Using the Evidence: Developing an ICU Delirium Protocol
Transcript of Using the Evidence: Developing an ICU Delirium Protocol
Scope of Problemq Delirium is a common brain disorder with an acute
onset and fluctuating course occurring within Intensive Care Units1
q It is a serious medical condition associated with negative outcomes for patient safety and quality of care1
q > 7 million Americans develop delirium in hospitals each year2
q > 60% of patients with delirium are not properly diagnosed by healthcare providers2
Purpose and Objectivesq This quality improvement project emphasizes the
importance of nursing contributions to delirium assessment and management in preventing complications that impact patient safety and quality of care
q This project improves current nursing practice by improving nurses’ knowledge of delirium and implementing an effective delirium protocol
Evidence-Based Initiativeq Several evidence-based studies demonstrated
significant nurse enhancement of delirium knowledge, assessment, intervention, and prevention strategies through nursing education
q Several evidence-based studies regarding delirium assessment, management, and care protocols that have yielded positive changes in patients’ outcomes
q Structured educational nursing interventions and patient care protocols must be developed to improve delirium nursing practice
q Conceptual Framework
The Knowledge to Action Framework 3
Using the Evidence: Developing an ICU Delirium ProtocolWhayoun Lee, MA, MSN, APRN, RN, Kimberly J. Oosterhouse, PhD, RN
Loyola University of Chicago Marcella Niehoff School of Nursing
Project PlanqEthics: Quality Improvement approval
was received from University of Chicago Medicine. Institutional Review Board approval was received from Loyola University Health System; verbal consent obtained
qFeasibility of the site: Site does not implement specific delirium protocols or guidelines that nurses can follow, or provide nursing education to improve knowledge on delirium
qStakeholder’s support: Intensive Care Unit Medical Director, Nurse Manager, Unit Educator, staff nurses, and hospital administration
qBudget: No specific funds allocated to this project; printing costs for presentation & pocket card for CAM-ICU tools and ABCDEF patient care bundle
qDesign: A quality improvement project with a pre- and post-test design performed at a single center
qSetting: 16-bed surgical/trauma ICU of 811-bed single center tertiary teaching hospital in Midwest America
q Participants: Registered nurses (RN) working in the surgical/trauma ICU
q Implementation: December 2020-March, 2021
Results and Evaluation qDemographics and Experience
q Nurse’s Delirium Confidence Level
qDelirium Knowledge Scores (N=38)
qNurse’s Perception Level
• Self-administered questionnaire regarding nurse’s demographic data • Assessment of Nursing Knowledge Regarding ICU Delirium• Assessment of Nursing Perception Levels on Usefulness of CAM-ICU and ABCDEF Care Bundle• Nursing Staff Compliance with Delirium Assessment Screening Instruments and Care Bundle
Items
Pre-Test (2 weeks)
• Formal Didactic Educational Intervention for ICU Delirium• Formal Education for CAM-ICU Screening Tool and ABCDEF Delirium Care Protocol BundleIntervention (5 weeks)
• Paired t-test to evaluate pre-and post-intervention delirium knowledge and the nurse’s perception on use of delirium assessment tools and patient care bundles
• Evaluated the frequency of the proper usage of CAM-ICU assessment and ABCDEF patient care bundles
Post-Test (2 weeks)
<25 years (5)13%
26-34 years (15)40%
35-44 years (11)29%
45-54 years (2))5%
> 55 years (5)13%
Age Group (N=38)
<25 years (5) 26-34 years (15) 35-44 years (11)45-54 years (2)) > 55 years (5)
0-5 years (11)29%
6-10 years (10)26%
11-15 years (8)
21%
16-20 years (2)5%
>20 years (7)19%
Years of experiences (N=38)
0-5 years (11) 6-10 years (10) 11-15 years (8)
16-20 years (2) >20 years (7)
Bachelors (33)87%
Masters (5)13%
Level of nursing education (N=38)
Bachelors (33) Masters (5)
2.42 2.42 2.71 3.02 2.92 2.95 3.24 3.02
4.68 4.66 4.67 4.97 4.9 4.9 4.814.09
0123456
Knowled
ge…
I rece
ived…
My deli
rium…
The CAM-IC
U is…
Patient c
are is…
Monitorin
g for…
Frequen
t…
Routine…
Nurse's Perception Level of CAM-ICU & ABCDEF Bundle (N=38)
Pre-Test Post-Test
3.612.47 2.76 2.18
4.71 4.79 4.71 4.34
0123456
I feel confidentdefining delirium
I feel confidentdifferentiating thedifferent types of
delirium
I feel confidentcompleting the
CAM-ICU
I feel confidentcompleting the
ABCDEF carebundle
Nurse's Confidence Level on CAM-ICU and ABCDEF Bundle (N=38)
Pre-Test Post-Test
Pre-test Correct M(SD)
Post-test Correct M(SD)
t(df) P
Overall Knowledge
72.37 (12.83)
95 (6.47)
-9.29(37) p<0.0001
71.32
95
0102030405060708090
100
Pre-Test Post-Test
Nurse's Knowledge Level of Delirium
Results and Evaluation Cont.qCompliance Rates of CAM-ICU
qCompliance Rates of ABCDEF Bundle
Practice ImplicationsqAppropriate educational interventions significantly
improve nursing knowledge and perception levels on ICU delirium assessment and management
qDelirium assessments and management protocols at an institutional level must be developed for for improvement of patient safety and practice change
ConclusionqThis quality improvement project demonstrates that
an educational intervention for nurses can result in improved knowledge of ICU delirium and nurse’s confidence and perception levels on usefulness of delirium assessment tools and intervention bundles.
qAn adequate formal education involvement is essential to promote ICU delirium management practice and to develop delirium protocol
AcknowledgementsThe author would like to thank Dr. Kimberly
Oosterhouse, Dr. Audrey Klopp, the nursing staff at University of Chicago Medicine, “Delirium Champions” Griselda Hempstead, Nicole Holcomb, and Kimberley
Reed.References
1. Arumugam, S., El-Menyar, A., Al-Hassani, A., Strandvik, G., Asim, M., Mekkodithal, A., Mudali, I., & Al-Thani, H. (2017). Delirium in the intensive care unit. Journal of Emergencies, Trauma and Shock, 10(1), 37–46. https://doi.org/10.4103/0974-2700.199520
2. American Delirium Society. (n.d.). Retrieved from https://americandeliriumsociety.org/
3. Field, B., Booth, A., Liotta, I., & Gerrish, K. (2014). Using the Knowledge to Action Framework in practice: a citation analysis and systematic review. Implementation Science : IS, 9, 172. https://doi.org/10.1186/s1301-014-0172-2
Pre-test Frequency
Rates (N=80)
Post-test Frequency
Rates (N=76)
Overall Rates of CAM-ICU
6.25% (5 times/80 patients over
6 days)
48.68% (37 times/76
patients over 6 days)
Pre-test Frequency
Rates(N=80)
Post-test Frequency
Rates (N=76)Overall Rates
of ABCDEF intervention
Bundle
3.75% (3 times/80
patients over 6 days)
46.05% (35 times/76
patients over 6 days)
6.25%
48.68%
0.00%10.00%20.00%30.00%40.00%50.00%60.00%
Pre-Test Post-Test
Compliance Rates of CAM-ICU
3.75%
46.05%
0.00%10.00%20.00%30.00%40.00%50.00%
Pre-Test Post-Test
Compliance Rates of ABCDEF Bundle
Paired t-test(p<0.05): Significant changes in confidence and perception level scores from pre- to post-test (P<0.0001)
Paired t-test(p<0.05): Significant changes in nurse’s knowledge of delirium scores from pre- to post-test (P<0.0001)