• Implementation of a Nurse-Driven Nonpharmacological Sleep Bundle to Reduce Delirium in a Surgical Intensive Care Unit

      Turnbaugh, Lindsey D.; Hammersla, Margaret (2019-05)
      Background: The prevalence of delirium, an acute syndrome causing changes or fluctuations in baseline mental status leading to inattention, disorganized thinking, and altered levels of consciousness, afflicts patients residing in the intensive care unit. Several negative outcomes may occur in patients diagnosed with delirium in the intensive care unit, including increased mortality, hospital length of stay, cost of care, and long-term cognitive impairment. Sleep, a critical component of health and recovery, is noted to be disrupted in intensive care unit settings resulting in a correlative effect between sleep deprivation and delirium. Multicomponent nonpharmacological interventions are intended to reduce the predisposing factors of this syndrome and have been shown in randomized control trials and systematic reviews to be effective in preventing delirium. Local Problem: The purpose of this quality improvement project was to implement a nursedriven non-pharmacological sleep bundle with a checklist of interventions to reduce intensive care unit delirium, which was noted by staff as an increasing problem, in an adult 12-bed Surgical Intensive Care Unit at a community hospital in Towson, Maryland. Interventions: An evidence-based checklist of nonpharmacological interventions related to reducing noise, light, and patient care interruptions was implemented by the Surgical Intensive Care Unit nurses on patients admitted over an eight week period. Checklist compliance was measured during the eight weeks of implementation by counting the number of completed checklists and comparing that to the number of admissions per week. The interventions performed on all completed checklists were evaluated using descriptive statistics. Delirium was measured by the Confusion Assessment Method Intensive Care Unit tool in the electronic health record and evaluated through an electronic chart review. A data analysis was performed using a chi-square test and odd’s ratio to compare the Confusion Assessment Method Intensive Care Unit scores pre-implementation versus post-implementation of the sleep bundle. Results: During the first four weeks of project implementation, the weekly completed checklist compliance rate was 98%, however, the remainder of the implementation phase was at 100%. There was a high rate of noise, light, and patient care interventions labeled as “not-complete” due to patient refusal or “not-applicable” due to the inappropriateness of the intervention for the patient population. In the pre-implementation phase, delirium was reported as positive on the Confusion Assessment Method Intensive Care Unit tool 22% of the time versus 51% of the time in the post-implementation phase. A chi-square test determined a statistically significant association between the variables (p<0.001), though an odd’s ratio test (OR=0.26) revealed no association between the nonpharmacological sleep bundle and delirium scores. Conclusions/Implications: Documentation compliance was sustained by having the Confusion Assessment Method Intensive Care Unit documentation already embedded in the electronic health record. There was an increase in the awareness and nursing documentation of Confusion Assessment Method Intensive Care Unit scores during and after project implementation. Despite an increase in delirium among patients post-implementation, the literature still suggests a correlative effect between sleep deprivation and ICU delirium. Further studies are needed to determine whether multicomponent nonpharmacological sleep bundles can reduce delirium.
    • Implementing the Confusion Assessment Method to Improve the Care of Delirious Patients

      Akande, Irene (2016)
      Background: Delirium affects approximately fifty percent of adults aged 65 years or older. The prevalence of delirium can be as high as 74% in surgical patients and 11% to 42% in non-surgical patients. Delirium can go undetected in 72% of Intensive Care Unit (ICU) patients when routine neurological monitoring tool is not used but could be prevented in 30 to 40% of cases, if detected early. Using a valid and reliable delirium assessment tool in the ICU, is essential so early interventions can be initiated. Purpose: The purpose of this scholarly project was to implement use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for delirium assessment at a hospital in the Mid-Atlantic region of the United States. Methods: This quality improvement project was conducted with nurses that work in the intensive care unit. Informed consent was obtained by all nurse participants whose participation in the project was strictly voluntary. Pre and post-intervention questionnaires measured perceived self-confidence and comfort levels with providing ICU delirium care and delirium knowledge. The project involved three phases: pre-intervention questionnaire administration, in-service, case scenarios, brief videos and one-on-one training and implementation of the CAM-ICU tool in the ICU setting, and the administration of post-intervention questionnaire. Laminated CAM-ICU worksheet and flowsheet were placed at each bed space to provide cues to the nurses to complete their delirium assessment. Multiple modes of interventions were used for the implementation of the CAM-ICU. A total of 34 ICU nurses consented to the project. Results: Thirty-four participants completed the pretest; 22 participants completed the posttest. The age of the participants ranged between 36 - 66 years, the average age was 53 years (SD = 7.94); years of ICU experience ranged between 3 - 40 years, average ICU experience was 20 years (SD = 9.09); 77% of participants had a Bachelor of Science degree. Comfort assessing ICU patients for delirium increased, t(21) = -2.339, p =.029, confidence providing accurate definition of delirium increased, t(21) = -3.052, p = .006, and nurses improved ability to identify interventions to prevent or decrease delirium, t(21) = -2.731, p = .013. There were statistically significant differences between the mean scores on the knowledge test from pre- to post-intervention, t(21) = -10.784, p < .001. Nurses age (p = .620), years of ICU experience (p = .352) and level of education (p = .129) did not influence the knowledge scores. Compliance in using paper CAM-ICU worksheet for documentation was 21%. Nurses scored 28% of the ICU patients screened as delirious. Conclusion: This quality improvement project suggests that a formal training program for ICU nurses coupled with the use of in-service, one-on-one sessions, and videos for the implementation of the CAM-ICU tool, can result in increased awareness and knowledge of ICU delirium. The positive results have the potential to prompt treatment and improve outcomes for ICU patients who experience delirium. Adoption of the CAM-ICU into patient electronic health record is recommended for sustainability.
    • Reducing Post-Operative Delirium and Cognitive Dysfunction: Intraoperative Anesthesia Interventions Guideline

      Crisostomo, Ryan P.; Franquiz, Renee (2021-05)
      Problem: Post-operative delirium, a common complication in the elderly after surgery, is associated with poor outcomes such as post-operative cognitive dysfunction which is a reduction in cognitive performance following surgery that lasts months after surgery or longer. Implementation of anesthetic interventions can reduce the development of cognitive dysfunction, estimated 40 percent of post-operative delirium cases are preventable using these interventions. Purpose: The purpose of this quality improvement project was to implement and evaluate tailored anesthesia interventions for surgical patients who screened preoperatively as high risk of developing post-operative delirium/post-operative cognitive dysfunction. Methods: The project involved patients ≥ 65 years old undergoing surgery at a suburban hospital that screen as high-risk for cognitive dysfunction. Anesthesia providers were educated and demonstrated understanding of the intraoperative anesthesia interventions guideline. Anesthesia providers considered, and when clinically appropriate, provided the interventions in accordance with the guidelines and documented as customary in the patient record. Data regarding the provider’s adherence to the guidelines were collected weekly by retrospective chart review. Results: Of the eligible 345 patients, 217 underwent a cognition screening pre-operatively and 50 screened positive. Anesthesia providers gave consideration to the intraoperative guidelines an average of 96 percent during the project with a range of 50 to 100. On average, the intraoperative guidelines were adhered to 85 percent of the time with a range of 43 to 100. Conclusions: While the recommended intraoperative care was evidence based and often received consideration, execution of those cares occurred less often. This may have been an oversight on anesthesia providers or due to the contextual nature of intraoperative anesthesia care wherein the recommended guidelines were appropriate in one clinical situation but not another.