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Delirium in the Intensive Care Unit

A Case for Improvement Science

Gould, Kathleen Ahern PhD, RN

doi: 10.1097/DCC.0000000000000134
DEPARTMENTS: Editorial
Free

Kathleen Ahern Gould, PhD, RN Editor in Chief Dimensions of Critical Care Nursing Adjunct Faculty William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts

There is no greater agony than bearing an untold story inside you. —Maya Angelou

Once again, I was informed and inspired by the 2015 American Association of Critical Care Nurse’s National Teaching Institute. Critical care nurses came together to network, present, display posters, and share expertise. This year’s venue did not disappoint. It was futuristic, person centered, and innovative. Most importantly, it felt like improvement science at work. Improvement science is a proven model for moving health care forward. Improvement science is guided by the Triple Aim, which is simply improving the individual experience of care, improving the health of populations, and reducing the per-capita cost of care.1

In every presentation, poster session, daily newsletter, or scholarly work, I saw run charts, Paredo charts, fish diagrams, flow charts, and PDSA (Plan, Do, Study, Act) cycles. These are the tools of improvement science. Many presentations explained how improvement teams used Lean, Six Sigma, and bundled care, while incorporating new technology. Evidence, outcomes, and innovation were terms heard at every presentation, coffee counter, and dinner. One topic, delirium in the intensive care unit (ICU), led many discussions, as it is a continuing challenge for nurses, with devastating consequences for our patients and families. This topic was addressed with renewed purpose in presentations and posters, including one completed with the support of a Clinical Scene Investigator award.

We all learned more about this topic throughout the week. I was struck by a presentation given by Elizabeth Bridges, who shared evidence-based research that indicates delirium in ICU patients is associated with posttraumatic stress disorder (PTSD) in both patients and families, well after discharge from the hospital.2

This experience happens under our care; much of what trauma and critically ill patients experience occurs well after the event that brought them to our ICUs. As we heard more about the link between delirium and PTSD Bridges repeated the words of poet Maya Angelou: “There is no greater agony than bearing an untold story inside you.” A familiar quote, yet I had never thought of it in the context of the ICU experience. These words reminded me of the terror, confusion, and fear I have seen in the eyes of many patients and family members. I wanted to learn more. Each presentation left me with more questions. I was encouraged as I realized that this topic was being evaluated through the lens of improvement science! The first step of improvement work is to ask questions about our current practice and search for evidence to guide us toward better outcomes. Lean thinking, a proven improvement tool, tells us that to learn and to improve, we must ask at least 5 questions in our search for improvement.3 I have many. Do I know enough? Have I done enough to help patients? How can we improve the ICU experience? Who can help us? What are the models that will bring us there?

In this issue of DCCN, many talented and committed professionals discuss the complex topic of delirium in the ICU. Their work illustrates that there are many avenues to explore as we strive to improve short- and long-term outcomes for our patients who may be at risk of delirium.

Marino and colleagues bring an interprofessional perspective to the challenges of caring for critically ill patients with delirium. They remind us that delirium is a commonly observed problem for adult patients in the ICU that it is associated with increased mortality, increased hospital length of stay, and long-term disability of ICU survivors. Marino and colleagues share a quality improvement project through their article, “Implementation of an Intensive Care Unit Delirium Protocol.” This quality improvement project demonstrates that a formal didactic training program for ICU nurses can result in increased awareness and knowledge of ICU delirium and adequately prepare them for how to properly screen and treat patients.

Kram and colleagues share their experience implementing the ABCDE bundle in an adult ICU in a rural community hospital. Kram and colleagues embrace the guidelines of the Triple Aim, as their results were consistent with improved outcomes and cost-effectiveness. Their article, “Implementation of the ABCDE Bundle to Improve Patient Outcomes in the Intensive Care Unit in a Rural Community Hospital,” describes the use of the ABCDE (awakening, breathing, coordination, delirium monitoring and management, and early mobility) bundle, an evidence-based, multidisciplinary approach to minimize potentially deleterious effects of prolonged hospitalization, including the development of delirium. The purpose of this evidence-based practice project was to implement the bundle in an adult ICU of a rural community hospital. The results indicate that the ABCDE bundle can be implemented in rural, community-based hospitals and provides a cost-effective and safe method for enhancing patient outcomes in the ICU!

Volland et al address the complexity of impaired cognition associated with extended stays in the ICU. In their article, “Delirium and Dementia in the Intensive Care Unit: Increasing Awareness for Decreasing Risk, Improving Outcomes, and Family Engagement,” they explore interventions and practical applications the ICU clinician can use for increasing self, patient, and family awareness to decrease risk, improve outcomes, and promote ways to deepen family engagement.

These articles helped answer some of my questions. Each piece offers different models, perspectives, and techniques that will help us move our science forward. They represent improvement science at work as they contribute to achieving the Triple Aim for our patients and families at risk of the short- and long-term consequences of delirium experienced in our ICUs.

Kathleen Ahern Gould, PhD, RN

Editor in Chief Dimensions of Critical Care Nursing

Adjunct Faculty

William F. Connell School of Nursing

Boston College

Chestnut Hill, Massachusetts

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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References

1. Bisognano M, Kenney C. Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs. San Francisco, CA: Jossey-Bass; 2012.
2. Bridges E. Critical care studies you should know about. Presented at the American Association of Critical Care Nurses 2015 National Teaching Institute; May 19, 2015; San Diego, CA.
3. Gabow P, Goodman P. The Lean Prescription; Powerful Medicine for Our Ailing Healthcare System. New York: CRC Press; 2015.
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