Implementation of the Confusion Assessment Method on a Medical Intermediate Care Unit

Abstract

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.