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Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature
Australian Critical Care (2012) 25, 157—161
Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature Louise.G. Wells (BN, Grad Cert Perioperative Nursing, Grad Cert Critical Care Nursing, Master of Nursing) ∗ School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Avenue, Bathurst, NSW 2795, Australia Received 21 December 2010 ; received in revised form 16 February 2012; accepted 6 March 2012
KEYWORDS Intensive care unit; Delirium; Nursing; Assessment
Summary Delirium is a well recognised and serious problem in adult intensive care patients. With a reported incidence as high as 87%, it has been associated with increased length of stay, higher costs of care, ongoing cognitive impairment and increased mortality rates. The problem is so significant that routine, formal delirium assessment is recommended for all intensive care patients. However, there is evidence to suggest that few intensive care nurses are incorporating this screening into their daily practice. The aim of this paper is to discuss what is currently known about intensive care nurses’ attitudes and beliefs in relation to caring for adults who are experiencing delirium, with a focus on identifying possible barriers to formal delirium assessment. It will be argued that intensive care nurses are well placed to perform regular delirium assessment and therefore have a responsibility to promote an improvement in delirium assessment practices. © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Historically, delirium was accepted by health professionals as an unavoidable and harmless consequence of critical illness.1,2 Several terms have been used interchangeably to describe delirium in intensive care patients including intensive care unit (ICU) psychosis, ICU syndrome and acute confusional state. More recently, and following the ∗
Tel.: +61 02 63 38 4005; fax: +61 02 63 38 4408. E-mail address: [email protected]
recommendations of the American Psychiatric Association (APA)3 , there has been a shift in the literature towards the uniform use of the term delirium to describe a condition that includes an acute onset, impaired cognition, a fluctuating course and the presence of inattention or an altered level of consciousness.4—7 Delirium is caused by an underlying organic process and there is growing recognition that it represents acute brain dysfunction or failure.6,8,9 It is a condition that is frequently described as having three motoric subtypes: hyperactive delirium, hypoactive delirium
1036-7314/ $ — see front matter © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.aucc.2012.03.002
158 and mixed delirium.10 Individuals with hyperactive delirium experience increased psychomotor activity and exhibit behaviours such as restlessness, agitation, hyper-vigilance and aggression. In contrast, those with hypoactive delirium experience psychomotor retardation and exhibit behaviours such as lethargy, decreased responsiveness, apathy and withdrawal. Individuals experiencing the mixed subtype fluctuate between hyperactive and hypoactive symptoms.3,11 With a reported incidence between 16 and 87%, delirium is a well recognised and serious problem in adult intensive care patients.12,13 The evidence indicates that the more easily identified hyperactive subtype accounts for less than 2% of cases, while the more subtle hypoactive subtype is far more common with a reported incidence between 44 and 65%.10,11 The adverse clinical outcomes of ICU delirium are well documented. It has been consistently found to increase both ICU and hospital length of stay independent of other variable such as age, severity of illness and the administration of sedative or psychoactive medications.4,14,15 A recent study has identified delirium as an independent predictor of ongoing cognitive impairment16 and several studies have reported increased mortality rates among patients with ICU delirium.14,17,18 In addition to the direct impact on the patients, these adverse outcomes have been associated with higher costs of ICU and hospital care.19
Delirium assessment tools The growing body of evidence concerning the high incidence of ICU delirium and its negative impact on patient outcomes has prompted the American Society of Critical Care Medicine to recommend that all intensive care patients be screened for delirium using a validated assessment tool.20 It has been argued that routine screening for delirium will allow for early detection and the timely implementation of management strategies that may reduce its severity and/or duration.12,21—23 In 2001, the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were separately validated for use in non-verbal intensive care patients and have since been used in numerous studies investigating the prevalence, risk factors and clinical outcomes of ICU delirium.12,13 In all such studies reviewed for this paper, both screening tools have been found to be quick and easy to use with high compliance rates among nursing staff
Louise.G. Wells following the provision of education. For example, Roberts et al.1 found that the ICDSC was readily incorporated into routine observations and easy to complete following initial training. Similarly, two studies investigating the implementation of the CAM-ICU found high degrees of comfort, confidence and satisfaction with tool among nurses who had been formally trained in its use. Compliance rates were also high in these studies. Truman Pun et al. reported that 90% of nurses were still completing the CAM-ICU at least once every twelve hours six months after the initial implementation,24 while Soja et al. reported a similarly high compliance rate of 84%.5 According to Devlin et al., intensive care nurses’ near constant contact with their patients places them in the best position to perform routine delirium assessment.25 However, the literature suggests that the majority of intensive care nurses are not incorporating this assessment into their daily practice.7,26—28 In a survey of 912 health professionals, 12% of whom were nurses, Ely et al.26 found that only 40% were routinely screening for delirium. Of this group, only 16% were using a formal assessment tool. A follow up study published in 2009 demonstrated some improvement in delirium assessment practices with 59% of ICU health professionals routinely assessing patients for delirium, and 33% using one of the validated assessment tools.7 However, it is clear that these practices continue to fall well short of the guidelines.7 Other studies have supported this conclusion. A comprehensive survey of delirium assessment practices in Dutch ICUs found that only 14% employed regular delirium assessment using a validated tool.27 A similar study conducted in Sweden found that while 62% of units used some form of regular delirium screening, only one ICU was using a validated screening tool.28 The only recent study to exclusively investigate intensive care nurses’ practices in relation to delirium assessment reported similar results, with only 10% of nurses assessing for delirium the recommended once per twelve hour shift and the majority (53%) never or rarely assessing for delirium. Alarmingly, this was despite the fact that the majority worked in an ICU with guidelines advocating formal delirium assessment.25 It is unknown if these results can also that be applied to Australian ICUs as little research has been conducted here. However, a recent small survey which investigated sedation and delirium practices in twenty three Australian and New Zealand ICUs, found that only 9% of nurses routinely used a delirium screening tool.2 These results suggest that screening practices in Australia also fail to meet recognised international guidelines.
Why don’t intensive care nurses perform routine delirium assessment
ICU nurses’ beliefs and perceptions in relation to delirium assessment In order to achieve best practice in the assessment and management of ICU delirium, it is first necessary to understand why the majority of intensive care nurses are failing to formally assess patients for delirium. A thorough search of the recent literature revealed only one study that has investigated intensive care nurse’s perceptions regarding delirium assessment. In their survey of 601 critical care nurses from the United States, Devlin et al.25 found that only 3% of nurses thought it was important to routinely screen for delirium. Somewhat surprisingly, the survey showed a reasonable understanding of delirium among the nurses. The vast majority of nurses agreed that delirium was common in the ICU and that it was an under diagnosed problem requiring active intervention.25 Overall, it would appear that a lack of knowledge about the seriousness of delirium may not explain intensive care nurse’s reluctance to assess patients for delirium. A better explanation may lie with the barriers to delirium identified in the survey. The two main barriers identified by nurses in this study were the difficulty in assessing intubated patients and the complexity of the available screening tools.25 This is clearly at odds with the recent research discussed earlier which found that the CAM-ICU and ICDSC are quick and easy to use in ventilated patients and probably reflects ICU nurses’ lack of knowledge concerning these screening tools. In order to gain further insight into potential barriers to delirium assessment, it is necessary to look to research conducted outside the ICU. In 2008, Dahlke and Phinney29 conducted a qualitative study in which they interviewed medical and surgical nurses to explore: (1) their practices in relation to the assessment, prevention and treatment of delirium and (2) the challenges and barriers they faced while caring for patients who had delirium. This study found that nurses were mostly performing rapid, informal delirium assessments due to time pressure caused by the acuity of other patients and low staffing levels on the ward. The nurses involved had received very little formal education on delirium and therefore lacked the knowledge and skills required to care for these patients. This resulted in the implementation of ineffective and sometimes inappropriate nursing interventions. The nurses found caring for delirious patients to be a frustrating and unpleasant experience and many resented having to do so, preferring to spend their time with more interesting, younger patients. To date, no similar studies have been conducted in the ICU to determine if these challenges
159
and barriers also apply to ICU nurses. Differences in patient acuity and nurse to patient ratios mean that these findings may not be generalisable to ICU patient populations.
Implications for ICU nurses There is clearly a dearth of literature concerning the formal delirium assessment practices of Australian ICU nurses. Further research is necessary not only to determine how many nurses engage in routine formal delirium assessment, but also to investigate possible barriers to delirium assessment. The need for the introduction of routine, formal delirium assessment in all ICUs is not in question. Although there is currently a lack of evidence concerning the prevention and management of ICU delirium, it can be argued that at the very least, the early detection of delirium through the use of a validated assessment tool can alert the ICU team to acute brain dysfunction or failure and prompt the investigation and management of the underlying cause. There is strong evidence supporting the ease of use of both the CAM-ICU and ICDSC. When this is considered with the fact that compliance rates for both tools are high when adequate education is provided, the need for formal education on the use of these tools becomes very clear. It can be argued that there is little point in mandating the use of formal delirium assessment tools without also providing nurses with adequate support in the form of clear guidelines and appropriate education in relation to ICU delirium and the use of the assessment tools. The high prevalence of ICU delirium means that all ICU nurses will be required to care for patients with delirium on a regular basis. The documented adverse effects of delirium on patient outcomes make it essential that it is no longer accepted as normal and harmless part of the ICU experience. Delirium has an underlying organic cause and is in fact evidence of acute brain dysfunction or failure, requiring prompt recognition and intervention.6,8,9 This means that ICU nurses must take delirium as seriously as the many other types of organ failure they encounter as part of their daily practice.1,18 A shift towards regular and formal delirium assessment using one of the validated assessment tools is the important first step in improving practice in relation to ICU delirium. As the ICU health professionals best placed to perform regular delirium assessment, nurses are in a unique position to be able to increase awareness of delirium and delirium assessment among their nursing and non-nursing
160 colleagues as they move towards improved practices in the assessment and management of this complex problem.
Conclusion There is little doubt that delirium presents a number of challenges for intensive care patients and the nurses responsible for their care. While the true prevalence is difficult to determine, it is clear that ICU delirium has the potential to have significant adverse effects on patient outcomes. The evidence strongly supports the routine use of validated delirium assessment tools to facilitate the prompt recognition of delirium and treatment of its underlying cause. The fact that the literature indicates that most ICU nurses do not undertake regular formal delirium assessments is cause for concern. There is a clear need for future research which will investigate ICU nurses’ current practices in relation to the assessment of delirium. This research has the potential to highlight barriers to delirium assessment and provide an explanation for intensive care nurses’ reluctance to perform this important task. In the meantime, all intensive care units should be implementing routine delirium assessment using one of the validated screening tools. This should be accompanied by an increased emphasis on delirium in ICU orientation and clinical education programmes. Given their close and near constant contact with their patients, ICU nurses are well placed to drive this change.
References 1. Roberts B, Rickard CM, Rajbhandari D, Turner G, Clarke J, Hill D, et al. Multicentre study of delirium in ICU patients using a simple screening tool. Australian Critical Care 2005;18(1):6—16. 2. Shehabi Y, Botha JA, Boyle MS, Ernest D, freebairn RC, Jenkins IR, et al. Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesthesia and Intensive Care 2008;36(4):570—8. 3. Girard TD, Pandharipande P, Ely EW. Delirium in the intensive care unit. Critical Care 2008;12(Suppl. 3). 4. Thomason JWW, Shintani AK, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delrium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Critical Care 2005;9:R375—81. 5. Soja SL, Pandharipande P, Fleming SB, et al. Implemenation, reliability testing, and compliance monitoring of the confusion assessment method for the intensive care unit in trauma patients. Intensive Care Medicine 2008;34:1263—8. 6. Van Rompaey B, Schuurmans MJ, Shortridge-Bagget LM, Truijen S, Bossaert L. Risk factors for intensive care delirium: a systematic review. Intensive and Critical Care Nursing 2008;24:98—107.
Louise.G. Wells 7. Patel RP, Gambrell M, Speroff T, et al. Delirium and sedation in the intensive care unit: survey of behavious and attitudes of 1384 healthcare professionals. Critical Care Medicine 2009;37(3):825—32. 8. McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK. Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. JAGS 2005;53(3):495—500. 9. Plaschke K, Von Haken R, Scholz M, et al. Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the intensive care delirium screening checklist (ICDSC) for delirium in critical care patients gives high agreement rates. Intensive Care Medicine 2008;34:431—6. 10. Pandharipande P, Cotton B, Shintani AK, et al. Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care patients. Intensive Care Medicine 2007;33:1726—31. 11. Peterson JF, Pun BT, Dittus RS, et al. Delirium and it motoric subtypes: a study of 614 critically ill patients. JAGS 2006;54:479—84. 12. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine 2001;29(7):1370—9. 13. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium checklist: evaluation of a new screening tool. Intensive Care Medicine 2001;27:859—64. 14. Ely EW, Shintani A, Truman KB, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291(14):1753—62. 15. Lat I, McMillian W, Taylor S, et al. The impact of delirium on clinical outcomes on mechanically ventilated surgical and trauma patients. Critical Care Medicine 2009;37(6):1898—905. 16. Girard T, Jackson J, Pandharipande P, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine 2010;38(7):1513—20. 17. Lin S-M, Liu C-Y, Wang C-H, et al. The impact of delirium on the survival of mechanically ventilated patients. Critical Care Medicine 2004;32(11):2254—9. 18. Ouimet S, Kavanagh B, Gottfried PS, Skrobik BY. Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine 2007;33:66—73. 19. Milbrandt E, Deppen BS, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine 2004;32(4):955—62. 20. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedative and analgesics in the critically ill adult. Critical Care Medicine 2002;30(1):119—41. 21. Balas MC, Happ MB, Yang W, Chelluri L, Richmond TS. Outcomes associated with delirium in older patients in surgical ICU’s. Chest 2009;135(1):18—25. 22. Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the critically ill. Intensive Care Medicine 2007;33: 929—40. 23. Spronk PE, Riekerk B, Hofhuis J, Rommes J. Occurence of delirium is severely underestimated in the ICU during daily care. Intensive Care Medicine 2009;35:1276—80. 24. Truman Pun B, Gordon SM, Peterson JF, et al. Large scale implementation of sedation and delirium monintoring in the intensive care unit: a report from two medical centers. Critical Care Medicine 2005;33(6):1199—205. 25. Devlin JW, Fong JJ, Howard EP, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care 2008;17(6):555—66.
Why don’t intensive care nurses perform routine delirium assessment 26. Ely EW, Stephens RK, Jackson JC, et al. Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Critical Care Medicine 2004;32(1):106—12. 27. Van Eijk M, Kesecioglu J, Slooter A. Intensive care delirium monitoring and standardised treatment: a complete survey of Dutch Intensive Care Units. Intensive and Critical Care Nursing 2008;24:218—21.
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28. Forsgren L, Eriksson M. Delirium-Awareness, observation and interventions in intensive care units: a national survey of Swedish ICU head nurses. Intensive and Critical Care Nursing 2010;26:296—303. 29. Dahlke S, Phinney A. Caring for hospitalised older adults at risk for delirium: the silent, unspoken piece of nursing practice. Journal of Gerontological Nursing 2008;34(6): 41—7.
Available online at www.sciencedirect.com
Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature Louise.G. Wells (BN, Grad Cert Perioperative Nursing, Grad Cert Critical Care Nursing, Master of Nursing) ∗ School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Avenue, Bathurst, NSW 2795, Australia Received 21 December 2010 ; received in revised form 16 February 2012; accepted 6 March 2012
KEYWORDS Intensive care unit; Delirium; Nursing; Assessment
Summary Delirium is a well recognised and serious problem in adult intensive care patients. With a reported incidence as high as 87%, it has been associated with increased length of stay, higher costs of care, ongoing cognitive impairment and increased mortality rates. The problem is so significant that routine, formal delirium assessment is recommended for all intensive care patients. However, there is evidence to suggest that few intensive care nurses are incorporating this screening into their daily practice. The aim of this paper is to discuss what is currently known about intensive care nurses’ attitudes and beliefs in relation to caring for adults who are experiencing delirium, with a focus on identifying possible barriers to formal delirium assessment. It will be argued that intensive care nurses are well placed to perform regular delirium assessment and therefore have a responsibility to promote an improvement in delirium assessment practices. © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Historically, delirium was accepted by health professionals as an unavoidable and harmless consequence of critical illness.1,2 Several terms have been used interchangeably to describe delirium in intensive care patients including intensive care unit (ICU) psychosis, ICU syndrome and acute confusional state. More recently, and following the ∗
Tel.: +61 02 63 38 4005; fax: +61 02 63 38 4408. E-mail address: [email protected]
recommendations of the American Psychiatric Association (APA)3 , there has been a shift in the literature towards the uniform use of the term delirium to describe a condition that includes an acute onset, impaired cognition, a fluctuating course and the presence of inattention or an altered level of consciousness.4—7 Delirium is caused by an underlying organic process and there is growing recognition that it represents acute brain dysfunction or failure.6,8,9 It is a condition that is frequently described as having three motoric subtypes: hyperactive delirium, hypoactive delirium
1036-7314/ $ — see front matter © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.aucc.2012.03.002
158 and mixed delirium.10 Individuals with hyperactive delirium experience increased psychomotor activity and exhibit behaviours such as restlessness, agitation, hyper-vigilance and aggression. In contrast, those with hypoactive delirium experience psychomotor retardation and exhibit behaviours such as lethargy, decreased responsiveness, apathy and withdrawal. Individuals experiencing the mixed subtype fluctuate between hyperactive and hypoactive symptoms.3,11 With a reported incidence between 16 and 87%, delirium is a well recognised and serious problem in adult intensive care patients.12,13 The evidence indicates that the more easily identified hyperactive subtype accounts for less than 2% of cases, while the more subtle hypoactive subtype is far more common with a reported incidence between 44 and 65%.10,11 The adverse clinical outcomes of ICU delirium are well documented. It has been consistently found to increase both ICU and hospital length of stay independent of other variable such as age, severity of illness and the administration of sedative or psychoactive medications.4,14,15 A recent study has identified delirium as an independent predictor of ongoing cognitive impairment16 and several studies have reported increased mortality rates among patients with ICU delirium.14,17,18 In addition to the direct impact on the patients, these adverse outcomes have been associated with higher costs of ICU and hospital care.19
Delirium assessment tools The growing body of evidence concerning the high incidence of ICU delirium and its negative impact on patient outcomes has prompted the American Society of Critical Care Medicine to recommend that all intensive care patients be screened for delirium using a validated assessment tool.20 It has been argued that routine screening for delirium will allow for early detection and the timely implementation of management strategies that may reduce its severity and/or duration.12,21—23 In 2001, the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were separately validated for use in non-verbal intensive care patients and have since been used in numerous studies investigating the prevalence, risk factors and clinical outcomes of ICU delirium.12,13 In all such studies reviewed for this paper, both screening tools have been found to be quick and easy to use with high compliance rates among nursing staff
Louise.G. Wells following the provision of education. For example, Roberts et al.1 found that the ICDSC was readily incorporated into routine observations and easy to complete following initial training. Similarly, two studies investigating the implementation of the CAM-ICU found high degrees of comfort, confidence and satisfaction with tool among nurses who had been formally trained in its use. Compliance rates were also high in these studies. Truman Pun et al. reported that 90% of nurses were still completing the CAM-ICU at least once every twelve hours six months after the initial implementation,24 while Soja et al. reported a similarly high compliance rate of 84%.5 According to Devlin et al., intensive care nurses’ near constant contact with their patients places them in the best position to perform routine delirium assessment.25 However, the literature suggests that the majority of intensive care nurses are not incorporating this assessment into their daily practice.7,26—28 In a survey of 912 health professionals, 12% of whom were nurses, Ely et al.26 found that only 40% were routinely screening for delirium. Of this group, only 16% were using a formal assessment tool. A follow up study published in 2009 demonstrated some improvement in delirium assessment practices with 59% of ICU health professionals routinely assessing patients for delirium, and 33% using one of the validated assessment tools.7 However, it is clear that these practices continue to fall well short of the guidelines.7 Other studies have supported this conclusion. A comprehensive survey of delirium assessment practices in Dutch ICUs found that only 14% employed regular delirium assessment using a validated tool.27 A similar study conducted in Sweden found that while 62% of units used some form of regular delirium screening, only one ICU was using a validated screening tool.28 The only recent study to exclusively investigate intensive care nurses’ practices in relation to delirium assessment reported similar results, with only 10% of nurses assessing for delirium the recommended once per twelve hour shift and the majority (53%) never or rarely assessing for delirium. Alarmingly, this was despite the fact that the majority worked in an ICU with guidelines advocating formal delirium assessment.25 It is unknown if these results can also that be applied to Australian ICUs as little research has been conducted here. However, a recent small survey which investigated sedation and delirium practices in twenty three Australian and New Zealand ICUs, found that only 9% of nurses routinely used a delirium screening tool.2 These results suggest that screening practices in Australia also fail to meet recognised international guidelines.
Why don’t intensive care nurses perform routine delirium assessment
ICU nurses’ beliefs and perceptions in relation to delirium assessment In order to achieve best practice in the assessment and management of ICU delirium, it is first necessary to understand why the majority of intensive care nurses are failing to formally assess patients for delirium. A thorough search of the recent literature revealed only one study that has investigated intensive care nurse’s perceptions regarding delirium assessment. In their survey of 601 critical care nurses from the United States, Devlin et al.25 found that only 3% of nurses thought it was important to routinely screen for delirium. Somewhat surprisingly, the survey showed a reasonable understanding of delirium among the nurses. The vast majority of nurses agreed that delirium was common in the ICU and that it was an under diagnosed problem requiring active intervention.25 Overall, it would appear that a lack of knowledge about the seriousness of delirium may not explain intensive care nurse’s reluctance to assess patients for delirium. A better explanation may lie with the barriers to delirium identified in the survey. The two main barriers identified by nurses in this study were the difficulty in assessing intubated patients and the complexity of the available screening tools.25 This is clearly at odds with the recent research discussed earlier which found that the CAM-ICU and ICDSC are quick and easy to use in ventilated patients and probably reflects ICU nurses’ lack of knowledge concerning these screening tools. In order to gain further insight into potential barriers to delirium assessment, it is necessary to look to research conducted outside the ICU. In 2008, Dahlke and Phinney29 conducted a qualitative study in which they interviewed medical and surgical nurses to explore: (1) their practices in relation to the assessment, prevention and treatment of delirium and (2) the challenges and barriers they faced while caring for patients who had delirium. This study found that nurses were mostly performing rapid, informal delirium assessments due to time pressure caused by the acuity of other patients and low staffing levels on the ward. The nurses involved had received very little formal education on delirium and therefore lacked the knowledge and skills required to care for these patients. This resulted in the implementation of ineffective and sometimes inappropriate nursing interventions. The nurses found caring for delirious patients to be a frustrating and unpleasant experience and many resented having to do so, preferring to spend their time with more interesting, younger patients. To date, no similar studies have been conducted in the ICU to determine if these challenges
159
and barriers also apply to ICU nurses. Differences in patient acuity and nurse to patient ratios mean that these findings may not be generalisable to ICU patient populations.
Implications for ICU nurses There is clearly a dearth of literature concerning the formal delirium assessment practices of Australian ICU nurses. Further research is necessary not only to determine how many nurses engage in routine formal delirium assessment, but also to investigate possible barriers to delirium assessment. The need for the introduction of routine, formal delirium assessment in all ICUs is not in question. Although there is currently a lack of evidence concerning the prevention and management of ICU delirium, it can be argued that at the very least, the early detection of delirium through the use of a validated assessment tool can alert the ICU team to acute brain dysfunction or failure and prompt the investigation and management of the underlying cause. There is strong evidence supporting the ease of use of both the CAM-ICU and ICDSC. When this is considered with the fact that compliance rates for both tools are high when adequate education is provided, the need for formal education on the use of these tools becomes very clear. It can be argued that there is little point in mandating the use of formal delirium assessment tools without also providing nurses with adequate support in the form of clear guidelines and appropriate education in relation to ICU delirium and the use of the assessment tools. The high prevalence of ICU delirium means that all ICU nurses will be required to care for patients with delirium on a regular basis. The documented adverse effects of delirium on patient outcomes make it essential that it is no longer accepted as normal and harmless part of the ICU experience. Delirium has an underlying organic cause and is in fact evidence of acute brain dysfunction or failure, requiring prompt recognition and intervention.6,8,9 This means that ICU nurses must take delirium as seriously as the many other types of organ failure they encounter as part of their daily practice.1,18 A shift towards regular and formal delirium assessment using one of the validated assessment tools is the important first step in improving practice in relation to ICU delirium. As the ICU health professionals best placed to perform regular delirium assessment, nurses are in a unique position to be able to increase awareness of delirium and delirium assessment among their nursing and non-nursing
160 colleagues as they move towards improved practices in the assessment and management of this complex problem.
Conclusion There is little doubt that delirium presents a number of challenges for intensive care patients and the nurses responsible for their care. While the true prevalence is difficult to determine, it is clear that ICU delirium has the potential to have significant adverse effects on patient outcomes. The evidence strongly supports the routine use of validated delirium assessment tools to facilitate the prompt recognition of delirium and treatment of its underlying cause. The fact that the literature indicates that most ICU nurses do not undertake regular formal delirium assessments is cause for concern. There is a clear need for future research which will investigate ICU nurses’ current practices in relation to the assessment of delirium. This research has the potential to highlight barriers to delirium assessment and provide an explanation for intensive care nurses’ reluctance to perform this important task. In the meantime, all intensive care units should be implementing routine delirium assessment using one of the validated screening tools. This should be accompanied by an increased emphasis on delirium in ICU orientation and clinical education programmes. Given their close and near constant contact with their patients, ICU nurses are well placed to drive this change.
References 1. Roberts B, Rickard CM, Rajbhandari D, Turner G, Clarke J, Hill D, et al. Multicentre study of delirium in ICU patients using a simple screening tool. Australian Critical Care 2005;18(1):6—16. 2. Shehabi Y, Botha JA, Boyle MS, Ernest D, freebairn RC, Jenkins IR, et al. Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesthesia and Intensive Care 2008;36(4):570—8. 3. Girard TD, Pandharipande P, Ely EW. Delirium in the intensive care unit. Critical Care 2008;12(Suppl. 3). 4. Thomason JWW, Shintani AK, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delrium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Critical Care 2005;9:R375—81. 5. Soja SL, Pandharipande P, Fleming SB, et al. Implemenation, reliability testing, and compliance monitoring of the confusion assessment method for the intensive care unit in trauma patients. Intensive Care Medicine 2008;34:1263—8. 6. Van Rompaey B, Schuurmans MJ, Shortridge-Bagget LM, Truijen S, Bossaert L. Risk factors for intensive care delirium: a systematic review. Intensive and Critical Care Nursing 2008;24:98—107.
Louise.G. Wells 7. Patel RP, Gambrell M, Speroff T, et al. Delirium and sedation in the intensive care unit: survey of behavious and attitudes of 1384 healthcare professionals. Critical Care Medicine 2009;37(3):825—32. 8. McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK. Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. JAGS 2005;53(3):495—500. 9. Plaschke K, Von Haken R, Scholz M, et al. Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the intensive care delirium screening checklist (ICDSC) for delirium in critical care patients gives high agreement rates. Intensive Care Medicine 2008;34:431—6. 10. Pandharipande P, Cotton B, Shintani AK, et al. Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care patients. Intensive Care Medicine 2007;33:1726—31. 11. Peterson JF, Pun BT, Dittus RS, et al. Delirium and it motoric subtypes: a study of 614 critically ill patients. JAGS 2006;54:479—84. 12. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine 2001;29(7):1370—9. 13. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium checklist: evaluation of a new screening tool. Intensive Care Medicine 2001;27:859—64. 14. Ely EW, Shintani A, Truman KB, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291(14):1753—62. 15. Lat I, McMillian W, Taylor S, et al. The impact of delirium on clinical outcomes on mechanically ventilated surgical and trauma patients. Critical Care Medicine 2009;37(6):1898—905. 16. Girard T, Jackson J, Pandharipande P, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine 2010;38(7):1513—20. 17. Lin S-M, Liu C-Y, Wang C-H, et al. The impact of delirium on the survival of mechanically ventilated patients. Critical Care Medicine 2004;32(11):2254—9. 18. Ouimet S, Kavanagh B, Gottfried PS, Skrobik BY. Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine 2007;33:66—73. 19. Milbrandt E, Deppen BS, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine 2004;32(4):955—62. 20. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedative and analgesics in the critically ill adult. Critical Care Medicine 2002;30(1):119—41. 21. Balas MC, Happ MB, Yang W, Chelluri L, Richmond TS. Outcomes associated with delirium in older patients in surgical ICU’s. Chest 2009;135(1):18—25. 22. Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the critically ill. Intensive Care Medicine 2007;33: 929—40. 23. Spronk PE, Riekerk B, Hofhuis J, Rommes J. Occurence of delirium is severely underestimated in the ICU during daily care. Intensive Care Medicine 2009;35:1276—80. 24. Truman Pun B, Gordon SM, Peterson JF, et al. Large scale implementation of sedation and delirium monintoring in the intensive care unit: a report from two medical centers. Critical Care Medicine 2005;33(6):1199—205. 25. Devlin JW, Fong JJ, Howard EP, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care 2008;17(6):555—66.
Why don’t intensive care nurses perform routine delirium assessment 26. Ely EW, Stephens RK, Jackson JC, et al. Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Critical Care Medicine 2004;32(1):106—12. 27. Van Eijk M, Kesecioglu J, Slooter A. Intensive care delirium monitoring and standardised treatment: a complete survey of Dutch Intensive Care Units. Intensive and Critical Care Nursing 2008;24:218—21.
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28. Forsgren L, Eriksson M. Delirium-Awareness, observation and interventions in intensive care units: a national survey of Swedish ICU head nurses. Intensive and Critical Care Nursing 2010;26:296—303. 29. Dahlke S, Phinney A. Caring for hospitalised older adults at risk for delirium: the silent, unspoken piece of nursing practice. Journal of Gerontological Nursing 2008;34(6): 41—7.
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