Reducing Delirium In Post-Surgical Patients Through Pre-Operative Risk Assessment Screening: A Policy Option, Skye Porter Berg Msn, Fnp

Doctor of Nursing Practice Final Manuscripts

One of the major complications and reasons for prolonged stay amongst patients who undergo surgery is related to the occurrence of hospital associated delirium. Unfamiliar environment, previous comorbidities, age and anesthesia can alter and affect cognitive status in the general population. While there is substantial evidence previously listing high risk patients through demographics as well as prior medical history, this study collectively gathers information based upon prior evidence-based practice data to determine the benefit of prescreening patients through use of a predictive indicator tool. Based on the literature review and inclusion data gathered from fifty patients undergoing surgery, it was …

Using The Confusion Assessment Method For The Intensive Care Unit (Cam-Icu) To Decrease Length Of Stay: A Scoping Review, Brooke D. Ward Bsn, Rn, Dnp Agacnp Student, Martina Little Bsn, Rn, Dnp Agacnp Student, Tracy Mcclinton Dnp, Agacnp-Bc, Aprn

Doctor of Nursing Practice Projects

Purpose/Background

Delirium is a prevalent challenge among ICU patients, impacting approximately 30% of admissions (Brennan et al., 2023). If left untreated, delirium can increase use of restraints, hospital length of stay, intensive care unit length of stay, and ultimately, morbidity and mortality. This scoping review assesses the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) to gauge its efficacy in reducing the length of stay in the ICU for adult patients with delirium.

Methods

A literature review from 2018 and 2023, using PubMed, CINAHL, and Medline were utilized for the search along with key words such as: length of …

Sleep And Circadian Biomarkers Of Postoperative Delirium (Sleep-Pod): Protocol For A Prospective And Observational Cohort Study, Elizabeth Sugg, Elizabeth Gleeson, Sarah N Baker, Peng Li, Chenlu Gao, Ariel Mueller, Hao Deng, Shiqian Shen, Esteban Franco-Garcia, Richa Saxena, Erik S Musiek, Oluwaseun Akeju, Zhongcong Xie, Kun Hu, Lei Gao

2020-Current year OA Pubs

INTRODUCTION: Surgical patients over 70 experience postoperative delirium (POD) complications in up to 50% of procedures. Sleep/circadian disruption has emerged as a potential risk factor for POD in epidemiological studies. This protocol presents a single-site, prospective observational study designed to examine the relationship between sleep/circadian regulation and POD and how this association could be moderated or mediated by Alzheimer's disease (AD) pathology and genetic risk for AD.

METHODS AND ANALYSIS: Study staff members will screen for eligible patients (age ≥70) seeking joint replacement or spinal surgery at Massachusetts General Hospital (MGH). At the inclusion visit, patients will be asked a …

Evidence-Based Strategy To Improve Delirium Detection In Elderly Postsurgical Patients, Aimee Baker

Doctor of Nursing Practice Scholarly Projects

Postoperative delirium (POD) is a serious adverse outcome that frequently affects older adults. Patients experiencing POD are at greater risk for postoperative mortality, increased length of hospital stay, functional decline, and increased cost of care. Current global population trends indicate that the population of adults over the age of 60 years old will double over the next thirty years. Recent guidelines call for hospitals to implement routine delirium assessment to improve early intervention. Nursing delirium assessment tools are a critical resource for early delirium identification. Nursing delirium assessment tools are often highly sensitive and specific for delirium when used in …

The Association Between Medication Use And Peri-Operative Delirium In Older Hip Fracture Adult Patients At King Chulalongkorn Memorial Hospital, Krittin Wannarong, Yanin Thipakorn, Jirada Prasartpornsirichoke, Warong Sitthisarunkul, Chumpol Suraphanphairoj, Paul Thisayakorn

Chulalongkorn Medical Journal

Background: Delirium is a common adverse consequence in the hip fracture population. Many medications can affect the emergence of the perioperative delirium but the data in older hip fracture patients is lacking.

Objective: To investigate the association between the type and amount of the selected medication classes and the occurrence of perioperative delirium in older hip fracture patients.

Methods: This is a cross-sectional study which collected data from patients aged ≥ 65 years who underwent hip surgery at King Chulalongkorn Memorial Hospital. The Delirium Rating Scale–Revised-98-Thai version (DRS-R-98-T) was used to assess the delirium one day before the surgery, and …

Prevalence Of Preoperative Delirium And Associated Factors In Elderly Hip Fracture Patients At King Chulalongkorn Memorial Hospital, Paul Thisayakorn

Chulalongkorn Medical Journal

Background: Preoperative delirium in hip fracture is under-studied. Effective diagnosis, prevention, and management of preoperative delirium may be able to reduce the incidence of the postoperative complications.

Objective: To study the prevalence of preoperative delirium and its associated factors in elderly patients who underwent hip fracture surgery.

Methods: This is a cross-sectional study which collected the data from patients aged more than 65 years who underwent hip surgery at King Chulalongkorn Memorial Hospital. Preoperative cognitive status assessment was done by using the Thai Mental State Examination (TMSE) and The Confusion Assessment Method-Thai (CAM-T) on the day before surgery. The DSM-V …

Empowering Caregivers In The Prevention Of Clinical Delirium For At Risk Older Adults Boarding In The Emergency Department Setting, Danielle Brewer

DNP Projects

Background: Emergency Department (ED) overcrowding is a global healthcare crisis documented in the literature for more than a decade, impacting patient outcomes and resource availability. While awaiting delayed transfer to an inpatient room, older adults in the ED remain vulnerable to developing acute delirium. Boarding potentiates the risk for worsening health outcomes, which are further compounded by delirium. Scarcity of resources and time constraints delay delirium detection and increase risk for down-stream hospital-acquired complications, higher cost, and prolonged length of stay. Current ED models do not prioritize caregiver partnership or involvement in delirium-conscious care, which is a holistic approach to …

Increasing Education And Staff Knowledge Of Delirium Care: An Evidence-Based Quality Improvement Project, Serena Martinath

Master's Theses and Capstones

Introduction At a small, community hospital in Massachusetts a gap analysis was conducted leading to a quality improvement project to increase staff education and knowledge regarding delirium and evidence-based best practices for delirium care. Delirium is a growing, often under recognized medical condition that occurs in hospitalized patients (Loftus & Wiesenfeld, 2017). Delirium is characterized by acute changes in congnition, level of consciousness, and attention (Loftus & Wiesenfeld, 2017). A better understanding of this condition is expected to result in improved patient care.

Methods The clinical microsystem studied in this gap analysis project was assessed by using the AHRQ Gap …

Implementation And Evaluation Of Abcdef Bundle In The Surgical Intensive Care Unit (Sicu): A Quality Improvement Project, Carrie Blasko

Doctor of Nursing Practice (DNP) Manuscripts

Intensive Care Unit (ICU) delirium is highly prevalent in this patient population; however, it is a potentially avoidable hospital complication (Vasilevski et al., 2018). The Confusion Assessment Method (CAM) has been used as a tool to measure delirium in the SICU since 2014 (AHN, 2023). The SICU clinicians deliberated if a better assessment and management bundle is available to better identify and manage delirium as a concerning volume of patients continue to experience ICU delirium even with the current delirium assessment tool in place. Upon reflection, SICU clinicians acknowledge a gap in nurses’ knowledge in connection with identifying signs, symptoms, …

Providing Personalized Interest-Based Activities To Prevent Delirium: A Multicomponent Quality Improvement Initiative In An Acute Care Setting, Qianwen Liu, Elena V. Donoso Brown, Shauni Johnson, Autumn Moss-Corcoran

The Open Journal of Occupational Therapy

Background: Hospital-induced delirium is a prevalent condition across inpatient settings, frequently impacting older adults’ recovery. A 10-week multi-component quality improvement (QI) project was designed for an existing delirium prevention program in four acute care units, aiming to support patient and caregiver engagement in delirium prevention activities.

Method: The participants were hospitalized adults who were 70 years of age and older and met specific inclusion criteria. The project provided personalized interest-based activities, orientation stimulation, and caregiver education. An abbreviated version of the Modified Interest Checklist was used to identify the participants’ activity choices. Activity daily logs, satisfaction survey, and …

Severe Hyponatremia Associated With Partial Empty Sella Syndrome, Lily Chen, Shyama Appareddy, Laura Garcia

Research Colloquium

Hyponatremia, serum sodium concentration < 135 mmol/L, is further classified by patient volume status. Symptoms are dependent on the acuity of sodium loss. Acute onset hyponatremia can present with confusion, disorientation, headache, agitation, vomiting, and lethargy. Patients with hyponatremia warrant a thorough workup and can be a leading manifestation of hypopituitarism in the geriatric population. A 77 year old patient, history of pituitary adenoma, presented with generalized symptoms of fatigue, gait instability, poor appetite and confusion associated with severe hyponatremia and hypoglycemia. The patient has a history of pituitary adenoma treated with cabergoline, hypothyroidism treated with levothyroxine and gonadal insufficiency treated with testosterone, with no reported history of diuretic use. On admission, the patient had a sodium level of 116 mmol/L. While the patient reported improvement in symptoms, patient’s confusion was noted to persist despite appropriate correction of sodium and glucose. Patient had an AM cortisol of 4 mcg/dL. Cosyntropin test was conducted and noted to be negative. MRI Brain with Gadolinium revealed empty sella turcica with a small amount of enhancing pituitary tissue, which may indicate a response to previous cabergoline therapy. Despite negative cosyntropin results, the patient was suspected to have relative adrenal insufficiency due to multiple acute stressors including illness, hospitalization, disruption of routine and abrupt smoking cessation. Patient was given a trial of hydrocortisone with improvements noted in his mental status, strength and appetite. Thus, careful consideration should be given towards adrenal insufficiency secondary to hypopituitarism as an etiology for severe hyponatremia.

Postoperative Delirium After Hip Arthroplasty In The Elderly, Sung Kwan Hwang, Changho Yi

Research Symposium

Purpose: Our study was done to evaluate the influence of postoperative delirium on the prognosis of hip arthroplasty, and risk factors for postoperative delirium in individuals older than 65.

Materials and Methods: Among patients who received hip arthroplasty in our hospital (WCH) between March 2004and March 2008, we chose 193 patients for our study after excluding patients who had preoperative delirium and who had a history of dementia and cognitive dysfunction. We divided our cohort of 193 patients into two groups, 131patients with postoperative delirium and 62 patients without delirium. We checked for clinical results for hip arthroplasty. We checked …

The Missed And The Misdiagnosed: Geriatric Delirium In The Emergency Department, Christienne Shams, Yashar Eshman, Ronan Factora, Stephen Meldon, Saket Saxena

Journal of Geriatric Emergency Medicine

Background: Older patients with delirium are at increased risk for prolonged hospitalization, poor outcomes, higher costs and a greater risk for institutionalization. By identifying those at risk early, interventions can be implemented to prevent or minimize the severity of the delirium. Per hospital policy, our geriatric emergency department (ED) screens for delirium by performing a 4AT only if changes in mental status are noted by caregivers or healthcare providers familiar with the patient. We hypothesize this approach underestimates the prevalence of delirium on presentation to the ED, particularly among high-risk older patients. The aim of this study is to determine …

Effect Of Confusion Assessment Scores On Identifying Delirium In Intensive Care Patients, Kayla Jacobs

Dissertations

Delirium in intensive care unit (ICU) patients can lead to increased length of stay in the hospital, increased risk of complications, increased polypharmacy, family distress and increased rate of mortality (Vasilevskis et al., 2018). Research has shown that addressing modifiable risk factors can improve survival rate by up to 15%, and routine screening for delirium in ICU patients leads to decreased patient anxiety, reduced in-hospital mortality, early recognition, and treatment of delirium (Krewulak et al., 2021 ; Vasilevskis et al., 2018). This quality improvement project used evidence-based intervention to increase accurate documentation of the confusion assessment method in the ICU …

Reducing Delirium And Functional Decline In Hospitalized Older Adults: Implementation Of Cocare Help, Kara Marie Roman, Aaron Mestemaker

Culminating Experience Projects

Background: Delirium is a common disturbance in cognition among older adults in the hospital setting. It is associated with negative outcomes and high costs for patients, families, and hospital systems. Use of a reliable screening tool and evidence-based strategies such as CoCare: HELP demonstrates delirium prevention and functional decline in many geriatric hospitalized patients.

Objectives: This study examines the impact of implementing aspects of CoCare: HELP on two pilot units in an urban Midwestern hospital. Pre- and post-implementation measures of delirium rate, 30-day admission rate, length of stay, falls with injuries, safety attendant orders, restraint numbers, use of antipsychotics, and …

Reducing Delirium And Functional Decline In Hospitalized Older Adults: Implementation Of Cocare Help, An Evidence-Based Intervention, Kara M. Roman, Aaron Mestemaker

Culminating Experience Projects

Background: Delirium is a common disturbance in cognition among older adults in the hospital setting. It is associated with negative outcomes and high costs for patients, families, and hospital systems. Use of a reliable screening tool and evidence-based strategies such as CoCare: HELP demonstrates delirium prevention and functional decline in many geriatric hospitalized patients.

Objectives: This study examines the impact of implementing aspects of CoCare: HELP on two pilot units in an urban Midwestern hospital. Pre- and post-implementation measures of delirium rate, 30-day admission rate, length of stay, falls with injuries, safety attendant orders, restraint numbers, use of antipsychotics, and …

Nurses’ Perceptions Of Screening For Delirium In The Post Anaesthesia Care Unit And Orthopaedic Surgical Wards: A Qualitative Study, Rami Kamel Mustafa Aldwikat, Elizabeth Manias, Pat F. Nicholson Dr

Journal of Perioperative Nursing

Purpose: The aims of this study were to explore nurses’ perceptions of the usability and clinical utility of two screening tools for delirium detection in the Post Anaesthesia Care Unit (PACU) and orthopaedic surgical wards settings, and to identify nurses’ decisions about patient care delivery based on delirium assessment outcomes. The tools studied were the 3D-CAM and 4AT – the three-minute diagnostic interview for CAM (Confusion assessment method) delirium and the 4 ‘A’s test, respectively.

Method: A focus group methodology was used. Five semi-structured focus groups were conducted with 24 nurses working in the PACU and orthopaedic surgical wards. Focus …

Examination Of Geriatric Care Processes Implemented In Level 1 And Level 2 Geriatric Emergency Departments, Ilianna Santangelo, Surriya Ahmad, Shan Liu, Lauren Southerland, Christopher Carpenter, Ula Hwang, Adriane Lesser, Nicole Tidwell, Kevin Biese, Maura Kennedy

Journal of Geriatric Emergency Medicine

Background: Older adults constitute a large and growing proportion of the population and have unique care needs in the emergency department (ED) setting. The geriatric ED accreditation program aims to improve emergency care provided to older adults by standardizing care provided across accredited geriatric EDs (GED) and through implementation of geriatric-specific care processes.

Objective: The purpose of this study was to evaluate select care processes at accredited level 1 and level 2 GEDs.

Methods: This was a cross-sectional analysis of a cohort of level 1 and level 2 GEDs that received accreditation between May 7, 2018 and …

Challenges In Management Of Refractory Pain And Sedation In Infants., Alexandra Oschman, Karishma Rao

Manuscripts, Articles, Book Chapters and Other Papers

The survival of preterm infants continues to improve, along with an increased in neonatal intensive care unit (NICU) management of chronic infants who are medically complex infants who have prolonged hospital stays, sometimes up until 2 years of age. Despite advances in neonatal and infant care, the management of pain and sedation in chronic NICU patients continues to be a challenge. Challenges such as development of appropriate pain, sedation, and withdrawal scales along with unfamiliarity of the NICU care team with pediatric disease states and pharmacotherapy complicate management of these patients. Opioid induced hyperalgesia (OIH) and delirium may play a …

The Use Of Non-Icu Confusion Assessment Method (Cam) For Delirium Management, Stephanie Barendt, John Sharon Hudson

College of Health Sciences Posters

The purpose of this study was to determine the effect the use of the non-intensive care unit confusion assessment method (non-ICU CAM) as an early screening tool for delirium would have on the nursing practice of medical surgical nurses. This quasi-experimental study focused on early screening and prevention training of inpatient nurses caring for adult inpatients to proactively reduce episodes of delirium. The training included an educational video on how to perform the non-ICU CAM assessment, 4 scenarios to test knowledge on scoring patient, and techniques for reducing delirium if patient is positive. After one month of multimodal training for …

Evaluating The Effectiveness Of A Delirium Protocol Order Set At Hca Florida Osceola Hospital, Sarah Alam, Derek Lanuto, Mabit Gonzalez, Manojna Kintada, Harsh Patel, Michael Hale

North Florida Division Research Day 2023

No abstract provided.

Delirium And Staff Injury, John Olague Jr

Master's Projects and Capstones

Abstract

Problem: From April 2021 to January 2022 there were 17 cases of reported patient aggression and staff injury due to patients in the hyperactive state of delirium. In a stroke/tele unit, diagnosis of delirium was delayed due to subjective assessment from the confusion assessment method (CAM) tool. This delay allowed patients to reach the hyperactive state of delirium which poses a threat to patient and staff safety. An objective form of assessment for delirium was needed on this stroke/tele unit.

Context: Through a microsystem assessment and strengths, weaknesses, opportunities, and threats (SWOT) analysis, stakeholders in this performance improvement plan …

Promoting Sleep To Decrease Delirium, Stephanie Mayne

MSN Capstone Projects

Delirium is potent risk factor for complications, an increase length of stay, and mortality. Hospital acquired delirium is a prevalent and serious health condition that can occur in patients, especially the older adult population, when admitted to the hospital. It has the ability to be prevented if properly addressed and interventions are set in place to help reduce the occurrence of hospital acquired delirium. Many factors can contribute to the development of delirium, including a disruption of one’s circadian rhythm. Sleep is not always a high priority in the hospital, therefore there are little interventions and goals aimed at improving …

The Role Of Occupational Therapy In Adult Critical Care In Ohio, Taylor Stanford, Otr/L

Occupational Therapy Research Projects

Abstract

Objective: The purpose of this study was to explore the barriers and supports in the delivery of OT services, identify current OT-specific protocols, and explore opinions on critical care certification and OT-specific ICU best practice guidelines.

Methods: A non-experimental descriptive data collection study with the use of an online survey. The secure survey link was embedded via email and sent to 10,000 Ohio occupational therapy practitioners. Inclusion criteria were licensed therapists (OTR and COTA) with past or current experience in adult critical care. The primary researcher developed survey questions focused on practitioners’ perspectives and personal experiences with critical care …

Perioperative Mental Health Intervention Bundle For Older Surgical Patients: Protocol For An Intervention Development And Feasibility Study, Joanna Abraham, Katherine J Holzer, Emily M Lenard, Kenneth E Freedland, Bethany R Tellor Pennington, Rachel C Wolfe, Theresa A Cordner, Ana A Baumann, Mary Politi, Michael Simon Avidan, Eric Lenze

2020-Current year OA Pubs

INTRODUCTION: The perioperative period is high risk for older adults. Depression and anxiety are common perioperative problems, frequently coexisting with cognitive impairment. Older patients with these conditions are more likely than younger patients to experience postoperative delirium, long hospital stays, poor quality of life and rehospitalisation. These experiences can, in turn, exacerbate anxiety and depressive symptoms. Despite these risks, little is known about how to treat perioperative anxiety and depression among older adults.

METHODS AND ANALYSIS: We designed a feasibility study of a perioperative mental health intervention bundle to improve perioperative mental health, specifically depression and anxiety. The overarching goals …

Geriatric Emergency Medicine Fellowship Journal Club: Operational Changes For Recognizing Prevalent Delirium And Preventing Incident Delirium, Natalie M. Elder

Journal of Geriatric Emergency Medicine

N/A

Multicomponent Approach To Delirium Prevention In The Acute Care Setting: An Evidence-Based Quality Improvement Project., Kelley James

Doctor of Nursing Practice Papers

Background: Acutely ill, hospitalized individuals are at an increased likelihood of developing delirium. Between 30-35% of those patients admitted to the hospital will develop delirium, and as a result, these individuals will face an increased risk of mortality, adverse medical events, restraint usage, and incur a more extended hospitalization. The literature supports early screening utilizing the Confusion Assessment Method (CAM) tool and nurse-driven, multicomponent interventions to aid in preventing its development.

Environment: This project was implemented in a long-term, acute care facility specializing in patients requiring long-term mechanical ventilation, advanced wound care, pulmonary and respiratory care, and the rehabilitation of …

Can Variables From The Electronic Health Record Identify Delirium At Bedside?, Ariba Khan, Kayla Heslin, Michelle Simpson, Michael L. Malone

Journal of Patient-Centered Research and Reviews

Delirium, a common and serious disorder in older hospitalized patients, remains underrecognized. While several delirium predictive models have been developed, only a handful have focused on electronic health record (EHR) data. This prospective cohort study of older inpatients (≥ 65 years old) aimed to determine if variables within our health system’s EHR could be used to identify delirium among hospitalized patients at the bedside. Trained researchers screened daily for delirium using the 3-minute diagnostic Confusion Assessment Method (3D-CAM). Patient demographic and clinical variables were extracted from the EHR. Among 408 participants, mean age was 75 years, 60.8% were female, and …

Evaluation Of A Process Change Using An Updated Sedation Protocol, Rachel Allen

Dissertations

Problem: Pediatric delirium is continuing to increase intensive care environments and for patients who require mechanical ventilation and continuous sedative medications. Delirium is harmful to the patient creating lasting neurologic and mental health issues along with prolonged hospitalization and increased healthcare cost

Method: For this quality improvement (QI) project, a descriptive observational study was used to evaluate the implementation of a sedation protocol for patients who are mechanically ventilated and on continuous sedative medications. This was completed with the use of retrospective chart reviews three months prior to implementation and three months after the new protocol was implemented. Nurses were …

Evaluating The Rass And Cap-D In A Pediatric Cardiac Intensive Care Unit, Sarah Anderson

Dissertations

Abstract

Problem: Pediatric delirium is highly prevalent in the intensive care setting, as much as seventy to eighty-seven percent. Kalvas & Harrison (2020) found that sixty-six percent of critically ill children in a pediatric intensive care unit suffered from a diagnosis of delirium. Delirium has been widely linked with increased costs, mortality, and length of stay.

Methods: The quality improvement (QI) project used a descriptive design to collect retrospective and prospective data before and after an individualized bedside education session was completed. The QI project used a purposive convenience sampling to assess the ability to accurately identify the presence of …