Introduction
Critically ill patients face more challenges than other hospitalized individuals due to the nature of their health conditions. Patients receiving treatment at intensive care units (ICUs) face the risk of developing delirium more often than other healthcare facility clients. Particularly, the complication of brain function is likely to develop in elderly patients. Delirium is an acute dysfunction of a person’s brain associated with changing levels of cognition, attention, and consciousness (Whalin, Kreuzer, Halenda, & García, 2015).
Apart from posing difficulties to patients, this severe health condition also places a considerable financial burden on the system of healthcare. Delirium is most common in post-operative patients, with the prevalence varying between 10% and 80% depending on the type of population under analysis (Whalin et al., 2015). While delirium is a serious condition itself, it can also lead to significant adverse outcomes, such as patient falls, an increase in hospital stay duration, high mortality risks, and functional decline (Whalin et al., 2015). Therefore, there is an increased need for assessing ICU patients for delirium in order to find the most viable prevention and treatment strategies for each case.
ICU delirium may be typified into several classes based on patients’ reactions to surgery and mechanical ventilation. Hence, one can be either agitated and aggressive (hyperactive) or apathetic and slow in bodily movements (hypoactive) or fluctuate between the two forms (mixed delirium) (Tate & Balas, 2019). The major problem at the initial stage is to diagnose delirium correctly and timely. The best tool for such an evaluation is the Confusion Assessment Method (CAM) for the ICU. The use of the CAM enables physicians to detect delirium at an early stage by receiving appropriate neurocognitive data, which allows developing an effective plan of treatment (Tate & Balas, 2019).
The CAM-ICU consists of several rated items, the evaluation of which of them serving as a basis for the physician’s decision on the patient’s syndrome severity. The tool is specially designed for ICU patients who have restricted communication abilities (Boettger et al., 2017). There are four items on the CAM scale, each one containing an absent or a present level (Boettger et al., 2017). This assessment tool is helpful in identifying whether one is delirious or not, which promotes the success of treatment.
The CAM-ICU evaluates the patient’s condition on the acute onset and changing course of development, inattention, modified consciousness level, and disorganization of thinking. Delirium intensity is diagnosed based on such factors as short- and long-term memory problems, sleep disturbances, delusions, psychomotor agitation or retardation, and others (Gross et al., 2018). Based on patients’ responses or reactions, the following levels of delirium are differentiated: no delirium, mild to moderate, and severe delirium (Khan et al., 2017).
The major purpose of the project is to investigate solutions for patients who have been diagnosed as having a severe (high) level of delirium. Due to the seriousness of adverse outcomes associated with delirium, this health condition requires urgent establishment and treatment. The paper will offer an overview of pharmacological and non-pharmacological interventions for delirious ICU patients. The background and the nature of the project will be explained, along with the PICO question. The literature review section contains a synthesis of scholarly studies on the topic. A summary of the project includes a brief reiteration of the main points made in the paper.
Problem Statement
The specific problem under investigation is finding viable prevention and treatment solutions for patients with high scores on the CAM delirium scale. Researchers and practitioners have offered and tested a number of pharmacological and non-pharmacological approaches to delirium treatment (Barbateskovic et al., 2016; Carbone and Gugliucci, 2015; Herling et al., 2018; Hshieh et al., 2015). The project aims at comparing the effect of pharmacological delirium interventions to that of non-pharmacological ones. The quantitative methodology (a randomized control trial) will be employed to guide the research question.
Background
Delirium is a severe psychiatric syndrome that most frequently occurs in ICU patients. According to statistical data, about 12 million elderly Americans are diagnosed with delirium annually (Gross et al., 2018). Delirium affects nearly 70% of patients who undergo cardiac surgery, and nearly 80% of those admitted to ICUs (Boettger et al., 2017). Short- and long-term adverse effects of delirium include a longer hospital stay, a prolonged or more frequent mechanical ventilation, and a higher incidence of mortality and morbidity (Boettger et al., 2017). As a result of delirium, a person may experience the weakening of cognitive and functional abilities.
The cost of hospitalization in patients with delirium is rather high. According to different sources, the cost amounts to $38-152 billion, which is more than twice higher than expenditures on non-delirious patients’ hospitalization (Whalin et al., 2015).
The most typical type of delirium is hypoactive, which involves a decline in physical movements and lethargy. Although the prevalence of delirium is rather high among hospitalized patients, the mechanisms of its identification are still not sufficient (Whalin et al., 2015). Hence, the problem is both of oppressing societal concern and theoretical interest. The social value of the issue is that by solving it, researchers will be able to relieve complications to many patients’ health condition. The theoretical significance is in the ability to test the available approaches and come up with the most relevant one.
One of the problems making the prevalence of delirium in ICU patients so high is that the main stressors capable of causing delirium cannot be avoided. For instance, individuals undergoing surgery may develop an adverse reaction to such components of general anesthesia as benzodiazepine, anticholinergic, antihistamine, and opioid agents (Whalin et al., 2015). Furthermore, the risk of delirium grows with increased exposure to anesthetic agents, as determined by processed electroencephalography (Whalin et al., 2015).
Critical illness can lead to sepsis and inflammation disturbances, and circadian rhythm disruptions (Bannon, McGaughey, Clarke, McAuley, & Blackwood, 2016). Along with the potential to alleviate sleep pattern disturbances, sedatives can cause the development of delirium and damage the immune system (Bannon et al., 2016). Therefore, further elucidation of the problem is necessary in order to reduce its development and adverse outcomes.
Cognitive dysfunction caused by delirium Is not limited only to the patient’s hospital stay. According to Munro et al. (2017), cognitive dysfunction may continue to be noticed for several months or even become permanent. As a result, individuals may develop impairments in their daily activities. These adverse effects make it crucial for ICU nurses to be able to identify delirium as soon as possible (Piao, Jin, & Lee, 2016).
Carbone and Gugliucci (2015) emphasize two perplexing factors concerning delirium. On the one hand, the condition is preventable, which makes it difficult to understand why its incidence is so high. On the other hand, delirium is frequently misdiagnosed and, as a result, mistreated (Carbone & Gugliucci, 2015). The lack of experience or excessive workload of nurses can lead to their restricted ability to evaluate patients for delirium.
In such conditions, an effective method of patient assessment is required. Researchers note that it is highly possible to modify delirium in some patients (Bannon et al., 2016). Recently, scholars’ interest in effective delirium-screening programs has increased. The problem is that without a valid screening approach, as many as 70% of patients may be not diagnosed, which results in the lack of treatment (Bannon et al., 2016). The majority of researchers acknowledge the effectiveness of the CAM-ICU as a diagnostic tool for delirium (Bannon et al., 2016; Boettger et al., 2017; Gross et al., 2018; Tate & Balas, 2019; Whalin et al., 2015).
The gold standard for diagnosing delirium is the DSM-IV criteria, but since psychiatric services are not available in many ICUs, the CAM approach is preferred (Bannon et al., 2016). According to some reviews, the sensitivity of the CAM varies between 46.7% and 100%, which makes this method rather reliable (Boettger et al., 2017). Hence, the use of the CAM in ICUs is justified as it enables nurses to detect delirium in patients.
Timely screening for delirium and recognition of the related risk factors are reciprocally conditional for the successful management of the syndrome. The ratings of delirium severity are of utmost importance in clinical settings since they offer directly classified and consistent measures (Gross et al., 2018). These rates can serve as an effective prognostic measure and help to enhance clinical outcomes.
With the help of the CAM, a nurse can track changes in a patient’s condition, monitor modifications in the syndrome over time, and control recovery (Gross et al., 2018). Patients that score high on the CAM scale require immediate attention from nurses, which implies finding the most viable solution to mitigate delirium. The available interventions include pharmacological, non-pharmacological, and educational ones, depending on the individuals involved (nurses and family caregivers). Since the issue has considerable societal value, the search for an effective solution is an urgent need.
Purpose
The main purpose of the project is to evaluate various interventions suggested for patients scoring high on the CAM scale. Since it is impossible to incorporate all available interventions in one project, the most typical ones will be selected. The reason why the effectiveness of delirium-relieving interventions has to be addressed is that the syndrome under consideration affects patients’ mental health severely. Moreover, delirious individuals suffer from a variety of healthcare complications, which develop quickly, but require a long time for recovery. Hence, by running the project, it will be possible to find the most effective solution to delirium and further apply it in healthcare settings to reduce the incidence of this dangerous condition.
The project is an important issue for nurses, organizations, and leaders. Each of these members and units of the healthcare system has to realize the need for positive change in ICUs. It is possible to speak about the project in the context of Lewin’s theory of change. According to Lewin, there are challenges that can affect the durability of change in an organization (Batras, Duff, & Smith, 2016).
Hence, Lewin suggested a three-step model of change consisting of the stages of unfreezing, moving, and refreezing (Batras et al., 2016). It will be useful to apply this model to the project to make it easier for nurses to implement the intervention for delirium management. At the unfreezing stage, the problem will be outlined, and its significance will be discussed. During the moving stage, the selected interventions will be implemented. Finally, the refreezing phase will presuppose adding the best intervention to the regular practices of the healthcare unit.
The Nature of the Project
Interventions for delirium patients may be divided into pharmacological (Barbateskovic et al., 2016; Serafim et al., 2015), non-pharmacological (Bannon et al., 2016; Hshieh et al., 2015), educational (Carbone & Gugliucci, 2015), and automated reorientation (Munro et al., 2017). Most frequently, researchers focus on pharmacological and non-pharmacological approaches, so these two intervention types will be utilized in the project. The experimental design of the study, namely, a randomized control trial (RCT), will allow receiving the most reliable and valid results.
Participants will be randomly divided into three groups: the first group will receive a pharmacological intervention, the second group will receive a non-pharmacological intervention, and the third group will receive no intervention. In each group, there will be fifteen subjects, which will make it possible to analyze the obtained data promptly. The main inclusion criterion will be a high score of delirium on the CAM scale.
Other inclusion criteria will be the age of 65 and older, staying in an ICU for at least 24 hours, having undergone surgery, and the ability to sign a consent form. Exclusion criteria are being younger than 65, not being able to sign the consent form, receiving intensive care for less than 24 hours, and abusing substances that can affect the intervention’s results. Also, patients who do not speak English or whose providers anticipate their imminent death will be excluded.
The use of an RCT will promote the accomplishment of the study’s goals in the following ways:
- there will be a possibility to compare and contrast results received from equal groups of participants;
- a high level of reliability will be gained due to randomization;
- by using a quantitative approach, it will be possible to measure findings;
- by enrolling three groups of participants, the researchers will be able to compare two different types of interventions and to compare each of them to the placebo group.
The above reasons justify the viability of selecting an RCT as a research design. In the study were non-randomized, its procedures and results would be biased. If a qualitative design were selected instead of a quantitative one, there would be no possibility of measuring findings. A correlational study would be inappropriate since it aims at comparing variables, while the present project focuses on finding out the effects of interventions on delirious patients. Overall, an RCT is the most suitable research design for the current study.
The selection of interventions to include in the study will be based on existing research and recommendations. Among pharmacological approaches, antipsychotics, sedatives, cholinesterase inhibitors, opioids, and melatonin antagonists are suggested (Barbateskovic et al., 2016; Serafim et al., 2015). Since researchers give the most prominence to the effect of antipsychotics on delirious patients, the pharmacological intervention in the present project will use this group of medications. Non-pharmacological delirium interventions researched in scholarly literature involve the Hospital Elder Life Program (HELP) (Hshieh et al., 2015), education and orientation programs (Bannon et al., 2016), and automated reorientation (Munro et al., 2017).
Since the project aims at enrolling older adults, the HELP will be utilized as a non-pharmacological intervention. Patients will be allocated to groups randomly upon being evaluated with the CAM scale and indicating high delirium rates. The study will last for five days, upon which the results will be collected and evaluated. The project aims at interventions’ ability to decrease the incidence of delirium, falls, and length of hospital stay.
Research Question
The research question to be answered by the end of the project is, “What kind of interventions is the most successful when coping with the ICU patients’ high delirium rate on the CAM scale?” The following PICO process will be utilized to guide the research question: P – patients with high delirium scores on the CAM scale; I – non-pharmacological intervention; C – pharmacological intervention and no intervention; O – the decreased incidence of delirium, patient falls, and length of hospital stay. Thus, the PICO question is, “In ICU patients demonstrating high delirium scores on the CAM scale, will a non-pharmacological intervention, compared to a pharmacological intervention and no intervention, lead to better improvement in delirium incidence, patient falls, and hospitalization time?
Summary
The paper has outlined the nature of the problem to be investigated in the project. Delirium among ICU patients is a rather severe syndrome, and it is of utmost importance to find effective solutions to it. With the help of the CAM, nurses can evaluate patients’ rate of delirium even if no psychologist is available at the site. A variety of interventions signifies both the level of researchers’ interest in the topic and the lack of a unanimous opinion on their success. Hence, the project will help to identify the most productive intervention.
Literature review
The intent of this chapter is to provide a review of literature that will guide the capstone project. Scholarly articles from peer-reviewed journals focused on ICU patients’ delirium, the CAM approach to assessment, and interventions suggested for improving delirium rates will be reviewed in this chapter. The analysis of existing sources will help to single out the most relevant information on the identified research question.
Historical Overview
Scholars’ interest in delirium prevention and management strategies has increased over the years. However, both in the past decade and at present, scientists could not come to a single conclusion as to what approaches were the most effective when trying to reduce delirium prevalence in ICU patients. In their analysis of ICU patients’ delirium, Schiemann, Hadzidiakos, and Spies (2011) noted that the syndrome’s pathophysiology was not clear, and that pharmacological approaches to decreasing the development of delirium should be used.
The study by Hamdan-Mansour, Farhan, Othman, and Yacoub (2010) also acknowledged a lack of knowledge about delirium among critical care nurses. Meanwhile, research by Martinez, Tobar, Beddings, Vallejo, and Fuentes (2012), which focused on a non-pharmacological approach to delirium prevention, noted the existence of different strategies used for that aim. Thus, it is possible to conclude that in the course of time, researchers became more and more aware of the severity of delirium, but still, many questions remained unanswered.
Current Findings
More recent findings on delirium allowed gaining a deeper understanding of the topics related to the research question. The general issues investigated by scholars can be divided into the following major topics: the CAM for ICU, pharmacological interventions, and non-pharmacological approaches to managing delirium. It is viable to note that all research articles analyzing the CAM acknowledge the effectiveness of this assessment method (Boettger et al., 2017; Gross et al., 2018; Khan et al., 2017; Tate et al., 2019). Hence, the selection of this method for rating patients’ delirium was a beneficial decision.
The works analyzing pharmacological interventions admit that despite a variety of such approaches, their success rate is not high (Barbateskovic et al., 2016; Serafim et al., 2015). Barbateskovic et al. (2016) note that recommendations about various pharmacological treatments differ, which makes it difficult to select the most appropriate one. Serafim et al. (2015) report that none of the variety of pharmacological approaches analyzed in their systematic review demonstrated a considerable decrease in delirium incidence.
Meanwhile, the studies on non-pharmacological delirium interventions report more positive results. Specifically, educational interventions for family caregivers are considered to be promising as methods of delirium treatment (Carbone & Gugliucci, 2015). Family members’ role in positive delirium management is also acknowledged in the study by Munro et al. (2017). Scholars have found that an automated reorientation intervention brings the best outcomes when family members participate in the process of recording instructions for patients (Munro et al., 2017). Bannon et al. (2016) and Hshieh et al. (2015) have found that non-pharmacological interventions promote the decrease in patient falls, length of hospitalization, and delirium incidence.
Conclusion
The review of literature helps to find an answer to the research question, which is concerned with finding the most successful intervention to cope with the ICU patients’ high delirium rate on the CAM scale. The review has allowed singling out both positive and negative findings related to the topic. Specifically, it has been found that pharmacological interventions, though numerous, do not lead to beneficial outcomes. Also, despite the high prevalence and incidence of delirium in ICU patients, the syndrome remains insufficiently investigated. On the bright side, non-pharmacological interventions have proved to have a positive effect on delirious patients. Based on the reviewed studies, the continued need for the capstone project is justified since it has the potential to help solve a burning health issue.
Summary
The major points covered in the review of literature are concerned with the use of the CAM as the most common delirium assessment method and the variety of interventions available for delirium treatment. The review indicates that while scholars’ interest in ICU delirium has increased with time, the management of the problem is still to be enhanced. The most effective approach so far is the implementation of non-pharmacological interventions.
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