Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds

Abstract

Delirium is a key quality metric identified by The Society of Critical Care Medicine for intensive care unit (ICU) patients. If not recognised early, delirium can lead to increased length of stay, hospital and societal costs, ventilator days and risk of mortality. Clinical practice guidelines recommend ICU patients be assessed for delirium at least once per shift. An initial audit at our urban tertiary care hospital in Illinois, USA determined that delirium assessments were only being performed 31% of the time. Nurses completed simulation based education and were trained using delirium screening videos. After the educational sessions, delirium documentation increased from 40% (12/30) to 69% (41/59) (two-proportion test, p<0.01) for dayshift nurses and from 27% (8/30) to 61% (36/59) (two-proportion test, p<0.01) during the nightshift. To further increase the frequency of delirium assessments, the delirium screening tool was standardised and a critical care progress note was implemented that included a section on delirium status, management strategy and discussion on rounds. After the documentation changes were implemented, delirium screening during dayshift increased to 93% (75/81) (two-proportion test, p<0.01). Prior to this project, physicians were not required to document delirium screening. After the standardised critical care note was implemented, documentation by physicians was 95% (106/111). Standardising delirium documentation, communication of delirium status on rounds, in addition to education, improved delirium screening compliance for ICU patients.

Implementing delirium screening in the emergency department: a quality improvement project

“… 11 Research has also shown that education and training alone does not ensure knowledge and implementation and that it is suboptimal to sustain screening long term. 12 This provides support for interventions to be multifaceted. Further evidence for multifaceted interventions is supported by research into healthcare change, which found that interventions based on actions such as audit, feedback and reminders and education are more likely to succeed.…”

Implementation of a multiprofessional, multicomponent delirium management guideline in two intensive care units, and its effect on patient outcomes and nurse workload: a pre-post design retrospective cohort study

“…With the involvement of interprofessional teams at the unit or clinic, we aimed to support this cultural change via adaptation, where appropriate, of the relevant processes. With regard to the overall success of an implementation, the importance of involving all relevant stakeholders, including senior leaders and frontline providers, is supported by the results of other studies and quality improvement projects that use Lean Sigma methodology [37]. Since a cultural change requires time, our chosen time-frame might simply have been too short to show an effect in the expected direction.…”

A Delirium Monitoring Program for Hospitalized Older Adults: An Approach to Age-Friendly Health Systems

“…A different study confirmed that the use of these educational methods improved the rates of delirium screening by nurses when incorporated into standard daily nursing practice [42]. In addition to education, the standardization of delirium screening documentation and communication of delirium status to clinicians increases delirium screening by dayshift nurses to as high as 93% [43]. An implementation strategy used in another study focused on identifying probable barriers and facilitators for screening via medical staff interviews, resulting in significantly improved screening, from 77% to 92% [44].…”