Easy as ABC: How Staff Nurses Transformed Unit Culture to Assess and Manage Delirium in the Intensive Care Unit

Delirious patients are common in intensive care units (ICUs). Delirium occurs in 20% to 50% of nonintubated ICU patients and 60% to 85% of ICU patients who are receiving mechanical ventilation.1 Delirium is associated with increased mortality, increased hospital stay and cost of care, and long-term deterioration of cognitive and functional processes.2 Delirium is a multifactorial syndrome that is missed by critical care nurses and clinicians approximately 72% of the time when a nurse is completing a general bedside assessment.3,4 Positive outcomes for patients can be achieved through the use of evidence-based assessment tools to help better detect and manage delirium.The ICU at Fox Chase Cancer Center (FCCC) is an 8-bed unit that provides care to medical and surgical oncology patients. The patients at FCCC are at high risk for ICU delirium because of the chronicity of their illness and the possible cancer disease processes, which include brain metastasis, speech and hearing deficits, and increased use of narcotics and benzodiazepines. In 2013, 60% of our patients were more than 65 years old; the older population, in conjunction with frequent use of anesthetic agents from surgery, led to an increased prevalence of delirium. A team of 4 nurses participating in the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigator (CSI) Academy were empowered to adopt best-practice interventions in the identification and nonpharmacological management of delirious patients.No practice for assessing and managing delirious patients had been established at FCCC before this CSI project. A literature review was conducted, and the the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)5 was chosen as the assessment tool for its reliability and validity as well as ease of use for clinical staff (Figure 1). The ABCDE bundle was adopted for the nonpharmacological management of delirious patients. This bundle stands for awakening, breathing trial for patients receiving mechanical ventilation, choice of sedation, delirium detection, and exercise6 (Figure 2). The group had added an “F” for “further care” that included aspects of care that we thought were pertinent to the oncology patients at FCCC.The purpose of the FCCC CSI project, titled ABC Delirium: Fighting the Dysfunction Head On, was to adopt the CAM-ICU assessment tool and ABCDE care bundle into practice. The goals of the project were as follows:The CSI team believed that patients were being given haloperidol as a first-line option for managing the disruptive symptoms of delirium and that the use of this medication could be decreased with nurse-driven nonpharmacological measures. Baseline data were obtained for haloperidol use to evaluate the prevalence of pharmacological management of delirious patients. Staff nurses were surveyed to assess their confidence in assessing their patients for delirium and their comfort level in caring for delirious patients. It was important to the CSI team that the nursing outcomes, in addition to patients’ outcomes, were measured to show the impact that this project could have on ICU nurses’ professional practice.The team launched their project, providing in-service training about the CAM-ICU assessment tool and ABCDE bundle protocol for nurses on the day and night shifts, physicians, managers, and supporting staff. The education included poster sessions and a kick-off breakfast. Staff members received project promotional items of t-shirts, pens, and highlighters. Staff in the ICU were granted permission to wear the t-shirts to help promote the project to other interprofessional teams who entered the ICU. Participants were given pens and highlighters with the team logo to help promote the presence of the project and to serve as a catalyst for starting a conversation about delirium. Staff members were educated about the symptoms, prevalence, and long-term consequences of delirium. The team introduced the assessment and new documentation for the CAM-ICU and ABCDE bundle. The ICU nurses were assessed individually on the CAM-ICU to ensure accuracy; each nurse was observed performing the CAM-ICU and constructive feedback was provided. Further education sessions were provided after the 6-month mark and again when the assessment and bundle were introduced in the electronic medical record.In order to have continuity of buy-in from the important stakeholders of this project, such as the intensivists, respiratory therapists, managers, and surgical and medical physicians, the team reported their progress monthly to the interprofessional ICU committee. This strategy served as a vital communication conduit between the team and its stakeholders. Team members were able to engage in regular conversation with stakeholders to address any issues, showcase the progress that was being made, and garner support.The team implemented the project and collected data for 6 months. The results surprised everyone. The use of haloperidol decreased by 50% following the implementation of the CAM-ICU and ABCDE bundle (Figure 3). The mean length of stay in the ICU decreased by 0.1 days (Figure 4); the number of days of mechanical ventilation did not change.A postsurvey of the nursing staff indicated that 80% of staff now felt comfortable caring for delirious patients, which is 36% higher than on the presurvey (Figure 5). The percentage of nurses who were confident in assessing for delirium in ICU patients increased from 15% to 85% after implementation of the CAM-ICU and the ABCDE bundle (Figure 5). Compliance of the clinical staff with the CAM-ICU assessment was less than 60% for 5 months; this time frame reflects multiple unit transitions such as new staff members, management turnover, and introduction of other initiatives. However, the CSI team remained persistent and focused the repeated education in May 2014. The team also implemented a chart in the unit that displayed a mark for each CAM-ICU assessment performed by each nurse; this strategy turned into friendly competition among the staff and boosted the performance of completed CAM-ICU assessments within 1 month of implementation. This effort was reflected in the 100% compliance with the assessment by the end of the CSI academy in July 2014 (Figure 6).The CSI program is lovingly referred to as the gift that keeps on giving at FCCC. The project has catapulted the confidence of the team members in creating change at the bedside. It has empowered one team member to be a bold voice in a hospital-wide interprofessional initiative to bring delirium assessment and management to all inpatients at FCCC. The same team member also created an interprofessional early mobility program to support the exercise component of the ABCDE bundle. Delirium assessment and management are now embedded into the culture of the ICU at FCCC; adherence to CAM-ICU completion remains greater than 85% (Figure 7). Nurses report that the CAM-ICU helps them advocate for different medication management when giving report to clinicians. The success of this project exemplified the impact that clinical nurses have on patient care when they are given resources and protected time to work collaboratively to find innovative solutions.The following people were part of the CSI team with the author: Erin Longstreth-Papsun, rn, msn, ocn, Allyson Lloret, rn, bsn, and Ashley Moyer, rn, bsn.