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Prevention of delirium in acute decompensated heart failure using multi-component non-pharmacologic prevention
TagedEnHeart & Lung 47 (2018) 650 655
Contents lists available at ScienceDirect
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Heart & Lung
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journal homepage: www.heartandlung.com
AAHFN’S RESEARCH ABSTRACTS Prevention of delirium in acute decompensated heart failure using multi-component non-pharmacologic prevention TAGEDPBONNIE ALBERTTAGEDN Background: Delirium should be viewed as a "medical emergency until proven otherwise" (Fong et al., 2009, p. 2150). Delirium and its sequelae present significant risk for heart failure inpatients. Preventing delirium through the modification of known risk factors and alterable causes is the "cornerstone in decreasing hospital admissions, cost, morbidity, and mortality in acute decompensated heart failure patients" (Ampadu and Morley, 2015, p. 19). A paucity of research exists that addresses the incidence of delirium in heart failure. Uthalmalingam, Gurm, Daley, Flynn, and Capodilupo (2011) determined that 17.0% of 883 acute decompensated heart failure patients (ADHF) greater than 65-years-old had a positive diagnosis of delirium. A recent analysis by Honda, Nagai, Sugano, Okada, Asaumi, Aiba.& Anzai (2016) found 23% of 611 critically ill ADHF patients positive for delirium. Patients surviving to discharge were found to have an increase in all-cause, cardiovascular and non-cardiovascular death. The high documented incidence of delirium in heart failure patients further demonstrates the importance of prevention. An examination of the specific characteristics that predispose heart failure patients is worthy of consideration. The risk for delirium in ADHF patients is related to cognitive deficits, hemodynamic, and metabolic factors, and pathophysiologic mechanisms. Methods: A comprehensive search strategy was completed for the literature search for this project utilizing the databases CINAHL, PubMed, Cochrane, Joanna Briggs Institute, OvidSp, Ebsco Host Education, Ebsco Education Research Complete from 2010 2017 for studies relevant to non-pharmacologic delirium prevention and education. Search terms included delirium, cognitive impairment, prevention and control, knowledge and education, ICU, risk, adherence, heart failure, acute decompensated heart failure, cardiac failure, strategy, and policy. In addition, the websites for the National Guideline Clearinghouse, American Association of Critical Care Nurses, and the National Institute for Care and Excellence were also searched for relevant studies, systematic reviews, and guidelines on delirium. In addition, reference lists were hand searched. Abstracts were read and reviewed. Full text was obtained of all relevant articles, and guidelines for full and detailed analysis and review. A critical appraisal of the evidence was completed, which revealed two systematic reviews that supported delirium prevention protocols, including the NICE Clinical Guideline 103 on the Diagnosis, Prevention, and Management of Delirium (2010, 2012) with a 2015 evidence review, and a 2013 Joanna Briggs Institute systematic review on non-pharmacologic, multi-component prevention of delirium. Additional recent supportive evidence was also found to further document the effectiveness of prevention protocols in the ICU. Moreover, 8 studies were included in the literature review to substantiate the effectiveness of nursing education protocols on the prevention of delirium. Most significant among these was a two phase quasi-experimental study which reported both process and clinical
0147-9563/$ - see front matter
outcomes. The purpose of the study was to determine the effectiveness of a dementia/delirium specific nursing intervention (DDSNI) on nursing knowledge and self-efficacy in differentiating and recognizing delirium in older adults greater than 65-years-old on two telemetry units. Results demonstrated an overall increase in knowledge and self-efficacy scores, with a greater increase in the cognitive component. In regard to the clinical outcomes, results demonstrated a reduction in length of stay post-intervention of 0.35 days less, and a DRG deviation post intervention by 0.52 days less, as well as a reduction in the number of falls (Dienger, Bass, Milne, and Rentz, 2013). Results clearly demonstrate the effectiveness of educational interventions on delirium knowledge and clinical outcomes. The results of the extensive literature review on delirium prevention were shared through a pilot educational intervention conducted at a Nursing Research Symposium with nurses in voluntary attendance representing diverse areas of practice including medical-surgical, ER, telemetry, and intensive care units. The presentation was composed of a one hour lecture using PowerPoint and a decision tree. A preand post-assessment was given to determine the effectiveness of the educational program. A small sample of 35 nurses elected to attend the educational intervention. Twenty of the attendees voluntarily completed a pre- and post-assessment using a delirium prevention knowledge questionnaire. Participants in the educational intervention were given a copy of the power point and the decision tree. Laminated copies of the Decision Tree were also provided to any nurse wanting to share the information with her unit. Conclusions: The educational intervention was designed to increase awareness and understanding of the nursing staff regarding the nature, characteristics, negative outcomes, and costs of delirium, as well as the success and net monetary benefit of prevention protocols. The educational program focused on practical strategies derived from the NICE Clinical Guideline 103. Delirium prevention reduces length of stay, healthcare costs, and nursing hours per patient day. Prevention also improves patient outcomes. The minimal costs of the protocol will increase nursing and administrative support for prevention interventions. Nurses are personally motivated by compassion to prevent delirium. In addition, delirious patients require a higher number of nursing hours of care, and increased time for close supervision. Through the educational initiatives of the nursing staff, patients and families will also have a significant role in the implementation of prevention protocols. Nurses can engage families to bring in relevant and familiar personal items and sensory aides from home, as well as educate family members on effective communication and cognitive strategies that may be helpful in avoiding an episode of delirium. Driving and restraining forces have been shown to exert a significant impact on the success of delirium prevention protocols (HolroydLeduc et al., 2010). Primary drivers for the educational intervention are the need to reduce healthcare costs and length of stay, to increase patient safety, and to improve patient outcomes. Limiting in-patient and post-discharge costs will free up valuable healthcare dollars for other medical interventions and services. In addition, preventing delirium will reduce morbidity and mortality, and improve quality
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TagedEnAbstracts / Heart & Lung 47 (2018) 650 655
and length of life for any at risk patient, especially those with a diagnosis of acute decompensated heart failure. Potential barriers and resistance to change may arise due to perceptions of increased workload and time investments, mental perceptions and preferences for medical treatment, the apparent simplicity of prevention protocols, and extreme need for full adherence. Barriers can be overcome by increasing understanding of the proven benefits of prevention protocols, promoting teamwork, and valuing the interdisciplinary team, as well as understanding the difficulties involved in caring for delirious patients and the potential tragic outcomes of a diagnosis of delirium. Results: Results of the literature review revealed two systematic reviews that supported delirium prevention protocols, the NICE Clinical Guideline 103 (2010, 2012) and a 2013 JBI systematic review on non-pharmacologic, multi-component delirium prevention; thus demonstrating Level I evidence for non-pharmacologic delirium prevention and providing a "gold mine of evidence" Melnyk and Fineout-Overholt, 2011). The NICE guideline is published by the National Clinical Guideline Centre of the United Kingdom. The guideline offers "specific practice recommendations...that have been derived from a methodologically rigorous review of the evidence" (Melynk and Fineout-Overholt, 2011, p. 13). Primary studies included were randomized controlled trials, quasi-non-randomized controlled trials including large cohort studies. Hospital settings included medical, surgical, emergency room, and intensive care units. Studies addressing palliative care and alcohol withdrawal were excluded. Guideline recommendations focus on clinical indicators for the basis of prevention including cognition, dehydration/constipation, hypoxia, infection, immobility, medications, pain, nutrition, sensory impairment, and sleep (NICE, 2010, 2012). The delirium prevention protocol is highly feasible, inexpensive, simple, involves standard nursing care and poses minimal risk. In addition, the JBI systematic review also provides evidence for multi-component prevention of delirium. The meta-analysis included 10 scholarly articles, including 3 RCT's, and 7 prospective or case control studies. Studies were appraised using the Joanna Briggs MetaAnalysis of Statistics Assessment and Review Instrument (JBI MAStARI). The analysis also showed the degree of influence each study had on the composite result. Researchers found that patients who "received multi-component interventions had a 31% lower risk of developing delirium" (RR 0.69, 95% CI 0.60, 0.78, p< 0.0001) (Thomas et al., 2014); thus providing additional Level I evidence. The thirteen prevention intervention strategies of the NICE Guideline were reorganized into 5 core components for the one hour educational intervention with PowerPoint and decision tree at an annual nursing research symposium. Nursing knowledge was assessed using a pre- and post- assessment with anonymity protected, and retention of only the area of nursing practice of each nurse in attendance. The results of the pilot educational intervention demonstrated an increase in nursing knowledge of delirium prevention.
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Fig. 1. Kaplan-Meier analyses of clinical outcomes after discharge in patients with or without delirium. (A) All-cause death. (B) Cardiovascular death. (C) Non-cardiovascular death. (D) Worsening heart failure.TagedEn
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Fig. 2. Acute decompensated heart failure readmission risk at 30 and 90 days in patients with heart failure stratified by presence (gray bars) or absence (black bars) of delirium.TagedEn
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Fig. 3. Rates of nursing home placement and re-hospitalization as function.TagedEn
Approximately 35 nurses attended the voluntary educational intervention. Twenty nurses completed the pre- and post-test assessment: 5 ICU, 3 telemetries, 2 ERs, 9 medical surgical nurses and 1 research nurse. Questions addressed the nature, incidence, and means of prevention of delirium. Results demonstrated a mean pre- intervention assessment score of 65.5% and a mean post-assessment score of 84%; demonstrating an increase in the mean knowledge score of 18.5% immediately following the educational program. Barriers to realizing the full success of the intervention include the timing. Due to delays in starting, the presenter was not permitted the full hour. In addition, practical logistical help was limited in distributing and collecting the assessments. This also impinged on the presenter's use of the full presentation time. The speed of the presentation may have influenced the full comprehension of the learner; consequently, results may not fully reflect the potential of TagedEn TagedFiur educational intervention.TagedPFigs. 1, 2 and 3. the
TagedEn
Contents lists available at ScienceDirect
TagedFiur
TagedEn
Heart & Lung
TagedFiur
TagedEn
journal homepage: www.heartandlung.com
AAHFN’S RESEARCH ABSTRACTS Prevention of delirium in acute decompensated heart failure using multi-component non-pharmacologic prevention TAGEDPBONNIE ALBERTTAGEDN Background: Delirium should be viewed as a "medical emergency until proven otherwise" (Fong et al., 2009, p. 2150). Delirium and its sequelae present significant risk for heart failure inpatients. Preventing delirium through the modification of known risk factors and alterable causes is the "cornerstone in decreasing hospital admissions, cost, morbidity, and mortality in acute decompensated heart failure patients" (Ampadu and Morley, 2015, p. 19). A paucity of research exists that addresses the incidence of delirium in heart failure. Uthalmalingam, Gurm, Daley, Flynn, and Capodilupo (2011) determined that 17.0% of 883 acute decompensated heart failure patients (ADHF) greater than 65-years-old had a positive diagnosis of delirium. A recent analysis by Honda, Nagai, Sugano, Okada, Asaumi, Aiba.& Anzai (2016) found 23% of 611 critically ill ADHF patients positive for delirium. Patients surviving to discharge were found to have an increase in all-cause, cardiovascular and non-cardiovascular death. The high documented incidence of delirium in heart failure patients further demonstrates the importance of prevention. An examination of the specific characteristics that predispose heart failure patients is worthy of consideration. The risk for delirium in ADHF patients is related to cognitive deficits, hemodynamic, and metabolic factors, and pathophysiologic mechanisms. Methods: A comprehensive search strategy was completed for the literature search for this project utilizing the databases CINAHL, PubMed, Cochrane, Joanna Briggs Institute, OvidSp, Ebsco Host Education, Ebsco Education Research Complete from 2010 2017 for studies relevant to non-pharmacologic delirium prevention and education. Search terms included delirium, cognitive impairment, prevention and control, knowledge and education, ICU, risk, adherence, heart failure, acute decompensated heart failure, cardiac failure, strategy, and policy. In addition, the websites for the National Guideline Clearinghouse, American Association of Critical Care Nurses, and the National Institute for Care and Excellence were also searched for relevant studies, systematic reviews, and guidelines on delirium. In addition, reference lists were hand searched. Abstracts were read and reviewed. Full text was obtained of all relevant articles, and guidelines for full and detailed analysis and review. A critical appraisal of the evidence was completed, which revealed two systematic reviews that supported delirium prevention protocols, including the NICE Clinical Guideline 103 on the Diagnosis, Prevention, and Management of Delirium (2010, 2012) with a 2015 evidence review, and a 2013 Joanna Briggs Institute systematic review on non-pharmacologic, multi-component prevention of delirium. Additional recent supportive evidence was also found to further document the effectiveness of prevention protocols in the ICU. Moreover, 8 studies were included in the literature review to substantiate the effectiveness of nursing education protocols on the prevention of delirium. Most significant among these was a two phase quasi-experimental study which reported both process and clinical
0147-9563/$ - see front matter
outcomes. The purpose of the study was to determine the effectiveness of a dementia/delirium specific nursing intervention (DDSNI) on nursing knowledge and self-efficacy in differentiating and recognizing delirium in older adults greater than 65-years-old on two telemetry units. Results demonstrated an overall increase in knowledge and self-efficacy scores, with a greater increase in the cognitive component. In regard to the clinical outcomes, results demonstrated a reduction in length of stay post-intervention of 0.35 days less, and a DRG deviation post intervention by 0.52 days less, as well as a reduction in the number of falls (Dienger, Bass, Milne, and Rentz, 2013). Results clearly demonstrate the effectiveness of educational interventions on delirium knowledge and clinical outcomes. The results of the extensive literature review on delirium prevention were shared through a pilot educational intervention conducted at a Nursing Research Symposium with nurses in voluntary attendance representing diverse areas of practice including medical-surgical, ER, telemetry, and intensive care units. The presentation was composed of a one hour lecture using PowerPoint and a decision tree. A preand post-assessment was given to determine the effectiveness of the educational program. A small sample of 35 nurses elected to attend the educational intervention. Twenty of the attendees voluntarily completed a pre- and post-assessment using a delirium prevention knowledge questionnaire. Participants in the educational intervention were given a copy of the power point and the decision tree. Laminated copies of the Decision Tree were also provided to any nurse wanting to share the information with her unit. Conclusions: The educational intervention was designed to increase awareness and understanding of the nursing staff regarding the nature, characteristics, negative outcomes, and costs of delirium, as well as the success and net monetary benefit of prevention protocols. The educational program focused on practical strategies derived from the NICE Clinical Guideline 103. Delirium prevention reduces length of stay, healthcare costs, and nursing hours per patient day. Prevention also improves patient outcomes. The minimal costs of the protocol will increase nursing and administrative support for prevention interventions. Nurses are personally motivated by compassion to prevent delirium. In addition, delirious patients require a higher number of nursing hours of care, and increased time for close supervision. Through the educational initiatives of the nursing staff, patients and families will also have a significant role in the implementation of prevention protocols. Nurses can engage families to bring in relevant and familiar personal items and sensory aides from home, as well as educate family members on effective communication and cognitive strategies that may be helpful in avoiding an episode of delirium. Driving and restraining forces have been shown to exert a significant impact on the success of delirium prevention protocols (HolroydLeduc et al., 2010). Primary drivers for the educational intervention are the need to reduce healthcare costs and length of stay, to increase patient safety, and to improve patient outcomes. Limiting in-patient and post-discharge costs will free up valuable healthcare dollars for other medical interventions and services. In addition, preventing delirium will reduce morbidity and mortality, and improve quality
TagedEn
TagedFiur
TagedEnAbstracts / Heart & Lung 47 (2018) 650 655
and length of life for any at risk patient, especially those with a diagnosis of acute decompensated heart failure. Potential barriers and resistance to change may arise due to perceptions of increased workload and time investments, mental perceptions and preferences for medical treatment, the apparent simplicity of prevention protocols, and extreme need for full adherence. Barriers can be overcome by increasing understanding of the proven benefits of prevention protocols, promoting teamwork, and valuing the interdisciplinary team, as well as understanding the difficulties involved in caring for delirious patients and the potential tragic outcomes of a diagnosis of delirium. Results: Results of the literature review revealed two systematic reviews that supported delirium prevention protocols, the NICE Clinical Guideline 103 (2010, 2012) and a 2013 JBI systematic review on non-pharmacologic, multi-component delirium prevention; thus demonstrating Level I evidence for non-pharmacologic delirium prevention and providing a "gold mine of evidence" Melnyk and Fineout-Overholt, 2011). The NICE guideline is published by the National Clinical Guideline Centre of the United Kingdom. The guideline offers "specific practice recommendations...that have been derived from a methodologically rigorous review of the evidence" (Melynk and Fineout-Overholt, 2011, p. 13). Primary studies included were randomized controlled trials, quasi-non-randomized controlled trials including large cohort studies. Hospital settings included medical, surgical, emergency room, and intensive care units. Studies addressing palliative care and alcohol withdrawal were excluded. Guideline recommendations focus on clinical indicators for the basis of prevention including cognition, dehydration/constipation, hypoxia, infection, immobility, medications, pain, nutrition, sensory impairment, and sleep (NICE, 2010, 2012). The delirium prevention protocol is highly feasible, inexpensive, simple, involves standard nursing care and poses minimal risk. In addition, the JBI systematic review also provides evidence for multi-component prevention of delirium. The meta-analysis included 10 scholarly articles, including 3 RCT's, and 7 prospective or case control studies. Studies were appraised using the Joanna Briggs MetaAnalysis of Statistics Assessment and Review Instrument (JBI MAStARI). The analysis also showed the degree of influence each study had on the composite result. Researchers found that patients who "received multi-component interventions had a 31% lower risk of developing delirium" (RR 0.69, 95% CI 0.60, 0.78, p< 0.0001) (Thomas et al., 2014); thus providing additional Level I evidence. The thirteen prevention intervention strategies of the NICE Guideline were reorganized into 5 core components for the one hour educational intervention with PowerPoint and decision tree at an annual nursing research symposium. Nursing knowledge was assessed using a pre- and post- assessment with anonymity protected, and retention of only the area of nursing practice of each nurse in attendance. The results of the pilot educational intervention demonstrated an increase in nursing knowledge of delirium prevention.
TagedEn
TagedFiur
Fig. 1. Kaplan-Meier analyses of clinical outcomes after discharge in patients with or without delirium. (A) All-cause death. (B) Cardiovascular death. (C) Non-cardiovascular death. (D) Worsening heart failure.TagedEn
651
Fig. 2. Acute decompensated heart failure readmission risk at 30 and 90 days in patients with heart failure stratified by presence (gray bars) or absence (black bars) of delirium.TagedEn
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Fig. 3. Rates of nursing home placement and re-hospitalization as function.TagedEn
Approximately 35 nurses attended the voluntary educational intervention. Twenty nurses completed the pre- and post-test assessment: 5 ICU, 3 telemetries, 2 ERs, 9 medical surgical nurses and 1 research nurse. Questions addressed the nature, incidence, and means of prevention of delirium. Results demonstrated a mean pre- intervention assessment score of 65.5% and a mean post-assessment score of 84%; demonstrating an increase in the mean knowledge score of 18.5% immediately following the educational program. Barriers to realizing the full success of the intervention include the timing. Due to delays in starting, the presenter was not permitted the full hour. In addition, practical logistical help was limited in distributing and collecting the assessments. This also impinged on the presenter's use of the full presentation time. The speed of the presentation may have influenced the full comprehension of the learner; consequently, results may not fully reflect the potential of TagedEn TagedFiur educational intervention.TagedPFigs. 1, 2 and 3. the
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