Survey among critical care nurses and physicians about delirium management

Delirium is a serious complication in patients in intensive care units. Previous surveys on delirium management in daily practice showed low adherence to published guidelines | Nursing in Critical Care

Aim: To evaluate delirium management in nurses and physicians working in intensive care units in German-speaking countries and to identify related differences between nurses and physicians.

Conclusion: In German-speaking countries, assessment of delirium needs further improvement, leading to accurate assessment. Delirium-related structures and processes appear to be implemented widely, with only a few differences between nurses and physicians.

Full reference: Nydal, P. et al. (2017) Survey among critical care nurses and physicians about delirium management. DOI: 10.1111/nicc.12299

The Confusion Assessment Method for the ICU-7 Delirium Severity Scale

Khan, B.A. et al. (2017) Critical Care Medicine. 45(5) pp. 851–857

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Objectives: Delirium severity is independently associated with longer hospital stays, nursing home placement, and death in patients outside the ICU. Delirium severity in the ICU is not routinely measured because the available instruments are difficult to complete in critically ill patients. We designed our study to assess the reliability and validity of a new ICU delirium severity tool, the Confusion Assessment Method for the ICU-7 delirium severity scale.

Conclusions: Our results suggest that Confusion Assessment Method for the ICU-7 is a valid and reliable delirium severity measure among ICU patients. Further research comparing it to other delirium severity measures, its use in delirium efficacy trials, and real-life implementation is needed to determine its role in research and clinical practice.

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Quality of clinical practice guidelines in delirium

Bush, S.H. et al. (2017) BMJ Open. 7:e013809

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Objective: To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality.

Conclusions: Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.

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Intensive care nurses’ experiences and perceptions of delirium and delirium care

Zamoscik, K. et al. Intensive and Critical Care Nursing. Published online: 1 March 2017

Objective: To explore nurses’ experiences and perceptions of delirium, managing delirious patients, and screening for delirium, five years after introduction of the Confusion Assessment Method for Intensive Care into standard practice.

Conclusion: Nurses described perceiving delirium as a low priority matter and linked it to work culture within the intensive care specialty. Simultaneously, they expressed their readiness to challenge this culture and to promote the notion of providing high-quality delirium care. Nurses discussed their frustrations related to lack of confidence in assessing delirium, as well as lack of effective therapies in managing this group of patients. They declared their appreciation for non-pharmacological interventions in treatment of delirium, suggested improvements to current delirium approach and proposed introducing psychological support for nurses dealing with delirious patients.

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Occupational therapy for delirium management in elderly patients

Álvarez, E.A. et al. (2017) Journal of Critical Care. 37(2) pp. 85–90

Purpose: Delirium has negative consequences such as increased mortality, hospital expenses and decreased cognitive and functional status. This research aims to determine the impact of occupational therapy intervention in duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was to assess functionality at hospital discharge.

Conclusions: Occupational therapy is effective in decreasing duration and incidence of delirium in nonventilated elderly patients in the intensive care unit and improved functionality at discharge.

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Delirium in Critically Ill Children

Traube, Chani et. al. Delirium in Critically Ill Children: An International Point Prevalence Study.
Critical Care Medicine. published online ahead of print January 10th 2017

Objectives: To determine prevalence of delirium in critically ill children and explore associated risk factors.

Design: Multi-institutional point prevalence study.

Setting: Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia.

Patients: All children admitted to the pediatric critical care units on designated study days (n = 994).

Intervention: Children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the bedside nurse. Demographic and treatment-related variables were collected.

Measurements and Main Results: Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age less than 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and antiepileptics.

Conclusions: Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

Diagnosing delirium in very elderly intensive care patients

Heriot, N.R. et al. Intensive and Critical Care Nursing. Published online: September 3 2016

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Objective: To determine the incidence of delirium in elderly intensive care patients and to compare incidence using two retrospective chart-based diagnostic methods and a hospital reporting measure (ICD-10).

Design: Retrospective study.

Setting: An ICU in a large metropolitan private hospital in Melbourne, Australia.

Patients: English-speaking participants (n = 348) 80+ years, admitted to ICU for >24 hours.

Measurements and main results: Medical files of ICU patients admitted October 2009–October 2012 were retrospectively assessed for delirium using the Inouye chart review method, DSM-IV diagnostic criteria and ICD-10 coding data. General patient characteristics, first onset of delirium symptoms, source of delirium information, administration of delirium medication, hospital and ICU length of stay, 90 day mortality were documented. Delirium was found in 11–29% of patients, the highest incidence identified by chart review. Patients diagnosed with delirium had higher 90 day mortality, and those meeting criteria for all three methods had longer hospital and ICU length of stay.

Conclusions: ICU delirium in the elderly is often under-reported and strategies are needed to improve staff education and diagnosis.

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