Does introducing the CAM-ICU affect the rate at which delirium is diagnosed in a mixed medical-surgical ICU?

Intensive care nurses' opinions and current practice in relation to delirium in the intensive care setting

BACKGROUND

Delirium is a frequently encountered syndrome that negatively impacts on the well-being of the critically ill patient. Although international guidelines promote delirium monitoring, little is known regarding Irish intensive care (ICU) nurses' opinions and current practice in relation to delirium monitoring.

AIM

To ascertain ICU nurses' opinions on delirium among the critically ill and establish if delirium monitoring is part of current practice in the Republic of Ireland.

METHODS

A descriptive quantitative survey design was employed, utilising a self-report questionnaire. Participants were registered nurses selected using convenience sampling from two of the largest and leading teaching hospitals in the Republic of Ireland. The overall response rate was 70% (n=151/216).

FINDINGS

The majority of participants 143 (95%) recognised delirium as a serious problem and 93% considered delirium to be an under-diagnosed syndrome that requires active medical intervention. Only 17.9% reported screening for delirium and 4% ranked delirium important to monitor in the ICU setting. The majority of participants never attended a lecture (79%) or read an article (68%) pertaining to delirium.

CONCLUSION

The findings provide further evidence of the theory practice gap that is likely to exist internationally in settings where best practice guidelines on the management of delirium in the ICU setting are not implemented.

A questionnaire survey of critical care nurses' attitudes to delirium assessment before and after introduction of the CAM-ICU

BACKGROUND

Nurses are usually the first to identify delirium in ICU patients. We aimed to assess the attitudes of Australian critical care nurses when we introduced the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

METHODS

We surveyed all 174 nurses in our ICU using two questionnaires: first after a one-month period of mandated but unstructured delirium assessments, and then following one month of CAM-ICU assessments. We also quantified antipsychotic medication usage by inspecting pharmacy records.

FINDINGS

The first survey response rate was 65/174 (37%). Most nurses (73%) thought active delirium assessment was important, and 93% thought their assessments were worth the time required. These assessments were largely unstructured, as only 20% knew a formal delirium test, and only 7% sometimes used one. The second survey response rate was 45/174 (26%). Most (89%) still thought delirium assessment was important, but only 75% thought the CAM-ICU worth the time required (p=0.01 compared to unstructured assessments). Similar proportions (75% and 73%) were confident in the accuracy of their assessments. Many (33%) found the CAM-ICU 'quite' or 'very' hard to perform, but despite this, 82% wanted to continue to use it. Free-text answers suggested this was because medical staff paid more attention to the CAM-ICU. Supporting this, prescriptions of antipsychotic medications increased significantly in the CAM-ICU period.

CONCLUSION

Critical care nurses in our Australian ICU who responded to our survey think delirium assessment is important. Although they find unstructured assessments easier to perform, they wanted to persist with the CAM-ICU, in part because it facilitated more appropriate pharmacological treatment of delirium for their patients. We recommend the CAM-ICU as a tool to improve communication between nurses and physicians in the management of delirium.