Training hospital inpatient nursing to know (THINK) delirium: A nursing educational program

Delirium education and post-anaesthetics care unit nurses' knowledge on recognising and managing delirium in older patients

BACKGROUND

Postoperative delirium (POD) is a major complication following a surgical procedure. There is evidence that improving knowledge about POD could enhance POD care and patient outcomes.

AIM

The study aimed to evaluate whether the amount of delirium education among registered nurses working in post-anaesthetics care units (PACU) impacts on their self-reported confidence and competence in recognising and managing delirium as well as prior knowledge on factors that influence the risk of delirium onset for older people.

METHOD

The current study utilised an online survey on delirium care practice among registered nurses in PACUs. The survey consisted of 27 items. There were questions about confidence and competence in delirium care, knowledge about delirium risk factors, and ranked responses to two case scenario questions to evaluate the application of POD care. There were also demographic questions, including previous experience with delirium care education.

RESULTS

A total of 336 responses were generated from registered nurses working in PACU. Our findings found substantial variability among the respondents about their delirium care education. The amount of delirium education did not influence the PACU registered nurses' confidence or competence in delirium care. In addition, previous education did not have an impact on their knowledge about delirium risk factors.

DISCUSSION AND CONCLUSION

These findings suggested that the quantity of prior education about delirium did not improve the confidence, competence, knowledge, or case scenario questions of PACU registered nurses. Thus, delirium care education needs to be transformed to ensure it has a positive effect on delirium care clinical practice by registered nurses in PACU.

Managing delirium in acute inpatient units: A cross-sectional study of nursing teams' knowledge and perceived limitations

AIM

The aim of the study was to describe nursing teams' theoretical knowledge of delirium and their perceptions of the way in which it is handled in acute inpatient units.

DESIGN

This is a descriptive cross-sectional study using a questionnaire comprising ten questions on knowledge and seven on perception.

METHODS

The sample consisted of 216 professionals working at a hospital complex in Madrid, Spain. Descriptive and non-parametric bivariate analyses were performed for a p < .05.

RESULTS

Fifty-three point two per cent of staff possessed sufficient theoretical knowledge, and this figure rose significantly among professionals with more years of experience. Areas for improvement in theoretical knowledge included the use of therapeutic immobilization, screening scale, subtypes of delirium and precipitating factors. Sixty-eight point five per cent of staff perceived their knowledge as fair, 50% agreed that delirium was underdiagnosed and 48.1% agreed that preventive measures were only occasionally taken. Perceived barriers included lack of training, work overload, ineffective coordination and lack of standardized protocols.

Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial

Importance

Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored.

Objective

To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures.

Design, Setting, and Participants

This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021.

Interventions

First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion.

Main Outcomes and Measures

Postoperative delirium incidence and duration.

Results

Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98; P = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99; P = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99; P = .54).

Conclusions and Relevance

This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.

The New Frontier of Perioperative Cognitive Medicine for Alzheimer's Disease and Related Dementias

This is a review of preoperative cognitive assessment and other healthcare gaps in the care of older adults at risk for Alzheimer's disease and related dementias (ADRD) who have elected surgery with anesthesia. It summarizes concerns regarding ADRD perioperative healthcare, perioperative cognitive, and neuronal domains of vulnerability. It also offers a plan for phased preoperative cognitive screening and perioperative cognitive intervention opportunities. An argument is made for why medical professionals in the perioperative setting need fundamental training in cognitive-behavioral principles, an understanding of neurodegenerative diseases of aging, and an appreciation of the immediate and long-term medical risks for such patients undergoing anesthesia. The author's goal is to encourage readers to consider perioperative cognitive medicine as a new frontier for generating evidence-based care approaches for at-risk older adults with neurodegenerative disorders who require procedures with anesthesia.

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study

BACKGROUND

Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening.

OBJECTIVE

To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA).

DESIGN

Prospective cohort study.

SETTING

Large urban academic medical center and small rural community hospital.

PARTICIPANTS

527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs).

MEASUREMENTS

On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method.

RESULTS

Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%).

LIMITATION

Two sites; limited diversity.

CONCLUSION

An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists.

PRIMARY FUNDING SOURCE

National Institute on Aging.