Intensive care unit (ICU) delirium is a commonly observed problem in critically ill adults that is associated with many negative long-term outcomes.1 However, the pathophysiology of delirium is not well understood,2 and many critical care practitioners are not familiar with current evidence-based recommendations regarding prevention of delirium or the proper care of the delirious patient. Bedside critical-care nurses are in a unique position in that they are keenly aware of the patient’s behaviors on a minute-to-minute basis. Therefore, nurses, with adequate training, can serve as key members of the ICU multidisciplinary team who perform clinical delirium screenings and deliver evidence-based interventions aimed at the prevention and treatment of delirium.3 A quality improvement initiative was undertaken at a 446-bed acute community teaching hospital to provide bedside critical-care nurses with education regarding ICU delirium, to train them on the proper use of a reliable ICU delirium screening tool, and to provide them with a delirium care bundle protocol to be utilized on every ICU patient.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, delirium is characterized by acute disturbance in level of consciousness, inattention, and fluctuations in symptoms associated with drug toxicity or acute mental or physical illness.4 The pathophysiology of delirium that occurs in the ICU environment is unknown, but multiple hypotheses have been developed that speculate that GABA (γ-aminobutyric acid)–ergic, cholinergic, or dopaminergic pathways are involved in the process. In addition, the role of cytokines crossing the blood-brain barrier during inflammatory response may present another pathway that predisposes a patient to the development of delirium.1 Recent research utilizing brain magnetic resonance imaging in patients with and without ICU delirium shows that there may be an association between delirium in critical illness and cerebral white matter changes, although a causal relationship has not been determined.5
Delirium, which is a temporary and reversible condition, was once believed to be a benign, self-limiting adverse effect of ICU admission. However, recent evidence has shown that development of ICU delirium is associated with many short- and long-term negative outcomes for the ICU survivor, even after the acute change in mental status has resolved. These outcomes include increased length of hospital stay,6 increased odds of disability in activities of daily living,7 higher 6-month mortality,8 and severe long-term cognitive impairment.9 Unfortunately, because the biologic etiology of delirium is unknown at this time, no definitive pharmacologic treatment has been determined, and no compelling evidence exists to support use of antipsychotic agents for the prevention or treatment of delirium.10 Therefore, current evidence-based efforts are aimed largely at prevention of delirium through modification of risk factors.
Some studies have pointed to ICU care–related risk factors for developing delirium that can be modified. Use of benzodiazepines such as lorazepam in order to provide sedation is an iatrogenic factor that has been shown to be an independent risk factor for the development of delirium in the adult ICU patient.11-13 Fluctuations in level of sedation used while patients receive mechanical ventilation, as well as extended periods of oversedation, have also been implicated in the development of ICU delirium.14 Immobilization is also considered a risk factor. Early mobility efforts in ICU patients have been shown to decrease the incidence and duration of delirium, as well as lessen ICU length of stay.10
Current clinical practice guidelines published by the Society of Critical Care Medicine in 2013 based on an exhaustive 6-year review of literature make various evidence-based recommendations regarding the detection, monitoring, and prevention of delirium. These include routine monitoring of delirium with a valid and reliable screening tool by bedside staff, performance of early mobility and physical therapy interventions on all adult ICU patients when feasible, daily interruption of sedation, target of light level of sedation in mechanically ventilated patients, and promotion of sleep. These interventions are recommended to be implemented by a multidisciplinary team of providers after providing proper education and preprinted protocols and checklists to help facilitate the use of published guidelines.10
The Intensive Care Delirium Screening Checklist (ICDSC) is a validated delirium screening tool developed in 2001, which is composed of a checklist of 8 items based on the Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosis.15 Published data cite a predicted sensitivity of 99% and specificity of 64%,15 whereas pooled data from a recent meta-analysis report a sensitivity of 74% and specificity of 81.9%.16 This tool has been found to be adequate for detection of delirium in critically ill patients in multiple studies.10 It allows for the quick recognition of delirium in the adult ICU patient by the bedside staff member once proper training has been completed. One benefit of this tool includes the allowance for detection of “subsyndromal delirium,” which consists of an ICDSC score that is under the threshold for clinical delirium, but is associated with poor outcomes, such as increased hospital length of stay and long-term disability.17 Bedside staff nurses in critical care units have been shown to view the ICDSC tool favorably, citing that they feel this tool is easy to use, has improved their knowledge of delirium, and has enhanced their ability to provide patient care.18
Bedside critical-care nurses are uniquely poised to provide delirium monitoring and prevention care once armed with proper knowledge through formal education. In a recent systematic review, nurses who were provided with didactic and interactive education on how to use a validated delirium screening tool, such as the ICDSC, as well as written resources available after the education had been completed, were shown to have significant increase in knowledge and self-reported improved confidence in recognition of delirium.19
The ICU Delirium and Cognitive Impairment Study Group from Vanderbilt University has reviewed and summarized the available evidence and developed the ABCDE Delirium Safety and Prevention Bundle, which encompasses 5 key interventions for the prevention, detection, and treatment of ICU delirium. These interventions include daily spontaneous awakening trials, simultaneous daily spontaneous breathing trials, careful discernment in choice and level of sedation, early recognition of delirium and appropriate management, and early mobility and exercise.20 Critical-care nurses, with proper training and implementation of standard policies and procedures for the recommended interventions, can serve as leaders and multidisciplinary team champions of proper delirium care and management.
Our 446-bed local acute care teaching hospital has historically made attempts to implement delirium screening for adult ICU inpatients within the last decade. However, multiple changes made to the electronic medical record (EMR) over the years, along with a recent merger with a larger regional hospital system, had completely eliminated any structures previously put in place to allow for routine delirium screening of ICU patients. There have never been any attempts made to implement a formal delirium educational program for nursing staff, nor has there been any formal care bundle or protocol set forth detailing the care for prevention and treatment of delirium. Furthermore, the incidence of delirium at this particular facility is unknown, and thus there is a lack of preexisting baseline data in order to compare future quality improvement strategies’ outcomes.
The purpose of this quality improvement project was to develop, implement, and evaluate a nursing education program for critical-care nurses on a protocol for the prevention and management of delirium in adult ICU patient populations, as well as improve nurses’ familiarity, comfort, and compliance with using a standardized evaluation method for delirium and intervention care bundle.
This project was based on the framework of the PDSA (Plan-Do-Study-Act) model for quality improvement, which has been utilized by many health care organizations and advocated by the Institute of Healthcare Improvement and Associates in Process Improvement. This method of quality improvement within hospitals and health care systems consists of several steps toward implementing large-scale quality improvement changes: formation of a team, establishment of specific aims or goals, establishment of specific measurements of outcomes, selection of changes to be implemented, testing those changes, and then subsequent implementation of changes and further outreach of changes if successful.21 The team for this project was led by a senior-level bedside ICU nurse and doctoral student. Other key team members consisted of leaders from the facility’s critical care medical staff, pharmacy, and the doctoral student’s academic advisor. The facility’s multidisciplinary Pain, Agitation, and Delirium Taskforce was also involved in establishing policy changes to support this project’s goals.
One of the overarching goals of this project was to improve nursing staff’s knowledge regarding evidence-based ICU delirium care, which would be demonstrated by a statistically significant improvement in knowledge test scores, as well as final test raw scores averaging greater than 90% correct. A secondary goal was to document the incidence of positive delirium scores for comparison to published figures, which ideally would reveal less than 50% of screenings resulting positive for clinical delirium.
Approval for this quality improvement initiative was first obtained from the UPMC Hamot Institutional Review Board as per our facility’s policies regarding nursing quality improvement projects. Informed consent was obtained from all nursing staff participating in the educational portion of the project per their request. The implementation of a delirium screening and care bundle protocol for ICU patients in this project involved documentation of interventions that encompassed usual and customary care for the ICU patient; thus, informed consent was not required for the patients. No patient identifiers were collected in order to maintain privacy.
The setting of this project included a 14-bed medical ICU (MICU), a 15-bed trauma/neurosurgical ICU (TNICU), and a 13-bed cardiovascular ICU (CVICU) within a community acute care teaching hospital, which is designated as a level II trauma center. These ICUs operate with independent nursing staffs and nursing unit directors, but do simultaneously draw upon supplemental staff members from the nursing “float pool” who are designated as critical-care nurses.
Because literature supports the use of formal didactic delirium education for nursing staff, a live lecture format educational program was developed with the aid of Microsoft PowerPoint® presentation software. The program included background information regarding ICU delirium, current evidence-based recommendations, and specific instruction regarding the use of the ICDSC screening tool. Three fictional patient case studies were included in the program in order to facilitate group discussion of how to apply the ICDSC to a clinical scenario. Supplemental handout materials were developed, which consisted of a paper-based copy of the live lecture slides, copy of the ICDSC screening tool (Figure 1), and copy of the ABCDE delirium care bundle (Figure 2). The content of the live lecture was validated by a collaborating quality improvement project team member to ensure accuracy and inclusion of the most recent evidence from literature.
A 5-item Likert scale–based survey was developed in order for nursing staff participants to self-report their perceived self-confidence and comfort levels with providing ICU delirium care (Figure 3). Nurses were asked to rate their level of agreement with each statement on a 5-point scale, ranging from “strongly disagree” (1) to “strongly agree” (5). A 15 multiple-choice item knowledge assessment tool was additionally developed, which measured basic knowledge of delirium care, recognition, and management (Figure 4). As with the live lecture, the knowledge assessment tool was also screened for content validity by a collaborating team member.
Eight educational sessions were offered in 1-hour increments spaced over 2 weeks in July 2014 in order to allow nursing staff ample opportunity for participation. Staff members were recruited by e-mail, word-of-mouth encouragement by nursing unit directors, and paper posters placed in all unit staff lounge areas. Any nurse who provided care to critically ill adults in any one of the ICUs for greater than or equal to 50% of their entire caseload was considered eligible for inclusion in data collection. Any other staff member who wished to participate was encouraged to attend the educational sessions but was not included in formal data collection. Each educational session was led by a senior-level critical-care staff nurse member of the quality improvement project team. Informed consent was obtained from each nursing staff participant at the beginning of each session. A pre-educational survey was administered, which consisted of collection of basic demographic data (age range, gender, highest-level nursing degree obtained, and years of ICU nursing experience), the 5-item Likert scale perception statements, and the 15-item multiple choice knowledge test. The live lecture included 3 case scenarios that required audience collaboration and participation. The posteducational survey consisted of an identical copy of the pre-educational survey with the demographic data omitted.
Following the 2-week formal educational period, an additional period of 4 weeks was allotted for nursing staff who chose not to participate to engage in self-teaching. The paper-based educational materials were released to all critical care nursing staff via e-mail attachments, as well as provided to each designated ICU clinical nurse educator. Questions regarding the use of the ICDSC tool and ABCDE care bundle were encouraged either by e-mail or in person to the project team members. Also during this time period, a member of the project team met individually with each critical-care provider to discuss the forthcoming implementation of the ICDSC tool and ABCDE care bundle and to answer any questions and address any concerns they may have.
DELIRIUM SCREENING AND CARE BUNDLE IMPLEMENTATION PHASE
Four weeks after the conclusion of the formal didactic educational sessions, the ICDSC screening tool and ABCDE protocol were implemented daily at the bedside for every adult inpatient located in any 1 of the 3 ICUs. Because the ICDSC uses the patient’s behaviors within the past 24 hours to arrive at a screening score, a once-daily screening was used for this project. The nursing staff was instructed to complete the ICDSC screening tool daily on paper prior to the beginning of morning multidisciplinary rounds. In addition, the nursing staff was expected to complete a paper-based ABCDE care bundle checklist form daily, detailing which of the pertinent care bundle interventions the patient received in the past 24 hours. Paper-based forms were utilized because of lack of integration of these initiatives in the EMR. The forms were then collected by the charge nurse for each ICU daily, stored in a secure location, and then collected by a member of the project team. The number of forms received was compared with the number of patients physically present on the unit each day. The forms did not include any identifying information as to protect the privacy of patients being screened.
The initial intended duration of formal data collection during the implantation phase of this project was 90 days. However, the EMR was unexpectedly updated on October 1, 2014, to include provision for the ICDSC screening tool, which was 34 days after implementation. Because none of the project members had previous clearance to perform EMR chart reviews and did not wish to create additional documentation for the bedside nurses, a decision was reached to end this project phase early on October 1, 2014, with an official transition from paper-based delirium screening to EMR-based delirium screening on that date.
Despite recent literature’s support of using formal didactic education for improving knowledge of critical-care nurses regarding ICU delirium and implementing delirium programs in hospitals, no standard evaluation of these educational programs has been developed. Therefore, one of the aims of this quality improvement project was to develop measures of both nurses’ levels of perceived self-confidence and attitudes toward ICU delirium care, as well as level of basic knowledge regarding ICU delirium. In addition, because of the facility’s lack of ICU delirium care program prior to the implantation of this project, the project team lacked any data to perform a comparison of compliance with delirium screening and care bundle intervention implementation. Consequently, data obtained from the implantation phase are largely descriptive in nature.
A sample of 49 nurses was obtained during the formal educational phase, approximating one-third of the total critical-care nursing staff of the facility. During the protocol implementation phase of this project, compliance with total possible delirium screenings and accompanying ABCDE checklist was 56.3%, with 598 of 1061 possible patient assessments/protocols completed. The number of unique patients screened during this time is unknown, because of the lack of use of patient identifying information.
EDUCATIONAL PHASE RESULTS
Analysis of demographic data obtained from the nursing pre-educational surveys revealed that the nursing audience overwhelmingly consisted of females (82%). Twenty-three percent of the audience listed their age as less than 25 years, 25% listed their age between 25 and 34 years, and 27% listed their age as 35 to 44 years. The remaining participants listed their age as 45 years or older. The majority of participants indicated their highest nursing degree as a bachelor of science degree in nursing (78%), followed by 12% holding an associate degree in nursing, and 10% being graduates of a diploma-based program. No participants held a postbaccalaureate degree. Almost half of the participants reported 5 or less years of ICU nursing experience (49%), whereas 22% reported more than 20 years of ICU nursing experience. The remaining 28% reported years of experience ranging between 6 and 20 years (Figure 5).
Statistical analysis of the Likert scale items measuring nurses’ perceptions of ICU delirium care and perceived self-confidence revealed a significant improvement in positive perception for each item based on mean scores (P < .0001) (Table 1). Overall pre-educational responses for all items averaged in the neutral range, with posteducational responses averaging more positive responses, within the “agree” to “strongly agree” range, indicating more positive nursing perceptions regarding delirium care.
Overall pre-education and posteducation knowledge mean raw scores were compared. The average percentage of pre-education knowledge survey questions answered correctly was 70% ± 12.8%, and average percentage of posteducation knowledge survey questions answered correctly was 95% ± 6.9%. Statistical analysis of the average knowledge scores yielded a significant difference between the groups (P < .0001) (Table 2). All 15 items of the knowledge portion of the survey were analyzed for individual statistical significance in variation of scores between pre-education and posteducation surveys. Of the 15 items, 11 items were revealed to have been answered correctly more often in the posteducational phase (P < .05), with the remaining 4 items showing no statistically significant difference in scores after the educational session.
PROTOCOL COMPLIANCE RESULTS
During the 34 days of protocol implementation and data collection, there were 1061 opportunities for individual patient delirium assessments and care bundle documentation across all 3 ICUs. It is unclear how many unique patients this sample consisted of because this information was not collected as part of the project. In total, 598 patient delirium screenings and care bundle checklists were collected, representing a compliance rate of 56.3%. When compliance was examined by unit, it was revealed that a substantial lack of compliance occurred in 2 of the 3 ICUs. The MICU had the highest compliance (82.4%), followed by the CVICU (53%), and finally, the TNICU (34.6%) (Figure 6).
Overall, 20.4% (122/598) of the patient delirium screenings completed resulted positive for delirium, which consisted of a score of 4 or greater on the ICDSC. When stratified by unit, the proportion of positive delirium screenings in the MICU was 23.3%, CVICU was 13.5%, and TNICU was 21.3% (Figure 7).
Of the ABCDE protocol checklists received, each intervention category was analyzed individually, comparing utilization rates between all delirium-positive and delirium-negative patients across all units at the facility. A χ2 analysis was performed for each of the 5 categories of interventions: spontaneous awakening trial, spontaneous breathing trial, simultaneous pairing of spontaneous awakening trial with spontaneous breathing trial, nonpharmacologic delirium interventions, and early exercise and mobility. Results showed a lack of a statistically significant difference in application of the intervention categories between delirium-negative and delirium-positive patients overall (Table 3).
Based on the data collected from the first educational phase of this quality improvement project, critical-care staff nurses demonstrated a significant increase in knowledge that may be attributed to the intervention of providing live, didactic, and interactive formal education regarding ICU delirium. In addition, these nurses demonstrated a significant increase in positive perception of their role in ICU delirium care following formal education. These results correlate with previous studies that cite that formal didactic education is a feasible means to institute an ICU delirium care program in hospitals.19
The results obtained from delirium screenings indicate that the incidence of delirium may be relatively low at this particular facility among ICU patients. This is limited by the fact that the delirium assessments were not grouped according to unique patient, but were rather reported as results from individual patient encounters. In addition, the relatively poor compliance with delirium screening in 2 of the 3 ICUs may have skewed the true incidence of positive delirium screenings. Nevertheless, with the reported incidence of ICU delirium widely ranging from 16% to 89% in the literature, the baseline data obtained from this project suggest that the incidence of delirium at this facility may be relatively low when compared with these reported figures.
It is unknown why 2 of the 3 ICUs demonstrated poor compliance with completing delirium assessments and protocol checklists. In order to maintain confidentiality of nursing participants during the educational sessions, data were not collected regarding which unit the nurse worked in, so it is unknown if nurses from these units had relatively poor participation in the educational phase and thus lack of buy-in. Advanced practice nursing quality improvement projects are not routinely implemented in this facility, and therefore, the nursing staff may not have felt personally invested in the process of quality improvement because of lack of previous exposure. In addition, the nurse who provided the formal education is employed as staff in the MICU, which may have resulted in their relatively high compliance due to her advocacy of the project and personal availability in the unit as a resource.
Of those patient encounters where delirium screenings and protocol checklists were completed, it was found that patients whose daily screenings were positive for delirium received the care bundle interventions in a uniform fashion when compared with patients whose screenings were negative for delirium. This supports the ideal outcome that patients who are both delirious and nondelirious receive the care bundle interventions in a uniform manner, because these interventions have been shown not only to prevent delirium, but also decrease the duration of delirium symptoms.10,20
This project had limitations. First, the knowledge assessment tool was newly developed and thus was validated only for content and not for statistical reliability. Unfortunately, there was no previously validated, reliable tool developed for this purpose at the time of implementation. In addition, the amount of nurses who voluntarily participated in the formal educational phase of this project represented approximately only one-third of the total critical-care nursing staff of the facility. This may have ultimately contributed to both poor staff compliance with delirium screening and protocol implementation. Because of unexpected changes in the update of the EMR, the protocol implementation phase of this project was cut short in order to avoid duplicate documentation for delirium screenings. It is unclear if compliance may have improved over time, or if the number of positive delirium screenings would have differed significantly if this phase had continued for the original intended 90 days.
The next logical step in ongoing improvement is to complete an analysis of compliance with delirium screening now that the ICDSC screening tool has been integrated into the EMR. Because the ABCDE care bundle is not specifically outlined within the EMR as a protocol, it would be of interest to investigate if the individual interventions are being completed in a uniform manner without the daily visual reminder of the mnemonic. Recently, the ABCDE protocol has been expanded by the Cognitive Impairment Study Group at Vanderbilt University to include a new “F” intervention, with a provision to include the patient’s family in comprehensive delirium care. They have also made additional changes by expanding the “A” intervention to include assessment of pain.20 As the future of ICU delirium care forges onward, future evidence-based protocols will mostly likely be expanded to include provisions to prevent and treat the “ICU triad”2 of pain, agitation, and delirium together. As these changes are made, additional education will be necessary to provide bedside critical-care nurses with updated information regarding evidence-based practices.
The authors thank Timothy Cooney for assistance with statistical analysis for this project.
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