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CE Article

Assessment of Delirium in the Intensive Care Unit: Nursing Practices And Perceptions

Corresponding author: John W. Devlin, PharmD, BCPS, FCCM, FCCP, Northeastern University School of Pharmacy, Mugar #206, 360 Huntington Ave, Boston, MA 02115 (e-mail: j.devlin{at}neu.edu).

	Abstract

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Background Despite practice guidelines promoting delirium assessment in intensive care, few data exist regarding current delirium assessment practices among nurses and how these practices compare with those for sedation assessment.

Objectives To identify current practices and perceptions of intensive care nurses regarding delirium assessment and to compare practices for assessing delirium with practices for assessing sedation.

Methods A paper/Web-based survey was administered to 601 staff nurses working in 16 intensive care units at 5 acute care hospitals with sedation guidelines specifying delirium assessment in the Boston, Massachusetts area.

Results Overall, 331 nurses (55%) responded. Only 3% ranked delirium as the most important condition to evaluate, compared with altered level of consciousness (44%), presence of pain (23%), or improper placement of an invasive device (21%). Delirium assessment was less common than sedation assessment (47% vs 98%, P < .001) and was more common among nurses who worked in medical intensive care units (55% vs 40%, P = .03) and at academic centers (53% vs 13%, P < .001). Preferred methods for assessing delirium included assessing ability to follow commands (78%), checking for agitation-related events (71%), the Confusion Assessment Method for the Intensive Care Unit (36%), the Intensive Care Delirium Screening Checklist (11%), and psychiatric consultation (9%). Barriers to assessment included intubation (38%), complexity of the tool for assessing delirium (34%), and sedation level (13%).

Conclusions Practice and perceptions of delirium assessment vary widely among critical care nurses despite the presence of institutional sedation guidelines that promote delirium assessment.

Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: Characterize the signs and symptoms of delirium. Identify the importance of assessing ICU patients for the presence of delirium. Discuss the challenges associated with evaluation of delirium in ICU patients. To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.

Because delirium reportedly occurs in up to 87% of ICU patients receiving mechanical ventilation, the Society of Critical Care Medicine practice guidelines recommend that ICU patients be routinely screened for delirium by using a validated screening tool.^3–5,7,8 Prompt recognition of delirium in the ICU allows caregivers to differentiate patients’ symptoms (eg, pain, anxiety) from other conditions with similar features (eg, psychomotor agitation) and facilitates the initiation of both drug and non-drug therapies.

Delirium occurs in up to 87% of mechanically ventilated patients in the ICU.

 

Until recently, ICU clinicians had no instrument to detect delirium in patients receiving mechanical ventilation, because available instruments for detecting delirium (eg, the Confusion Assessment Method) required verbal communication.⁹ Since 2000, however, 2 highly sensitive, reliable, and easy-to-use screening instruments (the Intensive Care Delirium Screening Checklist [ICDSC] and the Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]) have been developed specifically for the detection of delirium in nonverbal ICU patients by nonpsychiatric personnel.^8,10,11 Because delirium is multidimensional and fluctuating, a cursory one-time-only evaluation is usually ineffective in detecting it. Thus, because of their contact with patients for an entire 8- or 12-hour shift, bedside nurses are ideally positioned to screen for delirium in the ICU.^12,13

Although most critical care nurses report routinely using a validated tool (eg, the Sedation-Agitation scale) to evaluate level of sedation in their patients, nurses’ practices and preferences for delirium screening are currently unclear.¹⁴ In a 2002 survey of Canadian intensivists, Mehta et al¹⁵ found that only 3.7% use a delirium scoring system in the ICU. In a survey of 912 ICU clinicians by Ely et al,¹² only 40% of respondents routinely screened for delirium, and only 16% used a validated delirium assessment tool. However, nurses represented only 15% of the respondents in the survey.¹²

Few data are available on nurses’ current practices in delirium assessment, potential barriers to delirium assessment, and the training that nurses have received in delirium assessment.¹⁶ The feasibility and success of nursing assessments for delirium among ICU patients depend on gaining a better understanding of nurses’ beliefs about and attitudes toward delirium assessment. Therefore, we developed and administered a survey questionnaire to determine ICU nurses’ current practices and perceptions of delirium assessment. The results were stratified among a number of different demographic factors, and delirium assessment practices were compared with sedation assessment practices.

	Methods

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Sedation assessment was considered the most useful comparison for delirium assessment for the purposes of the survey because (1) sedation is usually assessed by nurses, (2) the impact of sedation assessment on patients’ outcomes is well established, and (3) the Society of Critical Care Medicine sedation guidelines state that sedation should be assessed as a part of ICU care.^7,17–19 Other potential assessments to compare with delirium assessment (eg, pain assessment) were not incorporated in the survey because of the large number of methods that can be used to evaluate pain in the ICU.⁷

Instrument Development
The survey instrument was developed through a deliberate series of steps that included item generation and construction and then pilot testing and clarification. Delirium was defined as an acutely changing or fluctuating mental status, inattention, disorganized thinking, and an altered level of consciousness.²⁰ A panel of experts with experience in delirium assessment (a critical care nurse educator [C.Y.], 3 critical care pharmacists [J.W.D., J.J.F., J.M.], a nursing faculty member [E.P.H.], and an intensivist [Y.S.]) generated the initial survey items. The survey consisted of 3 sections: (1) demographics, (2) sedation and delirium assessment practices, and (3) current opinions about delirium and delirium assessment, including identification of potential barriers to delirium assessment. These initial survey instrument questions were used to devise a semi-structured nursing interview to identify additional items and responses for the survey.

Ten critical care nurses (6 medical and 4 surgical) at Tufts Medical Center were subsequently interviewed on an individual basis by an investigator (J.J.F.) using this interview instrument, and their responses were incorporated into the survey instrument. The draft survey instrument was then forwarded to US experts in ICU delirium and sedation (2 physicians, 2 nurses, and 2 pharmacists). These experts were asked to comment on the relevance and clarity of each survey item, the distinctiveness of response items, and the ease of completing the survey. The feedback and results were used to refine the survey instrument further. The survey was then distributed to a pilot group of 6 ICU nurses (3 medical, 3 surgical) at Tufts Medical Center who were not involved in the initial survey construction, and they were asked to comment on the clarity and distinctiveness of each response item. After the recommendations of this group were incorporated, the intrarater reliability of the survey instrument was measured by distributing the survey to a group of 10 pilot ICU nurses at Tufts Medical Center who had not previously been involved in the instrument validation process. These nurses completed the survey twice at an interval of at least 2 weeks. The resulting agreement between the answers provided during these 2 attempts was 86%.

Sample and Setting
The survey was distributed to registered nurses working in adult ICUs. A random numbers table was used to select the hospitals that were surveyed from the acute care hospitals in the Boston, Massachusetts, area that had at least 1 ICU where sedation guidelines stated that delirium should be assessed. This process continued until 3 academic teaching and 2 community hospitals had been selected. Nurses working in ICUs at these institutions where delirium assessment was not promoted in sedation guidelines were not surveyed. At these 5 hospitals, surveys were distributed to 601 critical care nurses who worked in the following types of ICUs: 4 medical, 4 surgical, 2 mixed medical-surgical, and 1 coronary. Nurses working in neurological, trauma, and burn ICUs were excluded from the study because the sedation guidelines in place in these units at the survey hospitals do not incorporate delirium assessment. The 5 ICUs selected were a convenience sample and represented the most common types of ICUs in the United States.²¹

Delirium is associated with increased mortality, ICU stay, and health care costs.

 

Procedures
When needed, approval for distributing the survey was obtained from the institutional review boards at the institutions where the survey was distributed. Identical versions of the survey (Figure 1) were distributed electronically via e-mail and as a hard copy at ICU bedsides. Each respondent received a description of the project survey and a rationale for completing the survey. Web-based software (Survey Monkey, Seattle, Washington) was used to send the survey at biweekly intervals to each nurse twice. Paper surveys were distributed to nurses either through the nurses’ hospital mailboxes and/or at patients’ bedsides and contained a stamped, addressed return envelope. Nurses were instructed to complete either the electronic or the paper version of the survey and to complete it only once. All responses were anonymous, and no incentives or compensation were offered to survey responders. Costs associated with the survey were covered by departmental research funds.

View larger version (29K): [in this window] [in a new window]   Figure 1

Data Analysis
Data from the survey were entered into a relational database (Microsoft Access, Seattle, Washington). Data were stratified to a number of demographic variables, including years of experience, highest degree, type of ICU, type and size of hospital, and time of most commonly worked shift. In some instances in which they were spread over multiple categories, responses were collapsed into 2 categories to permit comparisons among various demographic and practice variables. Responses were analyzed by using standard statistics, including t test, ² analysis, and Mann-Whitney test, when appropriate (SPSS version 14.0, SPSS Inc, Chicago, Illinois). A P value less than .05 was deemed significant.

	Results

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Of the 601 nurses who were sent surveys, 331 (55%) responded. Most respondents had a baccalaureate degree and worked in a medical or surgical ICU at a teaching hospital (Table 1). The nurses who responded had a mean age of 40.2 (SD, 9.8) years, had worked in an ICU for a mean of 13.6 (SD, 9.1) years, and currently worked a mean of 35 (SD, 6.4) hours per week. More nurses who responded worked predominantly day shifts (78%) rather than night shifts (22%).

View larger version (27K): [in this window] [in a new window]   Figure 2 Conditions that may occur in an intensive care unit deemed most important for nurses to routinely evaluate in patients during an average shift.

View larger version (41K): [in this window] [in a new window]   Figure 3 Frequency of use of possible methods of evaluating patients for delirium. Abbreviations: CAM-ICU, Confusion Assessment Method for the Intensive Care Unit; CIWA-Ar, Clinical Institute Withdrawal of Alcohol Scale, Revised; ICDSC, Intensive Care Delirium Screening Checklist.

View larger version (39K): [in this window] [in a new window]   Figure 4 Barriers to the evaluation of delirium in intensive care patients.

Nurses’ perceptions of delirium and its assessment are presented in Figure 5. When compared with nurses who either always or frequently evaluate their patients for delirium, nurses who never or rarely evaluate their patients for delirium were less likely to respond that delirium in the ICU is an underdiagnosed problem (P =.02) and that ICU patients with delirium are rarely agitated (P <.001). However, these nurses were more likely to state that initiation of antipsychotic therapy should be the initial intervention for patients with delirium (P < .001) and that patients with delirium usually have signs and symptoms that are consistent throughout the entire nursing shift (P < .001). Nurses who reported receiving any training about delirium assessment in the past year were more likely to disagree with the statements that ICU patients with delirium are rarely agitated (P <.001) and that patients with delirium usually have signs and symptoms that are consistent throughout the entire nursing shift (P=.01). Nurses’ perceptions of delirium did not differ when stratified among nurses who reported using a validated tool to assess for delirium and nurses who did not use an assessment tool.

View larger version (52K): [in this window] [in a new window]   Figure 5 Nurses’ perceptions of assessment of delirium.

	Discussion

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Several reasons may account for the low frequency reported for assessment of delirium. Although the Society of Critical Care Medicine sedation guidelines call for assessment of delirium in the ICU, screening has not yet been mandated by regulatory agencies such as the Joint Commission or Medicare. A focus in the ICU on the technical aspects of care (ie, a reliance on data from equipment for monitoring patients) rather than assessment of patients most likely also influences the low frequency of assessment. Respondents may have thought that the presence of an altered level of consciousness is synonymous with delirium, because alteration of consciousness is a criterion for delirium listed in the Diagnostic and Statistical Manual of Mental Disorders: Text Revision.²⁰ Finally, the low frequency of delirium assessment reported most likely stems from a lack of any published studies evaluating the impact of delirium screening in the ICU on patients’ outcomes.⁸

The greater frequency of delirium screening that occurs in medical ICUs (vs surgical and cardiac ICUs) is not surprising because of the far greater number of published reports of delirium assessment in medical patients.^8,26,27 The far lower frequency of delirium assessment at community institutions compared with teaching hospitals may be a result of the tendency for care at academic institutions to be delivered by the same patient care team for all patients admitted to the ICU (ie, closed units), whereas at a community hospital, care may be delivered by a number of different physician providers (ie, open units). ICU policies and procedures are more standardized in closed units.²⁸

Nurses’ perceptions, when categorized by frequency of delirium assessment, provide some helpful clues about the low frequency of delirium assessment reported. Nurses who do not routinely evaluate patients for delirium are unaware that (1) delirium is an under-diagnosed problem in the ICU, (2) patients with delirium are often hypoactive, (3) nondrug therapies should generally be considered before antipsychotic therapy, and (4) delirium is often associated with fluctuating signs and symptoms.²⁹

The survey highlights 3 major barriers to assessment of delirium: (1) the difficulty in evaluating delirium in patients who are intubated, (2) the inability to complete a delirium assessment in sedated patients, and (3) the use of delirium assessment tools that are too complex. The last barrier contrasts with research showing that these tools are quick and easy to use and that only 5% of the nurses surveyed reported that delirium assessments were too time-consuming to perform.^10,13,30 In addition, both the CAM-ICU and the ICDSC assessments incorporate a concomitant sedation assessment so that delirium assessments with these instruments are not attempted in heavily sedated patients.^10,11 It is unclear if the increasing ratio of patients to staff nurses in some ICUs is compromising the ability of nurses to screen for delirium or if the increasing level of acuity of care of patients is resulting in deeper sedation of patients and a greater emphasis on sedation rather than delirium.³¹ Fewer than half of the respondents used a validated delirium screening tool (eg, ICDSC, CAM-ICU) as the primary means for assessing delirium. Relying on the presence of agitation-related events or the inability to follow commands (the 2 most commonly reported methods of detecting delirium) to detect delirium will cause nurses to miss many cases of delirium, particularly in patients who have hallucinations, disorganized thinking, or sleep disturbances and patients who are hypoactive.²

Surprisingly, despite the complexity associated with detecting delirium in the ICU, more than one-third of the nurses reported receiving no training about delirium. Nurses who did receive training in assessing delirium in the previous year were more likely to have received the training in a live, out-of-hospital event than through either an in-service training session or at the bedside. The lack of institutional teaching about assessment of delirium most likely is due in part to a lack of clarity about the optimal way to educate nurses about assessment of delirium or to decisions about the nursing curriculum being made by persons who are either not aware of delirium assessment in the ICU or who think that assessment of delirium is not important.³²

Our findings highlight the importance of boosting educational efforts focused on assessment of delirium in the ICU. This training should emphasize the rationale for delirium assessment, the fluctuating and transient nature of delirium, the effect that screening for delirium may have on improving patients’ outcomes, and the importance of using a validated tool for screening. Interventions to help integrate efforts to assess delirium into everyday nursing practice in the ICU must be developed and tested.

A cursory one-time evaluation for delirium is usually ineffective due to the fluctuating nature of delirium.

 

Several limitations of our survey deserve mention. Although the response rate of 55% may lead to response bias, it is greater than the response rate for many other surveys of health care providers.³³ Although the purpose of the survey was to determine the priority that nurses place on delirium screening relative to other clinical conditions in the ICU, the choices were not mutually exclusive in all instances, because both agitation and altered level of consciousness are hallmark signs of delirium. All data were self-reported; no validation with practice was available. Therefore, our survey is more closely modeled to be an assessment of nursing education needs (conducted by addressing self-perception among nurses) rather than a practice validation such as the validations implemented during quality assurance programs. The survey was sent solely to staff nurses and not to other health care professionals (eg, physicians or pharmacists) who may be involved in decisions surrounding assessment or treatment of delirium.

Furthermore, the survey results represent only nurses from a single US city and thus may not be representative of critical care nurses in other US cities or in other countries. The survey results represent only practices and perceptions of nurses working in medical, surgical, and cardiac units and not those of nurses working in trauma or neurological ICUs, where practices and perceptions related to delirium assessment may be different. Other limitations include the limited number of respondents from community hospitals and the exclusion of institutions where delirium assessment was not part of the protocol. Lastly, few nurses who responded work primarily at night, and thus our results do not reflect practices during the night shift. Despite these limitations, our results provide the first extensive view of practices and perceptions of ICU nurses related to assessment of delirium.

	Conclusions

Top Abstract Methods Results Discussion Conclusions References

 
Practice and perceptions of delirium assessment vary widely among ICU nurses despite the presence of sedation guidelines in their ICUs that promote delirium assessment. Our results highlight potential areas for future research, including investigations of interventions to promote assessment of delirium by ICU nurses, the ideal educational strategy to promote assessment of delirium among nurses, the ideal frequency with which delirium should be assessed, and the effect that the routine assessment of delirium by ICU nurses has on patients’ outcomes such as duration of ICU stay or severity of longer-term cognitive abnormalities.

	ACKNOWLEDGMENTS

 
We acknowledge the efforts of Louise Caprielli, RN, Anne Mullen, MSN, Marjolein De Wit, MD, and Paul Szumita, PharmD, in this project.

FINANCIAL DISCLOSURES
None reported.

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SEE ALSO
To learn more about delirium in the acute care setting visit http://ccn.aacnjournals.org and read the article by Truman and Wesley, "Monitoring Delirium in Critically Ill Patients: Using the Confusion Assessment Method for the Intensive Care Unit" (Critical Care Nurse, April 2003).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

	REFERENCES

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This Article Abstract Full Text (PDF) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Related articles in AJCC Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Take the CE Test Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Devlin, J. W. Articles by Marshall, J. Search for Related Content PubMed PubMed Citation Articles by Devlin, J. W. Articles by Marshall, J.