Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients

Abstract

Objective-To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients.Design and setting-Prospective, observational study in a Level 1 trauma unit of a tertiary care, university-based medical center. Measurements and Results-Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond AgitationSedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU, in order to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period, the nurses completed a post-implementation survey. Patients-AcutelyOne thousand and eleven random CAM-ICU assessments were performed by the expert evaluator, within 1 hour of the bedside nurses' assessments. Nurses completed the CAM-ICU assessments in 84% (849 of 1011) of evaluations. Overall agreement ( ) between nurses and the expert evaluator was 0.77 (0.721, 0.822; p<0.0001). In TBI patients was 0.75 (0.667, 0.829; p<0.0001), while in mechanically-ventilated patients was 0.62 (0.534, 0.704; p<0.0001). The survey revealed nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training they received. The survey also acknowledged obstacles to Conclusions-The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.

Impact of a Delirium Screening Tool and Multifaceted Education on Nurses’ Knowledge of Delirium and Ability to Evaluate It Correctly

“…17,25,30,37,38 However, by combining these components as 1 intervention, the relative impact of implementing a delirium screening tool or various intensities of education about its use on the ability of nurses to evaluate delirium correctly remains unknown. Because the symptoms of delirium that the CAM-ICU and the ICDSC evaluate differ, one cannot extrapolate results from studies using the CAM-ICU to results of studies using the ICDSC.…”

“…[5][6][7][8][9][10][11][12][13][14][15][16] However, despite an increasing awareness among ICU clinicians regarding the sequelae of delirium and the ever-increasing use of protocols for delirium screening efforts in ICUs, most patients admitted to ICUs are not routinely screened for delirium. [17][18][19][20][21][22][23] Common barriers to delirium screening with a validated tool reported by clinicians include the perceptions that the tool takes too long to complete, that use of a tool does not enhance clinicians' ability to recognize delirium, and that assessment tools are too complex to use. [22][23][24] delirium.…”

“…[24][25][26][27] Pharmacists play a key role in optimizing the care of patients in the ICU and may be well suited to spearhead ICU delirium detection and education efforts, given pharmacists' daily presence in the ICU, their experience in optimizing sedation therapy, and their involvement with delirium recognition and prevention efforts. 8,17,23,28 Although a number of reports describe delirium screening efforts in medical or mixed medical-surgical ICUs, few studies have described the implementation of delirium screening efforts in STICUs. 17,18,[24][25][26][27]29,30 Furthermore, although results of studies on the impact of using a validated delirium screening tool, accompanied by education surrounding its use, on the ability of ICU nurses to recognize delirium have been published, the relative impact of each of these interventions on the knowledge of nurses about delirium and their ability to evaluate delirium remains unknown.…”

“…8,17,23,28 Although a number of reports describe delirium screening efforts in medical or mixed medical-surgical ICUs, few studies have described the implementation of delirium screening efforts in STICUs. 17,18,[24][25][26][27]29,30 Furthermore, although results of studies on the impact of using a validated delirium screening tool, accompanied by education surrounding its use, on the ability of ICU nurses to recognize delirium have been published, the relative impact of each of these interventions on the knowledge of nurses about delirium and their ability to evaluate delirium remains unknown. We therefore sought to measure the impact of using the ICDSC, with or without a multifaceted education program led by a pharmacist and a nurse, on the knowledge and perceptions of STICU nurses about delirium and their ability to evaluate delirium correctly.…”

Implications of Objective vs Subjective Delirium Assessment in Surgical Intensive Care Patients

“…We did not intend to assess the performance of nursing staff with the CAM-ICU; this topic has been covered in other studies. [35][36][37][38] Rather, we wished to elucidate the manifestitations that led nurses to rate patients as having delirium although the patients for discrepancies between subjective assessments of delirium and the CAM-ICU; the CAM-ICU was the a priori determined operational reference standard. A major finding was that subjective assessment indicated a higher rate of delirium than the CAM-ICU did.…”