screening using a validated screening instrument to improve delirium detection on the thoracic and surgical intermediate care units. Methods: The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a validated screening instrument (sensitivity 81%, specificity 95.8%; inter-rater reliability kappa=0.79-0.96), was implemented on two high-acuity intermediate care units over a fifteen-week period (September to December 2021). The CAM-ICU was located in the electronic health record (EHR), and all registered nurses (RN, n=47) and advanced practice registered nurses (APRN, n=16) on the two units were educated on how to complete the screen and manage screening results. Chart audits of the EHR were completed weekly for every patient admitted to the two units to assess adherence to the screening procedures. Results: Staff on both units achieved and sustained a high (>90%) rate of adherence to delirium screening among SIMC patients (n=110) and TIMC patients (n=101). Of the patients screened, 10% were identified as positive for delirium on the SIMC and 12.8% were identified as positive for delirium on the TIMC. Nurses notified the APRN or covering medical provider about patients with first-time positive screens 100% of the time. No special-cause variation was noted in the number of transfers to a higher level of care, falls, or restraint use. Conclusions: Implementing the CAM-ICU can increase delirium detection and interdisciplinary team communication on thoracic and surgical intermediate care units. Having the instrument in the EHR was a major factor in assuring adherence to and sustainability of the delirium screening procedures.
    • Implementation of the Confusion Assessment Method on a Medical Intermediate Care Unit

      Outen, Katharine; Akintade, Bimbola F. (2019-05)
      Background Delirium is a clinical syndrome characterized by acute onset fluctuations in mental status accompanied by inattention, an altered level of consciousness, and impairment in cognition. For all hospitalized adults, the prevalence of delirium is estimated at 20%, with an incidence ranging from 18% to 64%. Several hospital interventions put a patient at risk for developing delirium, including mechanical ventilation, medication interactions, urinary catheters, interrupted sleep cycles, and use of physical restraints. Developing delirium leads to an increased length of stay in an intensive care unit, length of overall hospital stay, likelihood of requiring nursing home care after discharge, and risk of mortality following hospitalization. Longer periods of delirium worsen cognition, executive functioning, ability to complete activities of daily living, and sensory-motor functioning. Local Problem The lack of delirium screening was identified as a potential patient safety issue on a medical intermediate care unit of a large, urban academic medical center on the East Coast. Interventions The Confusion Assessment Method is a widely used, specific and sensitive tool utilized to screen adult patients for delirium. A quality improvement project was conducted over a 13week period to implement and assess the nurse-perceived usability of the Confusion Assessment Method screening tool for patients on the medical intermediate care unit. Inclusion criteria was any patient over age 18 who transferred to the medical intermediate care unit directly from a medical intensive care unit. Eligible patients had a Confusion Assessment Method screening completed once per shift by the primary bedside nurse. The nurse was also asked to complete a System Usability Scale survey, a Likert-style questionnaire, to evaluate the nurse-perceived usability of the Confusion Assessment Method for this patient population. Participation by the nursing staff was voluntary. Results There were 329 eligible patient encounters with 183 Confusion Assessment Method screenings completed. Nurse compliance rate with completing the screening was 55.6%. Of the completed screenings, 8.7% (n=16) were “positive,” or suggestive that a diagnosis of delirium was present. A total of 181 System Usability Scale surveys were completed by the nursing staff with scores ranging from 35 to 100. The mean score was 77.94 (SD ±12.21), indicating above average usability. Conclusions Healthcare providers need to be aware of the risk of developing delirium for hospitalized adults and routinely screen patients. This quality improvement project provides initial support regarding the usability of the Confusion Assessment Method screening tool for non-critically ill adult patients on a medical intermediate care unit. Integration of delirium screening tools into the electronic medical records may improve compliance with screening.