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Meghani S, Timmins F. Intensive care nurses' perceptions and awareness of delirium and delirium prevention guidelines. Nurs Crit Care 2024. [PMID: 38634180 DOI: 10.1111/nicc.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Delirium is an acute and fluctuating disturbance of cognition and is a common occurrence in critically ill patients. It is a manifestation of an acute brain dysfunction often attributed to higher survival rates and a subsequently aging population. Intensive Care Unit (ICU) treatment and survival often contributes towards development of delirium, and lack of or inappropriate management can translate into the development of long-term psychological effects that last even after discharge. While a lot is already known about this topic, and several assessment tools exist, these are not being consistently used by ICU nurses and as a result delirium often goes unrecognized, with unwarranted consequences. AIMS The study aimed to explore the perception of delirium among ICU nurses, and the extent of their awareness about guidelines to assess and prevent delirium in ICU patients. It also sought to understand the application of delirium guidelines in ICU practice. STUDY DESIGN A quantitative, exploratory, self-reporting survey was conducted among 145 ICU nurses from one critical care unit in the Republic of Ireland. RESULTS The overall response rate was 71% (103/145). Most nurses (85%) who participated in this survey believed delirium was expected. However, only 45% acknowledged it is a complication. Only 31% of nurses monitored delirium using a validated scale and few observed this as a part of routine care. Most nurses had received education; however, this did not translate to their clinical practice. CONCLUSIONS Guidelines on managing delirium may not be routinely implemented in the ICU settings of hospitals in the Republic of Ireland. RELEVANCE TO CLINICAL PRACTICE As the findings suggest, a gap exists between theory and practice, necessary revision of policy or creating a new policy, supplemental educational sessions such as bedside sessions, e-learning module, study day or seminars need to be organized to improve nurses' awareness related to delirium and delirium prevention guidelines.
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Affiliation(s)
- Salima Meghani
- Department of Pulmonary Hypertension, Mater Hospital, Dublin, Ireland
| | - Fiona Timmins
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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McCartney H, Noble E, MacLullich AMJ, Davis DHJ, Evans J, Shenkin SD, Muniz-Terrera G, Sandeman D, Tieges Z. A systematic review of studies reporting on neuropsychological and functional domains used for assessment of recovery from delirium in acute hospital patients. Int J Geriatr Psychiatry 2023; 38:e5943. [PMID: 37294207 DOI: 10.1002/gps.5943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/17/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Assessing for recovery in delirium is essential in guiding ongoing investigation and treatment. Yet, there is little scrutiny and no research or clinical consensus on how recovery should be measured. We reviewed studies which used tests of neuropsychological domains and functional ability to track recovery of delirium longitudinally in acute hospital settings. METHODS/DESIGN We systematically searched databases (MEDLINE, PsycInfo, CINAHL, Embase, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials), from inception to October 14th , 2022. Inclusion criteria were: adult acute hospital patients (≥18 years) diagnosed with delirium by a validated tool; 1+ repeat assessment using an assessment tool measuring domains of delirium/functional recovery ≤7 days from baseline. Two reviewers independently screened articles, performed data extraction, and assessed risk of bias. A narrative data synthesis was completed. RESULTS From 6533 screened citations, we included 39 papers (reporting 32 studies), with 2370 participants with delirium. Studies reported 21 tools with an average of four repeat assessments including baseline (range 2-10 assessments within ≤7 days), measuring 15 specific domains. General cognition, functional ability, arousal, attention and psychotic features were most commonly assessed for longitudinal change. Risk of bias was moderate to high for most studies. CONCLUSIONS There was no standard approach for tracking change in specific domains of delirium. The methodological heterogeneity of studies was too high to draw firm conclusions on the effectiveness of assessment tools to measure delirium recovery. This highlights the need for standardised methods for assessing recovery from delirium.
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Affiliation(s)
- Haruno McCartney
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
| | - Erin Noble
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Jonathan Evans
- School of Health and Wellbeing, University of Glasgow, Scotland, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Scotland, UK
| | - Graciela Muniz-Terrera
- Edinburgh Dementia Prevention and Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK
- Department of Social Medicine, Ohio University, Athens, Ohio, USA
| | - Daisy Sandeman
- School of Health in Social Science, University of Edinburgh, Scotland, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Scotland, UK
- Department of Computing, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Scotland, UK
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Lange S, Mȩdrzycka-Da̧browska W, Tomaszek L, Wujtewicz M, Krupa S. Nurses' knowledge, barriers and practice in the care of patients with delirium in the intensive care unit in Poland-A cross-sectional study. Front Public Health 2023; 11:1119526. [PMID: 36935691 PMCID: PMC10020524 DOI: 10.3389/fpubh.2023.1119526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Background Delirium is a cognitive disorder that occurs with high frequency in patients in intensive care units and affects patient outcomes. Despite recommendations for monitoring and assessing delirium in the ICU, studies show that it is still not routinely assessed and often remains undiagnosed or misinterpreted as dementia or depression. Aim The aim of this study was (1) to assess nurses' knowledge and clinical practices regarding delirium, (2) to identify the factors associated with nurses' knowledge, and (3) to define barriers to effective control of delirium. Methods A cross-sectional study was conducted among 371 ICU nurses in Poland. Results 53.1% of nurses had never been educated on delirium control resulting in a deficit in knowledge of delirium symptoms, risk factors and complications associated with delirium in ICU patients. Master's degree in nursing (vs. Registered nurses + Bachelor's), female gender, and working in university hospital (vs. other) were positively correlated with nurse's knowledge, while age had a negative impact on knowledge. Delirium is a marginalized state in ICU patients, only 16.4% of nurses assessed delirium routinely and 35.8% assessed delirium occasionally, rarely using validated scales. Barriers to effective delirium control were primarily the lack of a requirement to assess delirium, the difficulty of assessing delirium in intubated patients and nurses' lack of confidence in their ability to use delirium assessment tools. Conclusions There is an urgent need to educate nurses about delirium and to make delirium assessment obligatory in clinical practice. The area of change should also include a hospital policy on delirium monitoring and management. The study was registered on ClinicalTrials.gov (NCT05384964).
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Affiliation(s)
- Sandra Lange
- Department of Internal and Pediatric Nursing, Faculty of Health Sciences, Medical University of Gdańsk, Gdańsk, Poland
- *Correspondence: Sandra Lange
| | - Wioletta Mȩdrzycka-Da̧browska
- Department of Anaesthesiology Nursing and Intensive Care, Faculty of Health Sciences, Medical University of Gdansk, Gdańsk, Poland
| | - Lucyna Tomaszek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój, Poland
| | - Magdalena Wujtewicz
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Sabina Krupa
- Institute of Health Sciences, College of Medical Sciences of the University of Rzeszow, Rzeszow, Poland
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Stokholm J, Steenholt JV, Csilag C, Kjær TW, Christensen T. Delirium Assessment in Acute Stroke: A Systematic Review and Meta-Analysis of Incidence, Assessment Tools, and Assessment Frequencies. J Cent Nerv Syst Dis 2019; 11:1179573519897083. [PMID: 31908562 PMCID: PMC6937530 DOI: 10.1177/1179573519897083] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The purpose of this systematic literature review was to examine whether different assessment methods contribute to the variance in delirium incidence detected in populations of patients with acute stroke. Specifically, the aim was to address the influence of (1) choice of assessment tool, (2) frequency of assessment, and (3) type of health professional doing the assessment. METHODS We searched MEDLINE, EMBASE, and PsycINFO and included pro- and retrospective cohort studies assessing delirium during hospitalization of adult acute stroke patients. RESULTS In 30 articles, 24 unique populations were identified and included in the review. Delirium incidence ranged from 1.4% to 75.6% in total and a chi-square test showed a significant heterogeneity across studies (χ2 = 536.5, df = 23, P < .0001). No studies had an assessment for delirium before a patient entered the study. No specific patterns regarding the influence of tool, assessment frequency or health professional were discernible. DISCUSSION Subgroups analyses were not conducted due to the heterogeneity across studies. Studies comparing delirium assessment tools directly with each other are needed. CONCLUSIONS Delirium is a common complication in acute stroke. No firm conclusions about a possible correlation of choice of tool, assessment frequency, and delirium incidence could be made due to the great heterogeneity of the study populations. Only 1 study compared 2 tools directly with each other. Further studies comparing delirium assessment tools directly with each other are needed.
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Affiliation(s)
- Jannik Stokholm
- Department of Neurology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Claudio Csilag
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Outpatient Clinic, Mental Health Centre North Zealand, Hillerød, Denmark
| | - Troels Wesenberg Kjær
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Center for Neurophysiology, Department of Neurology, Zealand University Hospital, Roskilde, Denmark
| | - Thomas Christensen
- Department of Neurology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Ramoo V, Abu H, Rai V, Surat Singh SK, Baharudin AA, Danaee M, Thinagaran RRR. Educational intervention on delirium assessment using confusion assessment method-ICU (CAM-ICU) in a general intensive care unit. J Clin Nurs 2018; 27:4028-4039. [PMID: 29775510 DOI: 10.1111/jocn.14525] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 03/27/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives. BACKGROUND Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools. DESIGN This study, performed in Malaysia, used a single-group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment. METHODS Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and postintervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance. RESULTS There were significant differences in the knowledge scores pre- and postintervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision-making" and "difficult to interpret delirium in intubated patients". CONCLUSIONS Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and interprofessional involvements are essential for a successful implementation of intensive care unit delirium assessment practice. RELEVANCE TO CLINICAL PRACTICE This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings.
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Affiliation(s)
- Vimala Ramoo
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Harlinna Abu
- Kulliyyah of Nursing, International Islamic University Malaysia, Pahang, Malaysia
| | - Vineya Rai
- KPJ Tawakkal Specialist Hospital, Kuala Lumpur, Malaysia
| | | | | | - Mahmoud Danaee
- Academic Enhancement and Leadership Development Centre (ADeC), Level 14, Wisma R& D, University of Malaya, Kuala Lumpur, Malaysia
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Abstract
OBJECTIVE To systematically evaluate the treatment of ICU delirium. DATA SOURCES Literature searches were conducted using PubMed and Ovid MEDLINE (January 1980 to March 2013). Clinical trials/reports evaluating the use of pharmacologic treatment for ICU delirium were selected. References from major guidelines and publications were reviewed. STUDY SELECTION AND DATA EXTRACTION English-language articles related to the treatment of ICU delirium were included. The following were excluded: (1) used pharmacologic treatment for the prevention of delirium; (2) inclusion of non-critically ill, palliative care, or hospice care patients; (3) letters to the editor; (4) case studies; (5) case series; (6) studies without delirium-related end points; and (7) studies with a predominantly postoperative population. Data extracted included: study design, population, treatment, number of participants, end points, outcomes/authors' conclusions, and adverse effects. DATA SYNTHESIS Four studies were included in this review. The US Preventative Services Task Force classification scheme was used to assess the quality of evidence. All 4 studies reviewed were level I evidence studies. There are few well-designed, randomized studies that evaluate ICU delirium treatment. The 2 main randomized studies have small sample sizes and methodological concerns. Antipsychotic therapy may reduce the duration of ICU delirium. However, more robust studies are needed to demonstrate benefit. CONCLUSIONS There is a lack of evidence supporting pharmacologic treatment for ICU delirium. Prospective, well-designed studies using proper delirium identification tools and severity are necessary to confirm the overall impact of pharmacologic therapy on the duration of delirium and associated complications.
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Affiliation(s)
- Matt Bathula
- University of Maryland School of Pharmacy, Baltimore, MD, USA
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Maclullich AMJ, Anand A, Davis DHJ, Jackson T, Barugh AJ, Hall RJ, Ferguson KJ, Meagher DJ, Cunningham C. New horizons in the pathogenesis, assessment and management of delirium. Age Ageing 2013; 42:667-74. [PMID: 24067500 PMCID: PMC3809721 DOI: 10.1093/ageing/aft148] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i) Pathogenesis: recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii) Prevention: delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii) Assessment: though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv) Management: studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues to make progress, with several promising lines of enquiry and an expanding base of interest among researchers, clinicians and policymakers.
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Affiliation(s)
- Alasdair M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
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