Delirium-Prevention Protocol Has Major Impact on ICU

A new standard of care for reducing delirium, based on nursing interventions and developed by nurses at a Philadelphia hospital, is better for patient outcomes and for nurses.

For Anne Jadwin, RN, MSN, AOCN, NE-BC, vice president of nursing and CNO at Fox Chase Cancer Center, in Philadelphia, getting the chance to participate in the American Association of Critical-Care Nursing's Clinical Scene Investigator (CSI) Academy was a little like serendipity.

She and the ICU committee had just been discussing the need to do more delirium prevention in their ICU, since literature shows that delirium among critical care patients can not only be debilitating in the short-term, but also lead to long-term cognitive impairments.

The following week, Jadwin got an email about the CSI Academy, a 16-month, hospital-based nurse leadership and innovation training program funded by the AACN. Immediately, her mind traveled to that ICU committee meeting, and she knew the delirium project would be perfect.

Once Fox Chase was selected as one of the seven hospitals to participate in the Pennsylvania cohort, "we had no trouble finding four staff nurses that wanted to participate in this project," she says.

At the core of the project was a delirium-prevention protocol, a risk-assessment and screening tool that creates a risk score for patients using measurements such as the confusion assessment method, and assigns certain types of interventions based on that score.

The ABCDE bundle was used: Awakening, breathing trial (to see if patients can be moved off of ventilators sooner), care coordination, delirium monitoring, and early exercise and mobility.

"They're all, for the most part, nursing interventions, so this is very much an independent nursing protocol," Jadwin says. "A lot of the interventions to prevent delirium are nurse-driven… these are things they can do without a physician order."

For instance, nurses can prevent delirium by getting patients up and walking around earlier in their ICU stay; orienting them to time and place; promoting better rest and minimizing sleep interruption; and encouraging passive range-of-motion exercises.

The nurses even recommended the purchase of a stationary bike that can attach to the bed, allowing patients to exercise while they're still in bed.

Ripple Effect
Delirium's ripple effect can be felt beyond the patient's health and cognitive outcomes.

"In addition to the cognitive impairment that patients can have long term…it's very distressing to patients," Jadwin says. It's also tough on patient families and the nurses themselves.

"From a nursing standpoint, it's very difficult to care for somebody" with delirium, Jadwin says. People who otherwise would not be problem patients become hard to care for because they're confused. They might even thrash around and hit nurses; Jadwin says nurses have even been injured.

"There was a lot of good reason to try to minimize this experience for patients," she says.

At first, the nurses at the helm of the project faced the challenge of getting the staff nurses onboard with this new protocol, Jadwin says. "They see this in some ways as creating more work for them," and one of the things the nurses learned from the program was: "How do you sell this idea to your peers?"

They sold it by sharing the evidence, which spoke for itself.

"I think that made sense to nurses. They saw that this is something that we need to make time for because this is better for patients," she says. "That was what really sold it for them. They recognized that this is better care."

It also demonstrates the importance of communicating evidence and literature with staff nurses when making changes like these, rather than issuing top-down directives.

Outcomes
The program's outcomes spoke for themselves, too.

"[The interventions] decreased the length of stay in the ICU by about a half of day," Jadwin says. That might not sound like a lot, but it's significant when you consider the high risks and cost of the critical care unit, she adds. In addition, pharmacy data shows that patients needed sedating drugs less often with this protocol in place.

Anecdotally, the nurses are more comfortable providing care to these patients and also feel good about their accomplishments. Now, it's the standard of care for the critical care unit.

"It's very powerful for them to develop those tools where they can really influence the practice change," Jadwin says. "That's just really very exciting for them to know that they were able to do this."