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Nurse project improves assessment and treatment of delirium

A team of intensive care nurses raised awareness of delirium and introduced a screening tool on their unit. Project lead Siby Sikhamoni tells us how.

A team of nurses raised awareness of delirium and introduced a screening tool on their intensive care unit. Project leader Siby Sikhamoni tells us how.

According to National Institute for Health and Care Excellence (NICE), hospitalised patients with delirium can die within a year after diagnosis. Delirium can occur in about 83% of patients in intensive care. It is an independent predictor of mortality, hospital readmissions and reduced quality of life. 

Clockwise from back left Alicia Johnson, Siby Sikhamoni, Adesuwa Ehigie.
Photo: Nathan Clarke

It is also associated with increased healthcare costs, costing US$4-16 billion (£3-12 billion) annually in the US and is recognised as major public health problem.

Caring for patients with combative and disruptive behaviour also affects staff morale, increases levels of stress and reduces job satisfaction. High standards of care are ruined and nurses fail to comprehend patient's behaviour due to their lack of awareness.
 
Length of hospital stay and risks for early dementia are also increased. And it affects the patient experience and has a significant impact on families – for relatives, seeing their loved ones with delirium can be distressing.

Earlier diagnosis

However, early recognition and intervention usually helps prevention and shortens the duration of the delirium. And cost benefit analysis in various studies shows implementing preventive strategies can be cost effective.

Savings can be made through preventing delirium, important at a time when the NHS is facing financial problems.

L-R Siby Sikhamoni, Adesuwa Ehigie, and Mrs Chinyelu Ajah. Photo: Nathan Clarke

Even though low cost interventions can prevent and manage delirium and make a significant improvement in patients’ lives, a two-week audit in my cardiothoracic intensive care unit showed that 26% of the patients had delirium, of which 66% cases were unrecognised.

It also highlighted that no screening tool for detection of delirium was being used.

I wanted to improve patient experience and ensure we were providing safe and quality health care by improving the nursing team’s awareness and ability to diagnose delirium and by embedding the NICE-recommended confusion assessment method for ICU (CAM-ICU) assessment tool.

The project was easy to sell to my matron as the prevalence of delirium had already been highlighted by the audit. I formed a team – the Delirium Care Group (DCG) – to take the project forward which included eight enthusiastic ICU nurses, an intensivist, matron, pharmacist and a physiotherapist.

I adopted a bottom-up approach making small incremental steps using a PDSA (plan, do, study, and act) cycle.

SMART goals were written, to be achieved in 3-6 months.

L-R Joanne Peh, Monika Krupa, Loyda Conejero, Dr A Crerar-Gilbert, Stuart Brandom,Siby Sikhamoni, Ali Gohobur, Adesuwa Ehigie and Alicia Johnson Photo: Nathan Clarke

The DCG created a pre-educational audit questionnaire that was completed by all nurses. A non-probability method of convenience sampling was used.

Data was collected electronically and exported to Excel for analysis. The results showed a lack of knowledge on delirium and the screening tool.

Based on the results, I organised a study day to train DCG members to become trainers. The group then began educating the rest of the unit’s nurses, including multiple bedside one-to-ones, teaching via demonstration, observation and active listening events, and monthly sessions on mandatory study days.
 
Any change comes with challenges. The greatest was achieving nurses’ acceptance of the new validated screening tool as part of their daily patient assessment and documentation. This was slowly overcome by continuously increasing nurses’ awareness of delirium’s impact and the tool through bedside coaching and on team days.
 
After 2 or 3 months, an initial lack of compliance demotivated my team but producing ideas on how to address this motivated them to continue with the project.

Siby Sikhamoni. Photo: Nathan Clarke

 Misunderstandings and doubts were cleared with questioning and active listening. Freedom of expression and empowering creative thinking and accountability helped to strengthen practice.

Through brainstorming and collaboration, more ideas were identified to increase awareness. Barriers to performing CAM-ICU were identified.

For example, the tool was seen as too complex to use, and nurses lacked confidence in using it. They reported that medical staff were not paying attention to CAM-ICU results and there was a lack of stimulating equipment such as television and radio.

Both at baseline and re-audit those areas were particularly targeted for improvement. 

The unit’s nurses took part in a charity fun run and raised approximately £1,000 to buy clocks, TVs and radio for patients.

Reminder stickers encouraging the tool’s use were made available on daily ITU charts and pocket cards with the CAM-ICU pathway were made easily accessible for all of the health care team.

Midway through the project we held delirium awareness week to reinforce practice, which included teaching and demonstrations of the assessment tool. Posters on think delirium were mounted in staff areas.

Alicia Johnson and Siby Sikhamoni. Photo: Nathan Clarke

We continually assessed compliance through staff feedback and audit. Monthly compliance on CAM-ICU performance was assessed and the results emailed to all.
 
A post-educational audit showed nurses’ awareness of delirium, which was assessed by true and false questions, improved significantly. The screening with a validated tool has now become a norm.
 
We are now teaching doctors to assess, prevent and manage delirium as well. A unit guideline for delirium management has been devised and made accessible to all staff on the unit drive and a pathway to manage delirium has also been established.
 
There has been interest in delirium awareness week from outside the trust and the results of the post-educational audit and the recommendations were presented in the Euroanaesthesia Conference, 2016 as a poster presentation.

We are going to do an oral presentation of our work for the BACCN Conference, on September 20 in Glasgow and hopefully publish it as well. 

Siby Sikhamoni
Siby Sikhamoni giving a presentation. Photo: Nathan Clarke

More preventive measures are required and we consider our improvement work to be ongoing. We saw such an improvement of compliance after our awareness week that we plan to repeat it on an adhoc basis. Our project’s results have laid a foundation for further research and innovation – more needs to be done to prove if early assessment and prevention of delirium helps to reduce the incidence of delirium in intensive care.
 
Meanwhile we are continuing with the PDSA cycle to strive for 100% compliance in assessment, for delirium, its prevention and early management. This will contribute to providing safe and quality care for our patients.


About the author

Siby Sikhamoni is a senior staff nurse at St George's University Hospitals NHS Foundation Trust. Her team was a finalist in the Leadership category of the Nurse Awards 2016 sponsored by NHS England and our sister title Nursing Management.

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