Delirium Management in the Intensive Care Unit

Delirium is a cognitive impairment that includes an altered level of consciousness, disorganized thinking and inattention. Hospitalized patients, especially those critically ill, are at an increased risk for developing acute delirium during the hospital stay. Delirium in the intensive care unit (ICU) has often been considered an unavoidable aspect of the complex care provided in the ICU setting. However, delirium in the intensive care unit is recognized as an independent contributor to several adverse outcomes. These adverse outcomes include an increase in mortality, hospital length of stay and long-term cognitive impairment following discharge from the hospital. Subsequently, the financial burden associated with the management of delirium in the ICU can be significant. While comprehensive delirium management practice recommendations have been published by the American College of Critical Care Medicine, implementation of these recommendations has been limited in many rural and community hospital settings. The purpose of this scholarly project is to promote the adoption of a delirium management guideline and electronic order set in the adult intensive care unit at a community hospital. Based upon the body of evidence, and incorporating published practice recommendations, the proposal of an ICU delirium management guideline and electronic order set will outline consistent and comprehensive management of delirium for adult intensive care patients. There are four objectives of this scholarly project: 1) Propose an intensive care unit delirium guideline for the management of delirium in the critically ill patient. 2) Propose an electronic order set for intensive care unit delirium treatment. 3) Provide nursing staff with education regarding the clinical significance of intensive care unit delirium. 4) Disseminate information related to the scholarly project. Implementation of the first two objectives included the development and proposal of an ICU delirium management guideline and electronic order set at the site of project implementation. The delirium management guideline included risk factor identification, screening and treatment options pertaining to ICU delirium. The electronic order set was published in the electronic health record test environment and demonstrated at the guideline and electronic order set proposal. Members of the intensive care unit committee at the project site were invited to adopt the guideline and electronic order set. Implementation of objective three and four included the development of an educational module for ICU nursing staff that included a pre- and post-education questionnaire. This educational module helped the nursing staff understand more regarding the clinical implications and significance of intensive care unit delirium. Nursing staff was invited to participate in the education at staff meeting or individually. Objective four of disseminating information related to the scholarly project was implemented through the submission of a poster abstract to a nursing conference.

Running head: DELIRIUM MANAGEMENT Delirium Management in the Intensive Care Unit Matthew Jarvis, RN, BSN University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 2 DELIRIUM MANAGEMENT Executive Summary Delirium is a cognitive impairment that includes an altered level of consciousness, disorganized thinking and inattention. Hospitalized patients, especially those critically ill, are at an increased risk for developing acute delirium during the hospital stay. Delirium in the intensive care unit (ICU) has often been considered an unavoidable aspect of the complex care provided in the ICU setting. However, delirium in the intensive care unit is recognized as an independent contributor to several adverse outcomes. These adverse outcomes include an increase in mortality, hospital length of stay and long-term cognitive impairment following discharge from the hospital. Subsequently, the financial burden associated with the management of delirium in the ICU can be significant. While comprehensive delirium management practice recommendations have been published by the American College of Critical Care Medicine, implementation of these recommendations has been limited in many rural and community hospital settings. The purpose of this scholarly project is to promote the adoption of a delirium management guideline and electronic order set in the adult intensive care unit at a community hospital. Based upon the body of evidence, and incorporating published practice recommendations, the proposal of an ICU delirium management guideline and electronic order set will outline consistent and comprehensive management of delirium for adult intensive care patients. There are four objectives of this scholarly project: 1) Propose an intensive care unit delirium guideline for the management of delirium in the critically ill patient. 2) Propose an electronic order set for intensive care unit delirium treatment. 3) Provide nursing staff with education regarding the clinical significance of intensive care unit delirium. 4) Disseminate information related to the scholarly project. Implementation of the first two objectives included the development and proposal of an ICU delirium management guideline and electronic order set at the site of project implementation. The delirium management guideline included risk factor identification, screening and treatment options pertaining to ICU delirium. The electronic order set was published in the electronic health record test environment and demonstrated at the guideline and electronic order set proposal. Members of the intensive care unit committee at the project site were invited to adopt the guideline and electronic order set. Implementation of objective three and four included the development of an educational module for ICU nursing staff that included a pre- and post-education questionnaire. This educational module helped the nursing staff understand more regarding the clinical implications and significance of intensive care unit delirium. Nursing staff was invited to participate in the education at staff meeting or individually. Objective four of disseminating information related to the scholarly project was implemented through the submission of a poster abstract to a nursing conference. Scholarly project committee members include Kristi Kissell, DNP, APRN A-G ACNPBC, CCRN Committee Chair, Denise Ward, DNP, APRN ACNP-BC, FNP-BC, ACACNP Program Director, Pam Hardin, PhD, RN, Assistant Dean for MS & DNP programs. Content expert includes Vicki Spuhler, MSN, RN, Content Expert 3 DELIRIUM MANAGEMENT Table of Contents Executive Summary.......................................................................................................................2 Acknowledgements…………………………….......…………………………………………….5 Problem Statements.......................................................................................................................6 Clinical Significance.......................................................................................................................7 Purpose and Objectives.................................................................................................................7 Literature Review..........................................................................................................................8 Search Methods...................................................................................................................8 Background of ICU Delirium..............................................................................................8 Current Delirium Management Recommendations...........................................................11 Benefits of Electronic Order Set Development.................................................................14 Factors Associated with Delirium Guideline Adoption………………………………….16 Theoretical Framework...............................................................................................................17 Implementation and Evaluation.................................................................................................18 Implementation and Evaluation Matrix.............................................................................22 Results……………………………...............................................................................................23 Recommendations........................................................................................................................27 Doctor of Nursing Practice Essentials........................................................................................27 Conclusions...................................................................................................................................28 References.....................................................................................................................................30 Figures...........................................................................................................................................34 Figure 1. Delirium Management Guideline…………………………………......……….34 Appendices 37 DELIRIUM MANAGEMENT 4 Appendix A. DNP Project Proposal PowerPoint Presentation ……………………...…..35 Appendix B. Institutional Review Board (IRB) Exemption……………………………..43 Appendix C. Delirium Management Guideline.................................................................45 Appendix D. Delirium Management Electronic Oder Set.................................................50 Appendix E. ICU Nursing Education Module...................................................................53 Appendix F. Pre-education Questionnaire.........................................................................59 Appendix G. Post-education Questionnaire.......................................................................62 Appendix H. Pre- and Post-education Questionnaire Results...........................................65 Appendix I. DNP Project Poster........................................................................................67 Appendix I. Utah Valley University Nursing Conference Abstract..................................69 5 DELIRIUM MANAGEMENT Acknowledgements Thank you to Timpanogos Regional Hospital Staff for your support of me and this project Thank you, Kristi Kissell & Vicki Spuhler, for your support, feedback and encouragement Thank you to my family for your ongoing support and encouragement 6 DELIRIUM MANAGEMENT Problem Statement In 2013 the American College of Critical Care Medicine published comprehensive practice guidelines for the treatment of pain, agitation and delirium (PAD) in adult patients in the intensive care unit. Key recommendations include routine pain assessment using standardized pain scales, maintenance of light levels of sedation by utilizing standardized sedation assessment tools and limiting the use of benzodiazepines for purposes of sedation (Barr et al., 2013). Recommendations for delirium monitoring and prevention included routine use of validated delirium screening tools, recognition of delirium risk factors and the use of various interventions to manage delirium. Recommended interventions include early mobility, daily sedation interruptions and sleep promotion. It is also recommended that facilities develop computerized protocols and order forms to facilitate pain, agitation and delirium management (Barr et al., 2013). Subsequently, adoption of a comprehensive PAD management guideline has been limited in many intensive care units especially in rural and community hospital settings (Cole & Stark, 2016). Despite barriers in many of these settings, it is essential that treatment teams adopt a comprehensive strategy that integrates the published pain, agitation and delirium guidelines into patient care. The site of project implementation is a community hospital that has effectively implemented various components of the PAD recommendations. However, a comprehensive guideline addressing delirium management has not been established. The purpose of this scholarly project is to promote the adoption of a delirium management guideline and electronic order set for adult intensive care patients. Additionally, a primary objective of this project is to increase awareness of ICU delirium among staff, through nursing education. Providing this education will also help nursing staff to better recognize ICU delirium. 7 DELIRIUM MANAGEMENT Clinical Significance and Policy Implications As primary stakeholders, the adult intensive care unit (ICU) patient and families of ICU patients are better served when comprehensive PAD guidelines are implemented into the treatment plan (Collinsworth, Priest, Campbell, Vasilevskis, & Masica, 2016). ICU delirium affects 35%-80% of all critically ill patients and is independently associated with increased mortality, hospital length of stay and cognitive impairment (Collinsworth et al., 2016). Additionally, it is estimated that ICU delirium costs between $4 and $16 billion annually in the United States (Barr et al., 2013). Patients that developed delirium after undergoing cardiac surgical procedures have an average of two days longer hospital stay resulting in an average $10,000 increase in hospital expenditures (Brown et al., 2016). This finding is significant for hospital administrators and payers of healthcare services. As hospital costs continue to drive many aspects of healthcare delivery, hospital systems are responsible for adopting established guidelines that will reduce costs and improve patient outcomes. Purpose and Objectives The purpose of this scholarly project is to propose the adoption of an ICU delirium management guideline, electronic order set and provide ICU delirium education at a community hospital. Objectives for this scholarly project include: • Propose an ICU delirium guideline for the management of delirium in the critically ill patient. • Propose an electronic order set for ICU delirium treatment. • Provide nursing staff with education regarding the clinical significance of ICU delirium. • Disseminate information related to the scholarly project. 8 DELIRIUM MANAGEMENT Literature Review Search Methods A search regarding delirium in the intensive care unit was done using PubMed, CINAHL, Cochrane Library Database, and Clinical Key. Keywords used included intensive care delirium, intensive care care bundles, non-pharmacological delirium strategies, awake/breathe coordination, intensive care early mobility, patient reorientation. Research studies were limited to those published in the English language with full-text, human subjects, and limited to the last eight years from 2007-2015 to reflect the most current literature. Further, articles were obtained from the primary article's reference sections using the above mentioned methods. Background of ICU Delirium Delirium is a syndrome with several etiologies that is characterized by a disturbance of consciousness accompanied by a change in cognition. Delirium often presents with a fluctuating course of impaired attention and either altered level of consciousness or disorganized thinking. Inattention is a hallmark differentiator between delirium and dementia in the adult patient (Cavallazzi, Saad, & Marik, 2012). Other characteristic features of delirium include disorientation and rapid progression in symptom manifestation. Several mechanisms have been proposed to explain the pathophysiology of delirium. However, it is likely that several physiologic and environmental factors contribute to the development of delirium (Cavallazzi et al., 2012). One hypothesis is supported by the finding that patients that develop delirium experience a decrease in acetylcholine activity. Considering the anti-inflammatory properties of acetylcholine, it is hypothesized that a dysregulation between inflammatory and antiinflammatory mediators contributes to delirium (Hshieh, Fong, Marcantonio, & Inouye, 2008). DELIRIUM MANAGEMENT 9 Physiologic mechanisms of delirium must be considered in the context of other contributors to delirium in the ICU setting. Risk factors for delirium. Risk factors for delirium can be divided into predisposing factors and precipitating factors (Girard, Pandharipande, & Ely, 2008). In most cases, predisposing factors are present before the patient is admitted to the ICU. Predisposing factors include advanced age, alcoholism, dementia, hypertension and vision/hearing impairment (Zaal & Slooter, 2012). Although difficult to alter, an understanding of predisposing factors for delirium is essential for integration in delirium prevention and detection strategies in the ICU setting. Precipitating factors are those that occur during acute or critical illness and may have more potential for modification. Precipitating factors include acidosis, anemia, fever, hypotension, electrolyte disturbances and respiratory disease (Girard et al., 2008). Precipitating risk factors associated with treatment therapies and environmental exposures in the ICU have also been identified. These include sleep deprivation, sensory deficiency, noise pollution and immobility (Zaal & Slooter, 2012). Additionally, prolonged exposure to continuous sedative agents and mechanical ventilation have been independently associated with delirium development and progression (Balas et al., 2014). Detection and monitoring of ICU delirium. Considering the many factors that may contribute to cognitive impairment in the ICU setting, differentiating delirium from other psychological disturbances can be challenging for clinicians. Routine delirium screening in the intensive care unit is limited. A survey of 331 intensive care nurses in various hospital settings reported that, while routine sedation assessment was conducted 98% of the time, routine delirium assessment was performed only 47% of the time (Devlin et al., 2008). Subsequently, it is estimated that up to 75% of ICU delirium cases are missed when a validated screening tool is not DELIRIUM MANAGEMENT 10 used on a routine basis (Zaal & Slooter, 2012). With an understanding of the hallmarks of delirium including inattention and a fluctuating course, validated delirium assessment instruments have been developed. Based on current practice recommendations, validated instruments include The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) (Barr et al., 2013a). It is recommended that patients in the ICU be monitored daily for delirium using one of these instrument (Barr et al., 2013a). Over the past several years, the effectiveness of the CAM-ICU instrument in detecting delirium has been well documented and has superior sensitivity over the ICDSC (Ely E, Inouye SK, Bernard GR, & et al, 2001). Complications of ICU delirium. For many years, ICU delirium was regarded as an inconvenient and reversible effect of intensive care treatment. However, many short and long term effects of ICU delirium have been identified (Barr et al., 2013a). An increase in mortality has been independently associated with the development of delirium in the ICU (Barr et al., 2013a). Duration of delirium has also been associated with an increase in six and twelve month mortality following ICU discharge (Barr et al., 2013a). ICU length of stay is affected by the development of delirium with an average of 45 hours longer ICU stay for patients that develop delirium (Brown et al., 2016). Subsequently, hospital length of stay is affected which results in an increase in healthcare costs and places the patient at an increased risk for hospital-associated infections (Collinsworth et al., 2016). There is also a relation between delirium and long term cognitive impairment (Girard et al., 2010). However, much of this research has involved non-ICU patient populations. One prospective cohort study focused on persons that had spent at least one day in the ICU during their hospital stay. This study found that delirious patients experienced a greater severity of DELIRIUM MANAGEMENT 11 illness and more severe self-reported problems in cognitive function after discharge when compared to subjects who did not have delirium in the ICU (Wolters et al., 2014). Finally, duration of delirium has been significantly associated with six- and twelve-month mortality rates after adjusting for relevant covariates (Pisani et al., 2009). Current Delirium Management Recommendations Current delirium management guidelines advocate for a multicomponent approach to delirium management in the ICU setting (Barr et al., 2013a). Inouye et al. (1999), were among the first to study a multicomponent approach to delirium management in hospitalized patients. In the randomized controlled trial, 9.9% of patients that had received a multicomponent delirium prevention intervention developed delirium as compared to 15.0% in the control group. A metaanalysis conducted by Collinsworth et al. (2016) found that of 8 studies, 5 found that multicomponent care approaches were associated with significant reduction in delirium incidence and duration. The appropriateness of a multicomponent care approach for delirium management is supported by studies that implemented a singular delirium prevention strategy with minimal effect on the incidence and duration of delirium. Mehta et al. (2012) evaluated the effectiveness of a daily sedation vacation program as a sole intervention to reduce ICU length of stay and hospital length of stay with no significant difference between the two study groups. Care bundles have been proposed as a way to effectively execute a multicomponent delirium management strategy. A bundle is a group of individual practices often involving multiple disciplines that, when performed collectively, improve patient outcomes (Balas et al., 2014). The Awakening and Breathing Coordination, Delirium Monitoring/Management and Exercise/Mobility (ABCDE) bundle is one example of a multicomponent strategy with the purpose of implementing delirium management recommendations. One study involving 296 DELIRIUM MANAGEMENT 12 patients found that patients that received delirium management with an ABCDE bundle had nearly half the incidence of delirium with an odds ratio of 0.55 when compared to the control group with routine management (Balas et al., 2014). Nonpharmacological management strategies. Several nonpharmacological strategies are included in care bundles and multicomponent treatment strategies to manage delirium. Early mobilization has been included as a primary component in the prevention of delirium. Early mobility in the ICU has been found to contribute to reductions in the incidence of delirium, depth of sedation and hospital length of stay (Barr et al., 2013). Physical activity has several outcomes including a heightened awareness of surroundings, increased blood flow and glucose delivery to the brain resulting in improved cognitive function and reduced delirium (Hopkins & Spuhler, 2009). Sleep promotion strategies are recommended to prevent delirium. Several alterations in sleep have been associated with mechanical ventilation in the ICU. These alterations include changes in the total sleep time, sleep fragmentation with frequent arousals and awakenings and disruptions in circadian rhythm (Blissitt, 2016). Sleep disturbances are also a significant risk for non-ventilated ICU patients. Many interventions have been proposed to address sleep deprivation in the ICU including noise/light reduction, patient care clustering and scheduled rest time in the patient's treatment plan. A systematic review comprised of 832 ICU patients with delirium found that the placement of earplugs in the patient's room was associated with a relative risk of delirium of 0.59 when compared to the control group suggesting that sleep hygiene significantly contributes to delirium prevention (Litton, Carnegie, Elliott, & Webb, 2016). Routine patient orientation and the prevention of sensory deprivation can contribute to the reduction of delirium. These strategies may be as simple as assisting the patient with his/her DELIRIUM MANAGEMENT 13 glasses or hearing aids. A randomized controlled trial of 287 patients at high risk for developing delirium found that delirium occurred in 5.6% of the intervention group receiving a patient reorientation intervention compared to a 13.3% incidence of delirium in the control group receiving routine care (Martinez, Tobar, Beddings, Vallejo, & Fuentes, 2012). Pharmacologic management strategies. Current recommendations do not suggest that pharmacological agents be routinely given for prevention of delirium. The administration of Haldol has been proposed but is not recommended therapy for the prevention or treatment of ICU delirium (Barr et al., 2013a). A meta-analysis designed to identify pharmacological agents for delirium evaluated the effectiveness of acetylcholinesterase inhibitor administration for the prevention of post-operative delirium. Of the 242 patients tested, no significant change in delirium incidence was found between the two groups (Zhang et al., 2013). Rather than adding pharmacological agents to treat delirium, it is often advocated to reduce the patient's medication regimen. Thorough medication review and dosage minimization can reduce the risk of ICU delirium as a result of medications commonly prescribed in the ICU (Clegg & Young, 2011). It is also recommended that pain be assessed and managed in the adult ICU patient to reduce the incidence of delirium. Assessing pain can be difficult in patients that are mechanically ventilated and/or sedated. Several validated assessment tools exist. Patients that are capable of communication can quantify pain on a 0-10 scale. For patients that are unable to self-report pain, it is recommended that behavioral pain scales be used to assess pain (Barr et al., 2013a). Vital signs alone should not be used to assess pain as these may be affected by medications and other factors. In conjunction with non-pharmacological interventions, intravenous opioids should be considered as the first-line agent to treat non-neuropathic pain in the ICU patient (Barr et al., 2013a). Non-opioid medications are important adjuvants to reduce DELIRIUM MANAGEMENT 14 the total amount of opioids administered. Although inadequate pain management contributes to delirium, opioid pain medications have the potential to contribute to the development of delirium (Clegg & Young, 2011). This illustrates the risks of solely treating ICU delirium with pharmacologic agents and the importance of nonpharmacological approaches to delirium management. Like pain management, several agitation and sedation management strategies reduce the incidence and duration of delirium. It is recommended that depth of sedation be routinely monitored using a validated assessment tool. The Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are effective in determining the depth of sedation (Barr et al., 2013a). Spontaneous awake trials coupled with spontaneous breathing trials contribute to fewer ventilator days and reduced hospital length of stay (Balas et al., 2014). Nonbenzodiazepines are the sedative agents of choice. Non-benzodiazepine agents include propofol and dexmedetomidine (Balas et al., 2014). A meta-analysis of 415 patients found that dexmedetomidine sedation was associated with less than half the incidence of delirium when compared to sedation with benzodiazepines (Zhang et al., 2013). Benefits of Electronic Order Set Development Several considerations support the development of order sets in the electronic format. Included in the comprehensive pain, agitation and delirium management guidelines is the recommendation that an interdisciplinary ICU team approach be utilized that includes computerized protocols and order sets (Barr et al., 2013). This recommendation is consistent with the transition to electronic health record adoption with computerized provider order entry (CPOE) that is mandated by Meaningful Use requirement of the Health Information Technology for Economic and Clinical Health Act (Waldren & Solis, 2015). In conjunction with other DELIRIUM MANAGEMENT 15 Meaningful Use requirements, healthcare providers and inpatient facilities are required to record more than sixty percent of medication orders using CPOE in order to be eligible for the associated incentives (Waldren & Solis, 2015). Reduction in preventable adverse drug events. Several benefits have been identified of electronic order entry or CPOE including reductions in medication errors. A meta-analysis of sixteen studies addressing preventable adverse drug events as they relate to CPOE found that hospitals with CPOE implementation experienced a greater than 50% decline in preventable adverse drug events (Nuckols et al., 2014). Additionally, processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (Radley et al., 2013). These findings suggest that electronic order entry can improve patient safety and limit the occurrence of medication errors and adverse drug events. While electronic health record adoption with CPOE is often associated with provider and time consuming documentation, the potential patient harm reduction of electronic order entry cannot be overlooked. Reduction in hospital length of stay. Financial benefits of electronic order entry have also been identified. Most rigorously evaluated is the relationship between hospital length of stay and CPOE usage. Increase and decrease usage of CPOE inversely correlates with increase and decrease in average hospital length of stay (Schreiber & Shaha, 2016). Others have also identified this inverse relationship with one retrospective study finding that once CPOE adoption exceeds sixty percent, decreases in hospital length of stay accelerates more rapidly (Schreiber, Peters, & Shaha, 2014). As electronic health record adoption and CPOE adoption increases, the risk of harm and financial burden is decreased for patients. These findings support the development and implementation of ICU delirium electronic order sets in the hospital setting which is consistent with practice recommendations. 16 DELIRIUM MANAGEMENT Factors Associated with Delirium Guideline Adoption Barriers to delirium management adoption have been identified. Many ICU settings continue to employ sedation practices that are not aligned with the American College of Critical Care Medicine PAD guidelines. Patient management that involves heavy sedation with benzodiazepine medications can hinder delirium prevention measures. A prospective, cohort study with the objective of implementing an ABCDE bundle in ICU patient care found that, while patients in the post-bundle implementation period experienced more spontaneous awake trials, the total average daily dose of benzodiazepine sedative agents did not change between the pre- and post-bundle implementation period. This finding illustrates the challenges that ICU clinicians have in avoiding benzodiazepines for sedation purposes. Clinical staff perceptions regarding ICU delirium can be a barrier to guideline implementation. A study of providers and nurses found that while 97% of respondents felt that ICU delirium assessment was very important, only 10% could identify published guidelines for the management of ICU delirium. Furthermore, when given a list of three negative outcomes associated with delirium, only 37% of respondents were able to correctly identify all three (Cole & Stark, 2016). Knowledge gaps regarding the appropriate management and associated outcomes of ICU delirium supports poor compliance with multicomponent bundles that are intended to prevent and treat ICU delirium. Adoption of multicomponent care bundles can be challenging for multidisciplinary care teams. Contributors to poor adoption of delirium screening tools include time and lack of confidence in performing delirium assessment (Collinsworth et al., 2016). Resource allocation can be especially difficult when attempting to implement a progressive mobility program as part of a multicomponent care bundle (Carrothers et al., 2013). Additionally, fear of adverse events, 17 DELIRIUM MANAGEMENT communication and care coordination challenges, workload concerns and documentation burden are identified as barriers to adoption of a care bundle (Balas et al., 2014). Several facilitators contribute to successful delirium guideline adoption. Hospitals with an existing culture of quality improvement achieve higher and more reliable implementation of all components of the delirium care bundle (Carrothers et al., 2013). Sites with successful implementation of progressive early mobility strategies to prevent delirium have generous allocation of physical therapy resources in the ICU setting. Additionally, sites that utilize an electronic health record to document multicomponent interventions, viewable by all disciplines, were more successful at bundle implementation (Carrothers et al., 2013). Theoretical Framework For the purposes of this scholarly project, a conceptual model was adopted rather than a theoretical framework. The conceptual model chosen for this DNP scholarly project is the ACEStar Model. This conceptual model offers a comprehensive approach to the translation of evidence into practice. Five steps described in the model include: research discovery, evidence summary, translation into guidelines, practice integration, process/outcome evaluation (Stevens, 2013). Research discovery includes discovery of primary research studies. This transitions into the summarizing of evidence and compiling research into a comprehensive statement or finding. Guideline development is based upon the evidence summarized and includes practice recommendations with guideline adoption being a primary step in practice integration. Evaluation is the final step of the model and includes an evaluation of outcomes and process changes (Stevens, 2013). This DNP scholarly project is supported by the ACE-Star Model of Knowledge Transformation. Objectives of the project include research discovery, evidence summary and 18 DELIRIUM MANAGEMENT practice guideline development. Translating evidence into practice is a principle aspect of the proposed ICU delirium management guideline and electronic order set. It is proposed that these tools are integrated into practice at the site of project implementation. In addition to guideline and order set adoption, practice integration includes education for stakeholders involved in practice changes (Stevens, 2013). A training module for ICU nursing staff will assist with the integration of evidence summary into the practice of participating staff members. Implementation and Evaluation Following approval of the project proposal defense presentation (see Appendix A) to University of Utah faculty, an Institutional Review Board (IRB) inquiry was made at the University of Utah as well as the project site and was provided to the project chairperson for review. An IRB exemption determination statement (see Appendix B) was obtained at the University of Utah as well as the project site. Scholarly Project Objective One The first scholarly project objective was to propose an ICU delirium guideline for the management of delirium in the critically ill patient. Implementation of this objective included a literature review to identify current recommendations for delirium management. Validated delirium screening tools were recognized. Strategies for the treatment of acute delirium were also delineated. Evidence-based findings pertaining to acute delirium in the intensive care setting were formatted into a comprehensive delirium management guideline (see Appendix C). This guideline includes three key areas; delirium risk factor identification, validated delirium screening and evidence-based management of ICU delirium. Guideline development also included the incorporation of current evidence-based practices already adopted at the project site. DELIRIUM MANAGEMENT 19 The project site currently uses an electronic guideline and policy management system for all facility policies and guidelines. The policy management system is accessible through the facility intranet. Therefore, the management guideline was drafted using a template that is consistent with other guidelines in the policy management system. The delirium management guideline was proposed for adoption to the intensive care committee including; the ICU medical director, nursing administration, ICU clinical pharmacist and the director of the quality department. The project chairperson and content expert were also invited to attend the proposal. The proposal consisted of a brief explanation of ICU delirium including clinical significance and risk factors. Members of the committee were also provided with copies of the proposed guideline including a diagram illustrating the evidence-based pathways in delirium management (see Figure 1). The proposal included time for members of the committee to review the guideline and provide feedback. At the conclusion of the proposal, committee members were invited to proceed with guideline adoption. Evaluation of scholarly project objective one included the consensus of the content expert and project chairperson as to the methods of literature review and delirium management guideline development. The content expert and project chairperson approved the guideline draft prior to the proposal at the project site. The proposal was coordinated to ensure representation from various stakeholders involved in ICU care. Scholarly Project Objective Two The second objective of the scholarly project was to propose an electronic order set for ICU delirium management. Based on current practice guidelines, it is recommended that order sets be developed in an electronic format to increase the likelihood of order set adoption (Barr et al., 2013b). An electronic order set was developed (see Appendix D). The order set was based DELIRIUM MANAGEMENT 20 on the proposed delirium management guideline. Individual orders in the order set were divided into pharmacological and non-pharmacological delirium management categories. The order set also included nursing assessment and diagnostic tests related to the development of ICU delirium. The Informatics Department at the project site is responsible for the programming and approval of all of the facility electronic order sets. This department was utilized to assist with programming the order set in the electronic health record. Considerations for order set navigation and ease of use were evaluated to enhance the usability of the order set in the electronic format. The order set was published in the test environment of the electronic health record. The electronic order set was demonstrated at the ICU delirium guideline proposal to the ICU committee mentioned above. Members of the committee were invited to provide feedback on the electronic order set. At the conclusion of the demonstration, members of the ICU committee were invited to adopt the electronic order set. Evaluation of scholarly project object two included the evaluation of the delirium management order set by the content expert and project chairperson. The content expert and project chairperson approved the electronic order set prior to demonstration and proposal. Additionally, the electronic order set was approved by the director of informatics at the project site to be published in the test environment. Scholarly Project Objective Three Scholarly project objective three was to provide nursing staff with education regarding the clinical significance of ICU delirium. A brief education module for nursing staff was developed. A PowerPoint presentation was utilized to convey education module information (See Appendix E). Content for the training DELIRIUM MANAGEMENT 21 module included; risk factor identification, validated screening methods and pharmacological/non-pharmacological management considerations as they pertain to ICU delirium. Education module content also included short-term and long-term outcomes associated with ICU delirium. Nurses were invited to participate in the training module individually or in small groups. Additionally, a pre- and post-education questionnaire was developed (Appendix F, Appendix G) and was administered in conjunction with the educational module. The PowerPoint educational module was submitted to the facility Education Director for possible future training of ICU nurses. To evaluate scholarly project objective three, the training module content and pre- and post-education questionnaire was approved by the content expert and project chairperson with feedback included. Module feedback from nursing staff was evaluated using the pre- and posteducation questionnaire (See Appendix H). The education module was evaluated by the facility education director and was included for future training of ICU nursing staff. Scholarly Project Objective Four Objective four of the scholarly project was to disseminate information related to the scholarly project. A poster summarizing the project was developed (Seep Appendix I). The poster included a detail of the proposed ICU delirium management guideline. Findings from the ICU nurse education module were also included. A poster abstract was submitted for the 2017 Utah Valley University Annual Nursing Conference (Appendix J). The poster presentation was given at the conference. Evaluation of scholarly project objective four included abstract and poster presentation approval by project chairperson. The poster presentation was coordinated with a representative from the nursing conference and included pertinent details of the scholarly project and notable 22 DELIRIUM MANAGEMENT findings. The poster presentation was given during breakout sessions of the conference. Conference attendees were provided with information regarding delirium in the ICU patient population. Implementation and Evaluation Matrix Objective Implementation Evaluation Propose an ICU delirium guideline for the management of delirium in the critically ill patient Literature review was performed with current, evidenced-based management considerations identified. An ICU delirium management guideline was developed. The guideline was proposed to an ICU committee content expert and project chairperson evaluated literature review and management guideline with feedback included in the guideline. Propose an electronic order set for ICU delirium treatment The order set was based on the proposed delirium management guideline. The Informatics Department was utilized to program the order set in the electronic health record. The electronic order set was demonstrated and proposed for adoption to the ICU committee. Content expert and project chairperson evaluated the electronic order set with feedback included. The director of informatics approved the electronic order set in the test electronic medical record environment. Provide nursing staff with education regarding the clinical significance of ICU delirium. A PowerPoint training module along with a pre- and post-education questionnaire was developed. ICU nursing staff were invited to participate in the training module. The training module was submitted to the education director for possible future training of ICU nurses Pre- and post-education questionnaires evaluated. Feedback from education director for future ICU nurse training. Content expert and project chairperson evaluated the training module and survey method with feedback included in the module. Disseminate information related to A poster summarizing the project was developed. the scholarly project. A poster abstract was submitted to the 2017 Utah Valley University Annual Nursing Conference Submission of poster abstract was presented to project chairperson. 23 DELIRIUM MANAGEMENT Results Objective one was successfully competed with IRB exemption determination, literature review, development of the delirium management guideline and proposal of the guideline at the project site. A literature review was successfully conducted and a summary was provided the project chairperson for approval. The ICU delirium guideline was organized and developed with drafts submitted to the project chairperson and content expert. Feedback from these individuals was included in the ICU delirium guideline. The guideline proposal was coordinated with the ICU medical director and nursing director. Those in attendance also include the chief nursing officer, ICU clinical pharmacist and representatives from the quality department. At the conclusion of the proposal, members of this committee agreed to proceed with ICU delirium guideline adoption at the project site. Facilitators of objective one included the cooperation of the ICU committee and administrative staff at the project site. Coordinating multiple disciplines to participate in the guideline proposal involved a concerted effort on behalf of scheduling and meeting space coordinators. Objective two was successfully completed with content expert and project chairperson approval of the order set. Working with the informatics department at the project site, the order set was successfully programmed in the electronic health record test environment. The order set was also effectively demonstrated and proposed for adoption to the ICU committee. At the conclusion of the demonstration and proposal, members of this committee agreed to proceed with the adoption of the ICU delirium order set at the project site. An important facilitator of objective two was the cooperation of the director of informatics at the project site and the willingness of the informatics department staff to assist with order set programming within the electronic health record. A barrier to objective two included difficulty in coordinating with the DELIRIUM MANAGEMENT 24 order set specialist in the informatics department. Time constraints truncated the editing process within the electronic order set prior to demonstration and proposal. Objective three was successful through the development and administration of a nursing educational module. The module was administered at ICU staff meetings. ICU nurses that were unable to attend the staff meetings were offered the education on an individual basis. Pre- and post-education questionnaires were administered to twenty participating ICU nurses (n=20). Both questionnaires utilized a five-point Likert scale with 1 being the lowest and 5 being the highest response. The results of the pre-education questionnaire (Appendix H) revealed the following mean participant responses: familiarity with the current ACCM delirium management recommendations 2.15 ± 0.81; knowledge regarding ICU delirium risk factors 2.90 ± 0.97; knowledge regarding ICU delirium diagnostic criteria 2.65 ± 0.75; familiarity with performing the CAM-ICU 3.05 ± 0.89; understanding of appropriate actions to take for CAM-ICU positive patients 2.45 ± 0.89; ability to identify non-pharmacological delirium reduction strategies 2.65 ± 0.87; understanding of pharmacological considerations for ICU delirium 2.25 ± 0.64; satisfaction with the hospital's current procedure for managing ICU delirium 2.85 ± 0.74. Participants were also given the opportunity to comment on the hospital's current delirium reduction strategies. Comments obtained during the pre-education questionnaire included "We need better identification and diagnosis of delirium on the ICU", "When I notice delirium in my patients, I am not sure what steps to take", and "I have never received education about delirium". Following the educational module, nursing staff members were given the post-education questionnaire. The purpose of this questionnaire was to evaluate for improvement in knowledge regarding ICU delirium and to obtain feedback regarding the training module. The results of the post-education questionnaire (Appendix H) revealed the following mean participant responses: DELIRIUM MANAGEMENT 25 familiarity with the current ACCM delirium management recommendations 3.80 ± 0.52; knowledge regarding ICU delirium risk factors 4.05 ± 0.39; knowledge regarding ICU delirium diagnostic criteria 3.85 ± 0.67; familiarity with performing the CAM-ICU 4.05 ± 0.69; understanding of appropriate actions to take for CAM-ICU positive patients 3.95 ± 0.60; ability to identify non-pharmacological delirium reduction strategies 4.0 ± 0.56; understanding of pharmacological considerations for ICU delirium 3.95 ± 0.60. Participants were also given the opportunity to comment on the delirium reduction strategies discussed in the module. Comments obtained during the post-education questionnaire included "It's good to know that things are being done to make this clearer", "I am now more familiar with Delirium", and "We need a dedicated portion of multi-disciplinary rounds to discuss this topic". Questionnaire respondents also expressed satisfaction with the module. The composite mean questionnaire response for satisfaction with the educational module was 4.45 ± 0.60. Composite mean scores were improved in all post-education questionnaire categories when compared to the pre-education questionnaire scores. Objective three was also successfully competed with the adoption of the education module to be used for future nurse education at the project site. This was approved by the facility education director as well as the nursing educator for the ICU. Objective four was successfully completed by submitting the project results and nursing conference poster abstract to the project chairperson. The poster presentation was successfully given at the Utah Valley University Annual Nursing Conference. Barriers to the success of objective four included an accelerated implementation phase with a consideration that the poster presentation at the Utah Valley University Nursing Conference was approximately three weeks DELIRIUM MANAGEMENT 26 prior to the scholarly project poster deadline. However, this timeline did not impede the project implementation or project results. Positive Unintended Consequences Prior to the implementation of this scholarly project, ICU nursing staff were already performing delirium screenings using the CAM-ICU. This project was intended to build upon the current practices of delirium screening by identifying evidence-based pathways for the management of delirium. After providing the educational module to nursing staff, several nurses commented on the increased awareness that they now have regarding the clinical significance of ICU delirium. Many of them reported that they plan to take the delirium screening process more seriously and improve screening competence. Improving screening competence will likely enhance early recognition and early treatment interventions for patients that have delirium. Additionally, providers and multidisciplinary teams will likely have more accurate delirium screening data to make the most appropriate treatment decisions. Another positive unintended consequence was the unexpected evaluation and feedback from Dr. Wes Ely. Dr. Ely was the co-developer of the CAM-ICU tool and has conducted extensive research on awake/breathing coordination, delirium reduction and ICU liberation strategies. Dr. Ely provided positive feedback on the delirium guideline and electronic order set with the feedback included in the final drafts of the proposed guideline and electronic order set. Limitations Nursing staff education was limited as a result of low turnout to ICU staff meetings. While all ICU nursing staff were invited to participate in the educational module, scheduling conflicts and other demands inhibited the ability to provide the education to all ICU nursing staff. This project was limited to the development and proposal of an ICU delirium management 27 DELIRIUM MANAGEMENT guideline and electronic order set. While delirium has been described in other inpatient hospital settings, this project was limited to the ICU patient population. Delirium management strategies may vary in non-ICU hospital settings depending on published practice recommendations. Measuring change in ICU delirium incidence and duration following guideline adoption was not explored in this project. Additionally, provider responses regarding the use of the electronic order set were not identified in this project. Recommendations This project has demonstrated that a delirium management guideline and electronic order set can successfully be adopted building upon established evidence-based practices at the project site. This project could be expanded by measuring the outcomes following guideline and order set adoption. These outcomes would include changes in ICU delirium incidence and duration. Additionally, provider usability of the electronic order set could be measured. While the electronic order set was programmed into the electronic health record specific to the project site. Variations of the same order set may be developed in other electronic health records. This would expand the reach of the order set to other facilities and require the involvement of informatics representatives at those sites. Doctorate of Nursing Practice (DNP) Essentials In 2006 The American Association of Colleges of Nursing(AACN) established the essentials for the education of doctoral prepared advanced practice nurses. Doctorate of nursing practice (DNP) essentials supported by this project include Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice and Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care. An objective of this DNP Essential III is the recognition of clinical scholarship in 28 DELIRIUM MANAGEMENT nursing practice and the application of research into practice (Hathaway et al, 2006). A primary function of this DNP project is the integration of evidence-based recommendations as they pertain to the diagnosis and treatment of delirium in the adult intensive care setting. Another function of this project supported by DNP Essential III is the dissemination of evidence-based treatment strategies through education and guideline development (Hathaway et al, 2006). As proposed by the AACN, the DNP graduate is prepared to apply information systems/ technology applications. Scholarly project objective two is supported by DNP Essential IV through the development of an ICU delirium electronic order set. The electronic order set utilizes the electronic health record to increase the ease and convenience of multi-component treatment approaches for ICU delirium. Implementing information systems in the clinical setting is an important role of the doctorate prepared advanced practice nurse. Conclusion ICU delirium is the most common acute brain dysfunction in the ICU patient population. Patients diagnosed with delirium are at an increased risk for mortality, hospital length of stay and long term impairments in cognitive functioning. Validated screening tools and evidence-based treatment considerations for ICU delirium have been identified by the American College of Critical Care Medicine. As discussed, adoption of comprehensive delirium management guidelines has been limited in many ICU settings. While many cases of ICU delirium go undiagnosed, there is often a general misunderstanding among ICU multidisciplinary teams regarding evidence-based treatment options for delirium in the ICU. Prior to this scholarly project, the project site had adopted a practice of screening for ICU delirium. However, there was no guideline adopted to intervene for patients that have positive screening results. DELIRIUM MANAGEMENT 29 The purpose of this scholarly project was to promote the adoption of an ICU delirium management guideline, electronic order set and provide ICU delirium education. The project site now has an adopted guideline for the management of ICU delirium following the implementation of this scholarly project. Additionally, providers have the ability to access an electronic order set specifically designed for ICU delirium management. Nursing staff knowledge of ICU delirium also improved as a result of this scholarly project. Despite the success of this project, ongoing efforts must be made to improve the diagnosis and management of delirium in the ICU. Going forward, ICU staff and providers should have a clear understanding of the diagnostic risk factors, disease burden and treatment options available to them. Improving the practices of diagnosis and treatment of ICU delirium begins the process of reducing the incidence and duration of delirium in the ICU. 30 DELIRIUM MANAGEMENT References Balas, M. C., Vasilevskis, E. E., Olsen, K. M., Schmid, K. K., Shostrom, V., Cohen, M. Z., … Burke, W. J. (2014). Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle*: Critical Care Medicine, 42(5), 1024-1036. https://doi.org/10.1097/CCM.0000000000000129 Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., … Jaeschke, R. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit: Critical Care Medicine, 41(1), 263-306. https://doi.org/10.1097/CCM.0b013e3182783b72 Blissitt, P. A. (2016). Sleep and Mechanical Ventilation in Critical Care. Critical Care Nursing Clinics of North America, 28(2), 195-203. https://doi.org/10.1016/j.cnc.2016.02.002 Brown, C. H., Laflam, A., Max, L., Lymar, D., Neufeld, K. J., Tian, J., … Hogue, C. W. (2016). The Impact of Delirium After Cardiac Surgical Procedures on Postoperative Resource Use. The Annals of Thoracic Surgery, 101(5), 1663-1669. https://doi.org/10.1016/j.athoracsur.2015.12.074 Carrothers, K. M., Barr, J., Spurlock, B., Ridgely, M. S., Damberg, C. L., & Ely, E. W. (2013). Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs: Critical Care Medicine, 41, S128-S135. https://doi.org/10.1097/CCM.0b013e3182a2c2b1 Cavallazzi, R., Saad, M., & Marik, P. E. (2012). Delirium in the ICU: an overview. Annals of Intensive Care, 2, 49. https://doi.org/10.1186/2110-5820-2-49 DELIRIUM MANAGEMENT 31 Clegg, A., & Young, J. B. (2011). Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing, 40(1), 23-29. https://doi.org/10.1093/ageing/afq140 Cole, J. L., & Stark, J. E. (2016). Provider and Nursing Perceptions and Practices: Gap Analysis for ICU Delirium Protocol Implementation. Journal of Intensive Care Medicine. https://doi.org/10.1177/0885066616654466 Collinsworth, A. W., Priest, E. L., Campbell, C. R., Vasilevskis, E. E., & Masica, A. L. (2016). A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. Journal of Intensive Care Medicine, 31(2), 127-141. https://doi.org/10.1177/0885066614553925 Devlin, J. W., Fong, J. J., Howard, E. P., Skrobik, Y., McCoy, N., Yasuda, C., & Marshall, J. (2008). Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care, 17(6), 555-565. Ely E, Inouye SK, Bernard GR, & et al. (2001). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (cam-icu). JAMA, 286(21), 2703-2710. https://doi.org/10.1001/jama.286.21.2703 Girard, T. D., Jackson, J. C., Pandharipande, P. P., Pun, B. T., Thompson, J. L., Shintani, A. K., … Wesley Ely, E. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness: Critical Care Medicine, 38(7), 1513-1520. https://doi.org/10.1097/CCM.0b013e3181e47be1 Girard, T. D., Pandharipande, P. P., & Ely, E. W. (2008). Delirium in the intensive care unit. Critical Care, 12(Suppl 3), S3. https://doi.org/10.1186/cc6149 Hopkins, R. O., & Spuhler, V. J. (2009). Strategies for promoting early activity in critically ill mechanically ventilated patients. AACN Advanced Critical Care, 20(3), 277-289. DELIRIUM MANAGEMENT 32 Hshieh, T. T., Fong, T. G., Marcantonio, E. R., & Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 63(7), 764-772. Litton, E., Carnegie, V., Elliott, R., & Webb, S. A. R. (2016). The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine, 1. https://doi.org/10.1097/CCM.0000000000001557 Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and Ageing, 41(5), 629-634. https://doi.org/10.1093/ageing/afs060 Nuckols, T. K., Smith-Spangler, C., Morton, S. C., Asch, S. M., Patel, V. M., Anderson, L. J., … Shekelle, P. G. (2014). The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic Reviews, 3(1), 1. Pisani, M. A., Kong, S. Y. J., Kasl, S. V., Murphy, T. E., Araujo, K. L. B., & Van Ness, P. H. (2009). Days of Delirium Are Associated with 1-Year Mortality in an Older Intensive Care Unit Population. American Journal of Respiratory and Critical Care Medicine, 180(11), 1092-1097. https://doi.org/10.1164/rccm.200904-0537OC Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association, 20(3), 470-476. https://doi.org/10.1136/amiajnl-2012-001241 DELIRIUM MANAGEMENT Schreiber, R., Peters, K., & Shaha, S. H. (2014). Computerized Provider Order Entry Reduces Length of Stay in a Community Hospital: Applied Clinical Informatics, 5(3), 685-698. https://doi.org/10.4338/ACI-2014-04-RA-0029 Schreiber, R., & Shaha, S. H. (2016). Computerised Provider Order Entry Adoption Rates Favourably Impact Length of Stay. Journal of Innovation in Health Informatics, 23(1), 459. https://doi.org/10.14236/jhi.v23i1.166 Stevens, K. R. (2013). The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas. Online Journal of Issues in Nursing, 18(2), 1-1. https://doi.org/10.3912/OJIN.Vol18No02Man04 Waldren, S. E., & Solis, E. (2015). The Evolution of Meaningful Use: Today, Stage 3, and Beyond. Family Practice Management, 23(1), 17-22. Wolters, A. E., van Dijk, D., Pasma, W., Cremer, O. L., Looije, M. F., de Lange, D. W., … Slooter, A. J. (2014). Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study. Critical Care, 18(3), 1. Zaal, I. J., & Slooter, A. J. C. (2012). Delirium in Critically I11 Patients: Epidemiology, Pathophysiology, Diagnosis and Management. Drugs, 72(11), 1457-1471 15p. Zhang, H., Lu, Y., Liu, M., Zou, Z., Wang, L., Xu, F.-Y., & Shi, X.-Y. (2013). Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials. Critical Care, 17(2), 1. 33 DELIRIUM MANAGEMENT Figure 1. Delirium Management Guideline. 34 DELIRIUM MANAGEMENT Appendix A DNP Project Proposal PowerPoint Presentation 35 DELIRIUM MANAGEMENT 36 DELIRIUM MANAGEMENT 37 DELIRIUM MANAGEMENT 38 DELIRIUM MANAGEMENT 39 DELIRIUM MANAGEMENT 40 DELIRIUM MANAGEMENT 41 DELIRIUM MANAGEMENT 42 DELIRIUM MANAGEMENT Appendix B Institutional Review Board (IRB) Exemption 43 44 DELIRIUM MANAGEMENT University of Utah IRB Correspondence From: Ann Johnson Sent: Wednesday, October 05, 2016 1:29 PM To: MATTHEW WAYNE JARVIS Subject: Re: IRB Approval for DNP Project Hi Matthew, Because you will not be studying human subjects or data about them, you would not need IRB approval for this project. If you have any other questions, please let me know. Best, Ann Ann Johnson, PhD, MPH IRB Associate Director University of Utah 801-587-9134 [e-mail] www.irb.utah.edu Project Site IRB Correspondence November 15, 2016 Dear Matthew, Your request for review of the above mentioned research has been reviewed by members of the Timpanogos Regional Hospital Institutional Review Board (IRB). It has been determined that the project does not qualify for IRB oversight. However, we would be interested in reviewing the results of the project. Sincerely, Paula Strasburg RN, MSN IRB Chair Timpanogos Regional Hospital Institutional Review Board 45 DELIRIUM MANAGEMENT Appendix C Delirium Management Guideline 46 DELIRIUM MANAGEMENT Timpanogos Regional Hospital Guideline Guideline: Intensive Care Unit (ICU): Delirium Management Date of Approval: Date of Revision: I. SCOPE: ICU RNs, ICU Physicians, ICU Advanced Practice Clinicians, ICU Multidisciplinary Team II. PURPOSE: To establish evidence-based pathways for the assessment and management of delirium in the intensive care unit with the objective of reducing the incidence and duration of ICU delirium. To outline the procedure for delirium risk factor identification, screening practices, nonpharmacological delirium reduction strategies and pharmacological considerations provided in the ICU Delirium Management Order Set. III. DEFINITION Delirium (Acute Brain Dysfunction) is a disturbance of consciousness characterized by inattention along with altered level of consciousness and/or perceptual disturbances that develops over a short period of time (hours to days) and fluctuates over time. IV. PROCEDURE Delirium Risk Factor Identification Upon admission to ICU, and with any change in cognitive function, consider predisposing risk factors associated with ICU delirium (preexisting dementia, history of hypertension and/or alcoholism, mechanical ventilation and a high severity of illness upon ICU admission). During the medication reconciliation process, the patient's medications should be reviewed to identify any medications that contribute to delirium (benzodiazepines, analgesics, anticholinergics, psychoactive agents, etc). Assessment of Delirium All ICU patients will be assessed for delirium by the RN using the Confusion Assessment Monitor-Intensive Care Unit (CAM-ICU) screening tool. CAM-ICU is to be performed upon ICU admission, at least once per shift and prn with any change in cognitive function. Results of the CAM-ICU screening will be discussed during nurse hand-off communication and reported during ICU multidisciplinary team rounds. For mechanically ventilated ICU patients, CAM-ICU screening will be performed in conjunction with the Richmond Agitation-Sedation Scale (RASS) assessment as well as spontaneous breathing trial/spontaneous awake trial practices as established by facility policy (See TRH Protocol: Spontaneous Awakening Trial and Spontaneous Breathing Trial). Prevention and Treatment of Delirium CAM-ICU Negative DELIRIUM MANAGEMENT 47 If the patient is CAM-ICU negative (non-delirious) with no change in cognitive function throughout the shift, CAM-ICU assessment will be completed by the RN again the following shift. As ordered or as appropriate for patients with predisposing risk factors, the RN will implement the NPDRS (non-pharmacological delirium reduction strategies) outlined in STEP 2 and treat the patient for pain and anxiety PRN. CAM-ICU Positive If the patient has a new CAM-ICU positive (delirious) result, the RN will notify the physician and/or advanced practice clinician and proceed to STEP 1 and STEP 2. If the patient remains positive after STEP 1 and STEP 2, proceed to STEP 3. STEP 1- Identify precipitating causes of delirium: Examples Include: • Immobility • Sleep Disturbances • Noise Pollution • Acidosis • Anemia • Hypotension • Electrolyte Disturbances • Respiratory Disease STEP 2- In addition to identifying possible causes of delirium, the RN will implement the following NPDRS (Non-Pharmacological delirium reduction strategies) as appropriate or as ordered by the physician/advanced practice clinician Note: NPDRS may be inappropriate in the following situations: Sedation infusion for active seizures, sedation infusion for alcohol withdrawal, evidence of myocardial ischemia in the last 24 hours, ICP > 20 mm Hg or on sedative to control ICP, paralytic agents, open chest/abdomen, end of life care Non-Pharmacological Delirium Reduction Strategies (NPDRS) Minimize risk factors: • In coordination with the multidisciplinary team, maximize mobility with the implementation of progressive mobilization strategies (ROM/sit/dangle/chair/ambulate), avoid physical & chemical restraints • Avoid high risk medications if possible • prevent/promptly treat infections, dehydration, electrolyte imbalances • Provide adequate pain control (See TRH Policy: Pain AssessmentReassessment and Management of Acute Pain) DELIRIUM MANAGEMENT 48 Maximize oxygen delivery (supplemental O2, blood pressure support, etc.) • Assist with sensory aids including glasses and hearing aids • Normalize bowel/bladder function • Provide adequate nutrition Promote Orientation: • Utilize easily visible calendars, clocks, caregiver identification badges. Frequently reorient the patient with every interaction and explain activities and procedures clearly. • Provide appropriate sensory stimulation with adequate lighting and noise reduction strategies. • Facilitate sleep hygiene with noise reduction and care clustering as feasible throughout the evening hours. Provide earplugs and relaxation techniques as appropriate. • Encourage family interaction by facilitating family presence including familiar objects from home in daily routines and minimizing relocation of the patient • Minimize invasive procedures and discontinue invasive devices as soon as clinically appropriate (e.g. urinary catheters, central lines) • STEP 3- If the patient remains CAM-ICU positive after STEPS 1 and 2, perform RASS (Richmond Agitation Sedation Scale) assessment if not previously performed and consider pharmacological interventions. Evidence-based practice recommendations advocate pain/agitation/sedation optimization before administering pharmacological agents to treat ICU delirium. (Target RASS for ICU patients is -2 to 0) CAM-ICU positive and RASS score +2 to +4: Assess pain using the numeric rating scale or CPOT (Critical Care Pain Observation Tool) as outlined in facility policy (See TRH Policy: Pain Assessment-Reassessment and Management of Acute Pain). If patient is experiencing pain, treat pain per provider order. Discuss RASS optimization with provider. Dexmedetomidine is preferred over benzodiazepines for sedation unless contraindicated (i.e. alcohol withdrawal). CAM-ICU positive and RASS score 0 to +1: Ensure adequate pain control as outlined above. Discuss RASS optimization with provider. CAM-ICU positive and RASS score -3 to -1: Reassess target sedation goal per provider orders. Consider pharmacological adjunctive strategies if NPDRS unsuccessful RASS score -5 to -4 (Unable to complete CAM-ICU assessment) For patients receiving sedatives or analgesics- Assess need for deep sedation. If deep sedation required, obtain provider orders for DELIRIUM MANAGEMENT 49 appropriate target RASS. If deep sedation is not required, wean sedatives medications until target RASS is met. Perform CAM-ICU when RASS is -3 or above For patients not receiving sedatives or analgesics: Reassess RASS as established in facility policy. Perform CAM-ICU when RASS is -3 or above. Reference Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., … Jaeschke, R. (2013b). Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit: Critical Care Medicine, 41(1), 263-306. https://doi.org/10.1097/CCM.0b013e3182783b72 DELIRIUM MANAGEMENT Appendix D Delirium Management Electronic Oder Set 50 DELIRIUM MANAGEMENT 51 DELIRIUM MANAGEMENT 52 53 DELIRIUM MANAGEMENT Appendix E ICU Nursing Education Module DELIRIUM MANAGEMENT 54 DELIRIUM MANAGEMENT 55 DELIRIUM MANAGEMENT 56 DELIRIUM MANAGEMENT 57 DELIRIUM MANAGEMENT 58 59 DELIRIUM MANAGEMENT Appendix F Pre-education Questionnaire 60 DELIRIUM MANAGEMENT Pre-Education Nursing Questionnaire Intensive Care Unit (ICU) Delirium Please answer the following questions as accurately as possible. 1. How would you rate your familiarity with the current American College of Critical Care Medicine ICU delirium management recommendations? Very poor 1 2. Poor 2 Average 3 Good 4 Very Good 5 How would you rate your knowledge regarding ICU delirium risk factors? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 3. How would you rate your knowledge regarding ICU delirium diagnostic criteria? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 4. How would you rate your familiarity with performing the Confusion Assessment Monitor-ICU (CAM-ICU) delirium screening tool? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 5. How would you rate your understanding of appropriate actions to take when a patient has a positive CAM-ICU score? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 6. How would you rate your ability to identify appropriate nonpharmacological delirium reduction strategies for the ICU? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 61 DELIRIUM MANAGEMENT 7. How would you rate your understanding of when pharmacological agents may be considered for patients with a positive CAM-ICU score? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 8. What comments do you have regarding the hospital's current procedure for delirium reduction in the intensive care unit? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 9. How satisfied are you with the hospital's current procedure for managing delirium in the intensive care unit? Very Dissatisfied 1 Dissatisfied 2 Neutral 3 Satisfied 4 Very Satisfied 5 10. What comments do you have regarding your knowledge of identifying and managing delirium in the ICU? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 62 DELIRIUM MANAGEMENT Appendix G Post-education Questionnaire 63 DELIRIUM MANAGEMENT Post-Education Nursing Questionnaire Intensive Care Unit (ICU) Delirium Please answer the following questions as accurately as possible. 1. How would you rate your familiarity with the current American College of Critical Care Medicine ICU delirium management recommendations? Very poor 1 2. Poor 2 Average 3 Good 4 Very Good 5 How would you rate your knowledge regarding ICU delirium risk factors? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 3. How would you rate your knowledge regarding ICU delirium diagnostic criteria? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 4. How would you rate your familiarity with performing the Confusion Assessment Monitor-ICU (CAM-ICU) delirium screening tool? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 5. How would you rate your understanding of appropriate actions to take when a patient has a positive CAM-ICU score? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 6. How would you rate your ability to identify appropriate nonpharmacological delirium reduction strategies for the ICU? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 64 DELIRIUM MANAGEMENT 7. How would you rate your understanding of when pharmacological agents may be considered for patients with a positive CAM-ICU score? Very poor 1 Poor 2 Average 3 Good 4 Very Good 5 8. What comments do you have regarding the delirium management strategies discussed in the presentation? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 9. How satisfied are you with the presentation on ICU delirium? Very Dissatisfied 1 Dissatisfied 2 Neutral 3 Satisfied 4 Very Satisfied 5 10. What comments do you have regarding the presentation? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ DELIRIUM MANAGEMENT Appendix H Pre- and Post-education Questionnaire Results 65 66 DELIRIUM MANAGEMENT Pre-Education Nursing Questionnaire Responses QUESTION MEAN SD 1 2.15 0.813 2 2.90 0.968 3 2.65 0.745 4 3.05 0.887 5 2.45 0.887 6 2.65 0.875 7 2.25 0.639 8 2.85 0.745 Composite 2.62 Post-Education Nursing Questionnaire Responses QUESTION MEAN SD 1 3.80 0.523 2 4.05 0.394 3 3.85 0.671 4 4.05 0.686 5 3.95 0.605 6 4.00 0.562 7 3.95 0.605 8 Composite 4.45 4.01 0.605 67 DELIRIUM MANAGEMENT Appendix I DNP Project Poster DELIRIUM MANAGEMENT 68 DELIRIUM MANAGEMENT Appendix J Utah Valley University Nursing Conference Abstract 69 DELIRIUM MANAGEMENT 70 Poster Abstract Submittal for the 2017 UVU Nursing Conference Delirium is a cognitive impairment that includes an altered level of consciousness, disorganized thinking and inattention. Hospitalized patients, especially those critically ill, are at an increased risk for developing acute delirium during the hospital stay. Delirium in the intensive care unit (ICU) has often been considered an unavoidable aspect of the complex care provided in the ICU setting. However, delirium in the intensive care unit is recognized as an independent contributor to several adverse outcomes. These adverse outcomes include an increase in mortality, hospital length of stay and long-term cognitive impairment following discharge from the hospital. Subsequently, the financial burden associated with the management of delirium in the ICU can be significant. While comprehensive delirium management practice recommendations have been published by the American College of Critical Care Medicine, implementation of these recommendations has been limited in many rural and community hospital settings. The purpose of this scholarly project is to promote the adoption of a delirium management guideline and electronic order set in the adult intensive care unit at a community hospital. There are four objectives of this scholarly project: 1) Develop an intensive care unit delirium guideline for the management of delirium in the critically ill patient. 2) Develop an electronic order set for intensive care unit delirium treatment. 3) Provide nursing staff with education regarding the clinical significance of intensive care unit delirium. 4) Disseminate information related to the scholarly project. Based upon the body of evidence, and incorporating published practice recommendations, the proposal of an ICU delirium management guideline and electronic order set will outline consistent and comprehensive management of delirium for adult intensive care patients.