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Introduction of issue
Delirium is an acute brain dysfunction
characterised by an alteration or
fluctuation in baseline mental status
combined with inattention and either an
altered level of consciousness or
disorganised thinking
Introduction of Issue
Summary of
Current Practice
ABCDE Bundle
PAD Guidelines
St Josephs Hospital:
Critical-Care Pain Observation
Tool (CPOT)
CAM-ICU Tool
UAMC Banner:
CAM-ICU Assessment Tool
ABCDE Bundle
TMC:
CAM-ICU
National Practice:
CAM-ICU is a widely used
instrument tool for detection
of delirium worldwide
5,000 original articles to date
Translated into 16 languages
Early mobilization
Avoidance of physical
quicker
Soften the environment
shutting off lights
minimizing noisy alarms
restraints
Removal of unnecessary
invasive tubes
Synopsis of current
literature research
findings
Studies:
Observational study
Randomized controlled trial
An Interdisciplinary Quality Improvement Project
2 cohort studies
Mixed-methods study
Descriptive qualitative and a Descriptive quantitative study
The research found delirium of the older population much more significant
Significant Findings
Strengths of current
research
Summary of strengths
Populations of participating individuals are clearly identified
and consistent
Measurement tools for delirium status are consistent
Levels of evidence are relatively high
Summary of strengths
Studies were performed in varied geographical settings
(U.S., Irish, Korea)
Studies have multifaceted focus for recommendation
(pharmacological, non-pharmacological and psychosocial)
Limitations of the
current research
Summary of limitations
Sample sizes are relatively small
Use of self-reporting questionnaires
No long-term follow-up
Some studies lack randomization
Evidence Based
Nursing
Recommendations
Supporting Best
Practice
Sleep enhancement
Promote sleep that would
occur during normal sleepwake cycles
i.e. turning off lights,
decreasing
volume/brightness of
monitors
Application/Implementation
to Nursing Practice
Timeline
Senior Leader's
Professional meet
1 to 2 months
Training of Unit-level
leaders
1 to 2 months
2 to 3 months
1 to 2 months
Didactic Training of
Floor level
individuals who
implement protocol
Interdisciplinary
team meet and plan
Implementation of
Bundle protocol
consider part of
hospital policy
1 month
Continued
Education
every 6 months
6 months
Cost Analysis
Benefits to patients:
-Patient distress.
-Decreased rest.
-Unnecessary delays in extubation.
Benefits to nurse:
-Increased workload.
-Increased documentation.
-Ethical dilemmas.
-Lack of time (75% of nurses).
Benefits to agency:
Evaluation
Evaluation/Outcomes
Patient:
Patients will experience no more than 3 consecutive days of delirium during
their ICU stay while on the ABCDE protocol.
Nurse:
Nurses will successfully perform and implement ABCDE protocol once a shift
and RASS or CAM-ICU assessments 3 times during their shift on all their
assigned qualifying ICU patients.
Protocol:
The local facility that initiates this protocol will have the training and
implementation of all staff completed in 18 months and the delirium protocol
will be a permanent part of the hospital policy within 2 years of the initiation of
the protocol.
Summary
References
American Association of Critical Care Nurses. (2015). Delirium Assessment and Management. Retrieved from
http://www.aacn.org/wd/practice/content/practicealerts/delirium-practice-alert.pcms?menu=practice
Balas, M. C., Burke, W. J., Gannon, D., Cohen, M. Z., Colburn, L., Bevil, C., . . . Vasilevskis, E.
E. (2013). Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility
bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium
guidelines. Critical Care Medicine, 41(9 Suppl 1), S116-27. doi:10.1097/CCM.0b013e3182a17064
Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., Peitz, G. J., Ely, E. W. (2012). Critical care nurses
role in implementing the ABCDE bundle into practice. American Association of Critical Care Nurse, 32(2), 35-47. doi: http:
//dx.doi.org/10.4037/ccn2012229
Bryczkowski, S. B., Lopreiato, M. C., Yonclas, P. P., Sacca, J. J., & Mosenthal, A. C. (2014). Delirium prevention program in the
surgical
intensive care unit improved the outcomes of older adults. Journal of Surgical Research, 190(1), 280-288.
Dale, C. R., Kannas, D. A., Fan, V. S., Daniel, S. L., Deem, S., Yanez III, N. D., ... & Treggiari, M. M. (2014). Improved analgesia,
sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. Annals of the American
Thoracic Society, 11(3), 367-374.
Desai, S., Chau, T., & George, L. (2013). Intensive Care Unit Delirium. Critical Care Nurs Q 36(4): 370-389.
References
Glynn, L., & Corry, M. (2015). Intensive care nurses' opinions and current practice in relation to delirium in the intensive care
setting. Intensive & Critical Care Nursing : The Official Journal of the British Association of Critical Care Nurses, 31(5), 269275. doi:10.1016/j.iccn.2015.05.001
Indeed (2015). ICU Nurse Salary in Tucson, AZ. Retrieved from
http://www.indeed.com/salary/q-Icu-Nurse-l-Tucson,-AZ.html
Indeed (2015). Critical Care Nurse Manager ICU Manager Director Salary in Tucson, AZ. Retrieved from
http://www.indeed.com/salary?q1=Critical+Care+Nurse+Manager+Icu+Manager+Director&l1=tucson%2C+arizona
National Quality Measures Clearinghouse. (2015). Delirium: Proportion of patients meeting diagnostic criteria on the
Confusion Assessment Method (CAM). Agency for Healthcare Research and Quality. Retrieved from
http://www.qualitymeasures.ahrq.gov/content.aspx?id=27635
References
Marino, J., Bucher, D., Beach, M., Yegneswaran, B., & Cooper, B. (2015). Implementation of an Intensive Care Unit Delirium
Protocol. Dimensions Of Critical Care Nursing, 34(5), 273-284. doi:10.1097/DCC.0000000000000130
Moon, K.J., Lee, S.M. (2015). The effects of a tailored intensive care unit delirium prevention protocol: a randomized controlled trial.
Internation Journal of Nursing Studies. 52, 1423-1432. doi:10.1016/j.ijnurstu.2015.04.021
Pisani, M. A., Murphy, T. E., Araujo, K., Slattum, P., Van Ness, P., Inouye, S. (2009). Benzodiazepine and opioid use and
the duration of intesive care unit delirium in an older population, Critical Care Medicine, 31(1), 177-183. doi: 10.1097/CCM.
0b013e318192fcf9
The American Association for the Surgery of Trauma (2015). Mechanical Ventilation in the Intensive Care Unit. Retrieved
from http://www.aast.org/GeneralInformation/mechanicalventilation.aspx
Whitney, K. (2015). Undone in the ICU. Vanderbilt University School of Medicine. Retrieved from
https://www.mc.vanderbilt.edu/vanderbiltmedicine/undone-in-the-icu/