Digital Repository Masters Projects Spring 2023 Intensive Care Unit Delirium Jessica Rasmussen Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Rasmussen, J. 2023. Intensive care unit delirium. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Intensive Care Unit Delirium Project Title by Jessica Rasmussen Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 2, 2023 Date Jessica Rasmussen, BSN, MSN Student April 2, 2023 Student Name, Credentials Date (electronic signature) April 2, 2023 MSN Project Faculty (electronic signature) Date Melissa NeVille Norton (electronic signature) Date DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. 1 Intensive Care Unit Delirium Jessica Rasmussen, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing Heather Clark September 25th, 2022 2 Abstract Due to increased sedation and ventilation time, confusion and delirious patients have become more common in intensive care and inpatient hospital units. These patients are at the highest risk for falls, as they can become violent or they are at risk for failure to thrive due to immobility. Additionally, these patients can be complex for staff and their families to control. For these reasons, it is vital to identify delirium as early as possible and begin treatment. Early identification can minimize these adverse behaviors and aid the transition from the intensive care unit to other floors. In addition, nurses can prevent the escalation of confusion that might result in utilizing medications like haloperidol or Ativan, which can worsen delirium symptoms in the long run. This project aims to provide supplemental education to staff in the intensive care unit to bolster knowledge of delirium and increase the identification of symptoms, which has been shown to improve identification and advance patient care satisfaction. Keywords: delirium, education, intensive care unit, non-pharmacologic interventions 3 Intensive Care Unit Delirium The study of intensive care medicine has seen vast improvements in the last few decades, including a reduction in mortality rates from sepsis, cardiac and respiratory diseases, and acute kidney injuries. As those advances have progressed, one thing underestimated or overlooked is the cognitive effect of experiencing an intensive care unit (ICU) admission. A patient’s mental health can be neglected due to the prioritization of their initial life-threatening diagnoses like the ones mentioned above. One of the ICU's most common cognitive health issues is delirium; two out of three patients in the intensive care setting develop this condition (Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, 2022). Delirium is also known by a few other names, including confusion and encephalopathy, and has been around since Hippocrates described it as ‘phrenitis (Slooter, 2017).’ The etiology of the word delirium comes from the Latin term delirare, which means to “go off the furrow” or “to go off and be crazy” (Online Etymology Dictionary, 2022). To go off and be crazy. Although, a current definition of delirium, according to Huang (2022), is that it “is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level.” Delirium can occur in patients of all ages. However, it is more frequent in the older population, with at least 10% of elderly patients admitted to the hospital meeting the criteria for the diagnosis (Huang, 2022). The pathophysiology of delirium is still not fully understood due to the vast complexities of the brain. Still, there is thought that it could be linked to reversible impairment of cerebral oxidative metabolism, neurotransmitter abnormalities, and inflammatory markers from the fight or flight response (Huang, 2022). It can be caused by multiple illnesses, drug or alcohol use, and surgery (Wilson et al., 2020). Symptoms of delirium can be characterized by an inability to focus 4 on reality, not being able to maintain consciousness, not being alert and oriented to person and place, and experiencing and hearing things that are not there (Huang, 2022). Statement of Problem Walthall (2020) identified that despite the movement to prioritize mental health in the last twenty years, delirium research and treatment have not progressed. Delirium has also become more prevalent in the intensive care unit setting due to medical advances and the ability to prolong life more with mechanical ventilation and medications. The risk of developing delirium in a mechanically ventilated patient is 73.3% higher than in a non-mechanically ventilated patient (Jayaswal et al., 2019). Due to the high prevalence of mechanical ventilation in the ICU, delirium needs more attention. After all, patients are typically sedated with medications (Yang et al., 2017); they do not have consistent sleep cycles and usually do not receive adequate education on all medicines and procedures prescribed to them. They experience life for days to weeks, utterly dependent on the care of others with limited sensory input. That leads to the manifestation of delirium symptoms, which can be classified into three categories: hyperactive, hypoactive, and mixed. The presentation of these three different types of delirium is an issue in healthcare because hyperactive delirium can cause severe anger and agitation, hypoactive delirium can cause somnolence and cognitive depression, and mixed is when a person switches back and forth from hyperactive to hypoactive (Jin, 2020). Due to the symptoms mentioned above, delirium is associated with prolonged ventilation, prolonged hospitalization, the danger of self-extubating, increased mortality, and potential longterm cognitive dysfunction (Arumugam et al., 2017). The associated consequences of ICU delirium can cost around $17,838 per patient (Vasilevskis et al., 2018). 5 Ways Project Contributes to Intended Recipients This project is intended to benefit the patients and staff at Ogden Regional Medical Center’s Intensive Care Unit. This project explores whether non-pharmacological interventions and education can help decrease the likelihood of patients developing intensive care unit delirium and improve patient outcomes for patients diagnosed with it. The intention is to spread awareness of the detrimental effects of delirium and educate staff and family members on potential non-pharmacological and educational interventions that have evidence-based positive effects. Rationale for Importance of Project This project focuses on non-pharmacological interventions and education as interventions to improve ICU delirium. Pharmacological measures are a temporary fix and typically worsen the patient’s level of consciousness and thus worsen the patient’s original delirium diagnosis. Ng et al. (2019) and Tachibana et al. (2021) indicate that benzodiazepines, haloperidol, or dexmedetomidine have been first-line treatments for altered levels of consciousness because of threats of violence from the patients’ agitated states from delirium. While most literature supports using these medications, benzodiazepines and haloperidol have been found to worsen or cause delirium in elderly patients (Hui, 2018). In summary, pharmacological management of delirium is not the most effective or evidence-based intervention. This project aims to delve into the nonpharmacologic interventions and education and how effectively they reduce ICU delirium. Faustino et al. (2022) and Bannon et al. (2018) state that non-pharmacological interventions could be reorientation, environmental and sleep management, staff/family journaling while the patient is sedated, sedation minimization, early mobilization, and staff and family education. 6 Literature Review and Framework Pharmacologic measures for treating and preventing ICU delirium have been found to prolong and not solve the diagnosis. Approaching the issue of treating and preventing delirium with non-pharmacologic measures like reorientation and managing patient environments could be a better solution to address delirium in patients. Another solution includes educational tools for staff and patients and their families and education for staff caring for the patient (Eberle et al., 2019). Framework The Iowa Model of evidence-based practice (EBP) is a model that focuses on clinical and administrative improvements in healthcare (Buckwalter et al., 2017). Utilizing this model allows nurses or other healthcare professionals to systematically make an effective change in their occupational setting to improve patient care by asking questions about issues that have arisen in their jobs. Next, this model allows for the creation of a group to systematically search the literature for potential solutions, develop a change that will fit the organization, and implement the change (Melnyk & Fineout-Overholt, 2019). Changes within the implementation phase for projects occur frequently. This model allows for redesign and changes to accommodate new evidence or setbacks (Melnyk & Fineout-Overholt, 2019). Utilizing the Iowa Model of EBP for implementing an ICU delirium evidence-based practice change is ideal because it supports redesigning a project when new evidence presents itself or with the realization that a specific change might not work. Due to the constant influx of new evidence-based practice, the ability to change or incorporate further information is imperative for the hospital setting. 7 Strengths and Limitations One of the greatest strengths of the Iowa model of EBP is that it allows for a trial of a potential change before deciding whether it will be implemented permanently (Zhao et al., 2016). For this reason, this model is ideal for supporting this project. One of the limitations of the Iowa model is that it is a thorough change process; it takes time and commitment to implement. This has been considered, and ample time will be designated for the implementation process. Implementing this model of EBP to change how nurses address patients in the ICU setting at Ogden Regional would be ideal for the following reasons: the numerous non-pharmacological options for treatment, flexibility with the implementation timeline, and the number of opportunities to address delirium in patients. Analysis of Literature Patients in the intensive care setting have a high mortality rate, between 20.5 and 43% (Akkoc et al., 2017). Patients in this critical situation are typically intubated, have support from a ventilator, and have sedation for comfort. The method of intubation and sedation puts the patient at significant risk of developing intensive care unit delirium. Delirium is defined as a disturbance in attention, a reduced ability to direct, focus, sustain, and shift attention and awareness (European Delirium Association & American Delirium Society, 2014). Patients can be unaware of what is happening to them, and their brain tries to fill in the information gaps. One possible way to combat the lasting effects of delirium is through patient and family education about delirium, family and staff keeping a journal/diary of patient events, and other nonpharmacological interventions. This literature review aims to show whether there is an improvement in symptoms for delirium patients with non-pharmacological interventions vs. pharmacological ones. 8 Search Strategies This literature review was completed by gathering information using Weber State University Stewart Library’s OneSearch, Google Scholar, CINAHL, and Medline. Reviewing articles from the last five years narrowed the search for the most relevant information. Keywords utilized in the search included delirium, intensive care unit delirium, post-traumatic stress from delirium, education, family experience of delirium, patient experiences with delirium, qualitative, quantitative, risk factors, and current assessment guidelines. The reviewed articles produced three significant themes. First is that family education is imperative, as staff education on the delirium process and why pharmacologic measures can cause and impede the treatment of delirium. Family Education One of the most significant issues surrounding ICU delirium is that thorough education is not provided to patients and their family members. Krewulak et al. (2020), in their quasiexperimental study, and Garrett (2020) found that families did not know enough about delirium to help care for their loved ones after they were discharged from the hospital. Family members are integral to patient care; they ultimately know their family members best and can be an essential part of the care team. According to Smithburger et al. (2017), many family members do not know how to interact effectively with the healthcare team and could benefit from delirium education. A systematic qualitative meta-synthesis study showed that patients and families appreciate it when staff educates them about a delirium diagnosis or possible symptoms (Boehm et al., 2021). Although, there are mixed interpretations of having a family intervention, like an ICU diary kept by family members documenting events that happened to sedated patients to help 9 patients decipher what happened to them from what they thought happened through their delirium experience (Sayde et al., 2020). Staff Education Patients admitted to intensive care units usually have life-threatening conditions that must be treated immediately (Akkoc et al., 2017). These conditions are the ones that are triaged and managed first. Sometimes it is easy for staff not to recognize the signs and symptoms of delirium immediately, especially in intubated patients (Ramoo et al., 2018). A cross-sectional study by Xing et al. (2022) showed that ICU nurses could overestimate their knowledge of delirium and how to identify it and that extra education is needed. This can be an issue, considering that some patients and their families in the ICU believe that the nursing staff does not view delirium as a priority (Boehm et al., 2021). Solberg et al. (2020) conducted a post-test study with 389 nurses at a veteran’s hospital on delirium education who showed a significant increase in knowledge from education from a t-test comparison from pre to post-test with a P-value of <0.0001. Continued training and education tools for nurses in the ICU can improve the dissemination of knowledge to patients and their families. Pharmacological Minimization Updated literature has shown that pharmacological interventions can have a detrimental effect on the length of delirium symptoms (Blair, 2018). Common medications that are utilized to manage delirium symptoms are antipsychotics like Haldol and Seroquel. A study by Boncyk et al. (2021) showed that medications like Haldol and Seroquel prolong delirium symptoms after analyzing 8591 cases of ICU delirium with a p-value of 0.001. Studies like the above have established new literature on medication minimization strategies to prevent ICU delirium (Blair, 2018). This article illustrates a pharmacological minimization strategy that includes ensuring that 10 a patient’s pain is managed; a lot of time, acute and severe pain can lead to the worsening or developing delirium symptoms. Another article by Lee et al. (2021) supports minimizing the use of antipsychotics and benzodiazepines in cases of delirium. This study was conducted on 7927 emergency room encounters, and 22.7% of the participants received benzodiazepines. It was shown that their administration increased the odds of developing delirium with a 95% confidence interval. Summary of Literature Review Findings and Application to the Project The literature review has shown supporting evidence for increasing education for the family members of patients and the staff. It also supports utilizing a medication minimization protocol, reducing the amounts of antipsychotics and benzodiazepines prescribed to prevent and treat delirium-like symptoms. Implementing a video for families to watch or a pamphlet to give out, then a HealthStream education session for staff, and then presenting studies and alternatives to pharmacological management of delirium to our intensivist team could be beneficial to prevent and aid in the management of delirium. Project Methodology The first thing that should be done to improve the rates of intensive care unit delirium at Ogden Regional Medical Center is to create supplemental education material on delirium to disseminate to the staff. As mentioned above, nurses can overestimate their knowledge of identifying delirium; it can be challenging in intubated and sedated patients since communication is severely impaired due to endotracheal tubes (Ramoo et al., 2018). This communication disruption has become even more paramount since the development of the COVID-19 pandemic, with patients being sedated for increased periods, sometimes even needing to have a tracheostomy performed because endotracheal tubes are only sustainable for a maximum of 11 twenty-one-days (Adly et al., 2018). Therefore, creating a training module to increase awareness of ICU delirium and educating staff is critical to improving patient outcomes. Description and Development of Project Deliverables Ogden Regional Medical Center utilizes an online educational platform called HealthStream for employees to complete supplemental education. This platform allows employees more autonomy in completing education because they do not have to schedule and come to a class to learn assigned information; it will enable them to complete assignments during their working hours or at home. HealthStream is also a resource for employees searching for items they are curious about. It is partnered with educational programs and companies like the American Association of Critical-Care Nurses, American Academy of Pediatrics, Association of PeriOperative Registered Nurses, American Red Cross, and EBSCO (HealthStream, 2023). Therefore, this platform would be the easiest way for employees to learn and access assignments to supplement their knowledge of intensive care unit delirium. Pre- and Post- Test A pre-test and post-test will be used to track the employee’s knowledge and progress and the delirium module. This process has been a reliable evaluation method since the 18th century. The pre-test must be taken for the rest of the delirium module to be unlocked (Stratton, 2019). This requirement will allow the nurse’s knowledge of delirium to be treated as a dependent variable, measuring how effective certain educational materials are as the independent variable, making it a quasi-experimental or non-experimental design (Stratton, 2019) (see Appendix A). Both tests will consist of the same questions, and the answers will be shown at the end of the module. 12 Delirium Training Module The delirium education will consist of a downloadable PowerPoint that staff can open from the delirium module on HealthStream. The module will cover the definition of delirium, the subtypes, differences between delirium and dementia, risk factors, screening techniques, and interventions that worsen delirium (see Appendix B). Post-Program Survey Feedback from consumers of delivered material is crucial in the change process. It allows the creators to obtain subjective information on how the consumer felt the education went and whether they believed it worthwhile. The danger of presenting a post-program survey is that the participants might fall into survey fatigue. That is why it is essential to minimize questions and keep them short and to the point (Bowman, 2021). This survey will comprise nine closed-ended questions required to close the module and one open-ended question that will allow them to provide detailed feedback. The close-ended questions will have options to select poor, fair, satisfactory, very good, and excellent (see Appendix C). Plan and Implementation Process This project will be implemented utilizing the Iowa evidence-based practice model. A starting point for the project will be to form a team of staff interested in changing the delirium practices on the unit as well as the intensive care unit educator. After the group formation, another literature review will be undertaken in addition to the one mentioned above, and then educational material will be created and piloted. Next, the project will be presented to the ICU leadership team to obtain feedback and support for implementation. Once the project is approved, a staff meeting will be scheduled to disseminate the pre-test and the learning module. This will lay the foundation for the implementation into practice. After six weeks of the project 13 implementation, a follow-up meeting and post-test will be given to the staff. This post-test will assess for an increased understanding of managing delirium in ICU patients. Interdisciplinary Teamwork Initiating and implementing a change requires support and investment for the transition to succeed. Therefore, it is essential to allow staff to become involved in potential changes and have input within the process (Rowland et al., 2022). To make this change effective, one change agent would lead the group, invite others to join the unit, give the group members assignments and eventually let them become more autonomous. Staff involved in this movement include the nursing staff in the intensive care unit, the intensivists and physicians, the unit educator, the unit manager, the nursing float staff in the hospital, the respiratory therapists, and the occupational and physical therapists. Managing patients in a hospital is a team effort. The primary educational material will be disseminated to the nursing staff. The other interdisciplinary teams will also be involved because they are engaged in direct patient care. A schedule for patients to work with physical and occupational therapy is vital. Respiratory therapy plays a significant role in managing the ventilation of intensive care patients. These team members are crucial in the care of ICU patients. Their input and skills can improve and prevent delirium, especially with improved education, because the staff involved in direct patient care are the ones who typically notice the early signs and symptoms of delirium and not the providers (Payne & Abdoli, 2022). Timeline After completing the initial literature review, five months will be taken to implement the initial education for staff on delirium. The first month will be used to introduce the initial topic at a monthly staff meeting, and the second month will be taken to formulate a team to develop the 14 module. The third month will be taken to create the initial HealthStream module utilizing the information from the literature review. The fourth month will be used to disseminate the assignment to the staff; this is when they will take the pre-test, complete the module, and then take the post-test. The last month will be used to interpret the information and decide if any changes need to be made to the educational matter (see Appendix D). Plan for Evaluation of Project The HealthStream delirium module will begin with a pre-test on delirium. This formative assessment will aid the change committee in determining the knowledge base of the staff before the educational material is presented to them. The delirium module will then be presented in a PowerPoint format. Lastly, following the PowerPoint, the team will complete a post-test to assess if their knowledge base on delirium has improved as a summative evaluation. Additionally, staff will be allowed to give feedback on the program via an anonymous survey. This survey will assess the staff's perception of the program's effectiveness. These assessments will help determine knowledge gaps and help tailor future education for the team (Poorvu Center for Teaching and Learning, 2021). Ethical Considerations When implementing any change with a large and dynamic group, one of the most important things to consider is ensuring everyone feels included and concerns are heard and addressed. If there is pushback or conflict during the implementation process, it is vital to address this immediately. Leaders should let individuals’ grievances and concerns be heard, not alienate them or brush their opinions aside. One way to do this will be to utilize the anonymous survey following the module's implementation. It is also critical to have frequent and open 15 conversations between staff and celebrate small steps towards a final goal (UC Santa Barbra, 2023). Discussion Intensive care unit delirium is a disease process that can get overlooked, especially when it comes to intubated and sedated patients. Therefore, it is imperative to disseminate education and improve the ability to recognize delirium’s subtle signs and symptoms. Educating ICU staff and family members could potentially increase diagnostic rates because these people are around the patient and know them the best. They will be able to notice subtle changes (Payne & Abdoli, 2022). Evidence-based Solutions for Dissemination This project could be disseminated through a HealthStream module to Ogden Regional Medical Center’s interdisciplinary ICU staff, as mentioned above in the methodology section. HealthStream allows easy access from home or works to complete education (HealthStream, 2023). This project will also be disseminated to several peers and Weber State University faculty at the end of this semester on April 19th. It will be presented through a poster visual that will include the abstract from this paper, the initial PICO question, essential parts of the literature review, the methodology of the project, plan, and development, evaluation, the framework of the project, the conclusion, and references utilized in the poster. Significance to Advance Nursing Practice Delirium is an acute change in mental status that can happen in up to 60% of ICU patients (Paixao et al., 2021). This acute change can be drastic and cause lasting changes for patients and their families, resulting in increased hospital stays, risk of injuries, and mortality. Delirium is not only a physical risk to the patient but can also increase hospital expenditures for 16 them and the hospital. On the patient scale, delirium can cost patients $806 to $24,509 in the United States and costs the nation approximately $82.4 billion (Kinchin et al., 2021). A change in mental status is significant for these patients because it causes them to become unoriented. As a result, these patients consistently set off bed alarms, become high fall risks, try to pull out their endotracheal tubes, and can become violent when they feel threatened. This diagnosis puts them at severe risk for injury and neurologic changes lasting up to six months after being discharged from the hospital (Waldo, 2016). Implications The main strength of this project is that it provides easy access to education on delirium to the ICU staff at Ogden Regional Medical Center. The project organizers and staff do not have to organize several educational lecture sections to disseminate all the material to the team. The staff can access the delirium module during free time at work or from home with their HealthStream login. Having the module on HealthStream also provides a straightforward interpretation of statistics on the pre-test and post-test to see if there is a correlation with an increase in scores after digesting the module’s education. Easy online access to the delirium module can also be detrimental because staff might not give the module their full attention to the educational material. Online access allows the trainees to do other things instead of solely focusing on learning what is presented to them. It also excludes the socialization and communication factor of education. There is less opportunity for the ICU team to have their questions answered, increasing the likelihood of technological issues and frustration (Blahusiakova et al., 2021). Implementing the survey at the end of the education module will aid in gaining feedback on improving the delivery of information on delirium. 17 Although, this educational module could be added to the in-person conscious sedation class the ICU team must take. Recommendations An option to continue this project would be to adapt and develop educational materials for families of patients with delirium. Furthermore, creating handouts and videos explaining the delirium process and providing local resources can improve the transition from the ICU to the home setting. The family members of the patients in the hospital setting can be the most significant resource. Family involvement can be a determining factor in the success of our patient’s health after discharge. Involving them in the care of their loved ones makes that transition easier, lessens stress, and improves care satisfaction (Krewulak et al., 2020). Another recommendation to improve the rates of delirium at Ogden Regional would be to produce a delirium detection algorithm. Moreover, educating staff on the benefits of sedation vacations would be beneficial. Spontaneous awakening trials, or sedation vacations, are an integral part of assessing the mental status of patients during care while they are intubated and sedated. Having more knowledge and structure during this process would benefit the staff. Setting criteria that clearly illustrate exclusions, re-sedation protocols, and weaning guidelines to aid in that evaluation process could assist the team, especially those on the night shift, where it has not been the standard to complete sedation vacations every shift. Conclusions Any change comes with a price; missteps and growing pains will always occur. It is crucial to involve the staff in all the steps of a change. Let the team have a voice and a say because that gives them a stake in the investment. This open communication will make staff more likely to want to continue the change through difficult periods (Rowland et al., 2022). A 18 change and improvement in knowledge of delirium are essential. It is becoming more frequent as medicine advances due to increasing age and ways of managing acute care. Medical treatment surrounding physical ailments is always progressive at a high rate, but treating mental health conditions is more of a stagnant process. Holistically viewing each patient is essential, especially in the intensive care unit. Even though it can be challenging, earlier identification is critical because it significantly lowers patients’ two-year mortality rates and justifies why extra delirium education is needed (Ni et al., 2022). 19 References Adly, A., Youssef, T., El-Begermy, M., & Younis, H. (2018). Timing of tracheostomy in patients with prolonged endotracheal intubation: A systemic review. European Archive of OtoRhino-Laryngology, 275, 679-690. https://doi.org/10.1007/s00405-017-4838-7 Akkoc, I., Yuceta, E., Isitemiz I., Toptas, M., Tas, A., Sen, O., Ozgur, F. & Erguven H. (2017). Mortality rate in intensive care units of tertiary health institutions and identifying risk factors: Analysis of 3945 patients. Bezmialem Science, 5. DOI: 10.14235/bs.2017.1102 Arumugam, S., El-Meynyar, A., Al-Hassani, A., Standvik, G., Asim, M., Mekkodithal, A., Mudali, I., & Al-Thani, H. (2017) Delirium in the intensive care unit. Journal of Emergencies, Trauma, and Shock, 10(1), 37-46. https://doi.org/10.4103/09742700.199520 Bannon, L., McGaughey, J., Clarke, M., McAuley, D., & Blackwood, B. (2018). Designing a nurse-delivered delirium bundle: What intensive care unit, staff, survivors, and their families think. Australian Critical Care, 31(2), 174-179. https://doi.org/10.1016/j.aucc.2018.02.007 Blair, G., Mehmood, T., Rudnick, M., Kuschner, W., & Barr, J. (2018). Nonpharmacologic and medication minimization strategies for the prevention and treatment of ICU delirium: A narrative review. Journal of Intensive Care Medicine, 34(3):183-190. doi:10.1177/0885066618771528 Boehm, L., Jones, A., Selim, A., Virdun, C., Garrad, C., Walden, R., Wesley, E., & Hosie, A. (2021). Delirium-related distress in the ICU: A qualitative meta-synthesis of patient and family perspectives and experiences. International Journal of Nursing Studies, 122. https://doi.org/10.1016/j.ijnurstu.2021.104030 20 Boncyk, C. S., Farrin, E., Stollings, J. L., Rumbaugh, K., Wilson, J. E., Marshall, M., Feng, X., Shotwell, M. S., Pandharipande, P. P., & Hughes, C. G. (2021). Pharmacologic management of intensive care unit delirium: Clinical prescribing practices and outcomes in more than 8500 patient encounters. Anesthesia and analgesia, 133(3), 713–722. https://doi.org/10.1213/ANE.0000000000005365 Bowman, R. (2021). 4 strategies to create a great post-learning survey. International Accreditors for Continuing Education and Training. https://www.iacet.org/news/iacet-blog/blogarticles/4-strategies-to-create-a-great-post-learning-survey/ Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., Steelman, V., Tripp-Reimer, T., & Tucker, S. (2017). Iowa Model of Evidence-Based Practice: Revisions and validation. Worldviews on Evidence-based Nursing, 14(3), 175–182. https://doi.org/10.1111/wvn.12223 Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center. (2022). Patients and families overview. Retrieved October 10th, 2022, from https://www.icudelirium.org/patients-and-families/overview Eberle, C. C., Alves dos Santos, A., Jacques de Macedo Júnior, L. J., & Bessa Martins, J. (2019). Non-pharmacological management of delirium from the perspective of nurses in an adult Intensive Care Unit. Revista de Pesquisa: Cuidado e Fundamental, 11(5), 1242–1249. https://doi-org.hal.weber.edu/10.9789/2175-5361.2019.v11i5.1242-1249 European Delirium Association, American Delirium Society. (2014). The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer. BMC Medicine, 12(141). https://doi.org/10.1186/s12916-014-0141-2 21 Faustino, T. N., Suzart, N. A., Santos-Rabelo, R. N., Santos, J. L., Batista, G. S., de Freitas, Y. S., Saback, D. A., Dantas-Sales, N. M. M., Barreto, B. B., & Gusmao-Flores, D. (2022). Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. Journal of Critical Care, 68, 114-120. https://doi.org/10.1016/j.jcrc.2021.12.015 Garrett. (2019). Reflections on delirium- A patient’s perspective. Journal of the Intensive Care Society, 20(3), 258–262. doi:10.1177/1751143719851352 HealthStream. (2023). Maximize learning for the healthcare workforce. https://www.healthstream.com/solution/learning-performance/learning-management Huang, J. (2022). Delirium. Merck manual. https://www.merckmanuals.com/professional/neurologic-disorders/delirium-anddementia/delirium Hui, D. (2018). Benzodiazepines for agitation in patients with delirium: Selecting the right patient, right time, and right indication. Current Opinion in Supportive and Palliative Care, 12(4), 489–494. https://doi.org/10.1097/SPC.0000000000000395 Jayaswal, A. K., Sampath, H., Soohinda, G., & Dutta, S. (2019). Delirium in medical intensive care units: Incidence, subtypes, risk factors, and outcome. Indian Journal of Psychiatry, 61(4), 352–358. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_583_18 Jin, Z., Rahman, A., Pattnaik, S. & Smith, M. (2020). Postoperative delirium: The findings from a multidisciplinary survey. Psychogeriatrics, 20: 495-500. doi:10.1111/psyg.12518. Krewulak, K. D., Bull, M. J., Ely, E. W., Stelfox, H. T., & Fiest, K. M. (2020). Psychometric evaluation of the family caregiver ICU delirium knowledge questionnaire. BMC health services research, 20(1), 116. https://doi.org/10.1186/s12913-020-4892-5 22 Krewulak, K. D., Bull, M. J., Ely, W., Davidson, J. E., Stelfox, H. T., Kirsten, M. F. (2020). Effectiveness of an intensive care unit family education intervention on delirium knowledge: A pre-test post-test quasi-experimental study. Canadian Journal of Anesthesia, 67, 1761-1774. https://doi-org.hal.weber.edu/10.1007/s12630-020-01810-5 Lee, S., Okoro, U., Swanson, M., Mohr, N., Faine, B., & Carnahan, R. (2021). Opioid and benzodiazepine use in the emergency department and the recognition of delirium within the first 24 hours of hospitalization. Journal of Psychosomatic Research, 153. https://doi.org/10.1016/j.jpsychores.2021.110704 Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia: Wolters Kluwer. ISBN: 9781-4963-8453-9. Ng, K.T., Shubash, C. J. & Chong, J. S.(2019). The effect of dexmedetomidine on delirium and agitation in patients in intensive care: Systematic review and meta-analysis with sequential trial analysis. Anesthesia, 74: 380–392. https://doi.org/10.1111/anae.14472 Ni, J., Ding, Y., Miao, L., & Zhu, B. (2022). Post-intensive care syndrome: A problem cannot be ignored in ICU. Comment on Inoue et al. prevalence and long-term prognosis of postintensive care syndrome after sepsis: A single-center prospective observational study. Journal of Clinical Medicine, 12(1), 268. https://doi.org/10.3390/jcm12010268 Payne, S., & Abdoli, S. (2022). Implementation of an educational guide to improve ICU delirium awareness and detection. Graduate Publications and Other Selected Works- Doctor of Nursing Practice (DNP). https://trace.tennessee.edu/cgi/viewcontent.cgi?article=1041&context=dnp 23 Poorvu Center for Teaching and Learning. (2021). Formative and summative assessments. Yale. https://poorvucenter.yale.edu/Formative-Summative-Assessments Ramoo, V., Abu, H., Rai, V., Singh, S., Baharudin, A., Danaee, M., & Thinagaran R. (2018). Education intervention on delirium assessment using confusion assessment method-ICU (CAM-ICU) in a general intensive care unit. Journal of Clinical Nursing, 27(21-22). https://doi-org.hal.weber.edu/10.1111/jocn.14525 Rowland, D., Brauckmann, N., & Thorley, M. (2022). How to get your team on board with a major change. Harvard Business Review. https://hbr.org/2022/08/how-to-get-your-teamon-board-with-a-major-change Sayde, G., Stefanescu, A., Conrad, E., Nielson, N., & Hammer, R. (2020). Implementing an intensive care unit (ICU) diary program at a large academic medical center: Results from a randomized control trial evaluating psychological morbidity associated with critical illness. General Hospital Psychiatry. 66, 96-102. https://doi.org/10.1016/j.genhosppsych.2020.06.0171016/j.genhosppsych.2020.06.017 Slooter, A. (2017). Delirium, what’s in a name? BJA: British Journal of Anesthesia, 119(2), 283– 285. https://doi.org/10.1093/bja/aex125 Smithburger, P., Korenoski, A., Alexander, S. & Kane-Gill, S. (2017). Perceptions of families of intensive care unit patients regarding involvement in delirium-prevention activities: A qualitative study. Critical Care Nurse, 37(6). https://web-p-ebscohostcom.hal.weber.edu/ehost/pdfviewer/pdfviewer?vid=0&sid=7bfdfad9-a2d1-443e-847442f07db6de4c%40redis Solberg, L. M., Campbell, C. S., Jones, K., Vaughn, I., Suryadevara, U., Fernandez, C., & Shorr, R. (2021). Training hospital inpatient nursing to know (THINK) delirium: A nursing 24 educational program. Geriatric nursing (New York, N.Y.), 42(1), 16–20. https://doi.org/10.1016/j.gerinurse.2020.10.018 Stratton, S. (2019). Quasi-experimental design (pre-test) and post-test studies) in prehospital and disaster research. Prehospital and Disaster Medicine, 34(6), 573-574. doi:10.1017/S1049023X19005053 Tachibana, M., Inada, T., Ichida, M., & Ozaki, N. (2021). Risk factors for inducing violence in patients with delirium. Brain and Behavior, 11(8), e2276. https://doi.org/10.1002/brb3.2276 UC Santa Barbara. (2023). Managing change + workplace conflict. https://www.hr.ucsb.edu/hrunits/employee-labor-relations/managing-change-workplace-conflict Vasilevskis, E. E., Chandrasekhar, R., Holtze, C. H., Graves, J., Speroff, T., Girard, T. D., Patel, M. B. Hughes, C. G., Cao, A., Pandharipande, P. P., & Ely, E. W. (2018). The cost of ICU delirium and coma in the intensive care unit patient. Medical Care, 56(10), 890–897. https://doi.org/10.1097/MLR.0000000000000975 Walthall, J. (2020). The evolution of the mental health movement. National Alliance on Mental Illness. https://www.nami.org/blogs/NAMI-Blog/June-2020/The-Evolution-of-theMental-Health-Movement Wilson, J., Mart, M., Cunningham, C. Shehabi, Y., Girard, T., Maclullich, A., Slooter, A., & Ely Wesley. (2020). Delirium. Nat Rev Dis Primers, 6(90). https://doi.org/10.1038/s41572020-00223-4 Xing, H., Zhu, S., Liu, S., Xia, M., Jing, M., Dong, G., Ni, W., & Li, L. (2022). Knowledge, attitudes and practices of ICU nurses regarding subsyndromal delirium among 20 25 hospitals in China: a descriptive cross-sectional survey. BMJ Open, 12(9). doi: 10.1136/bmjopen-2022-063821 Yang, J., Zhou, Y., Kang, Y., Xu, B., Wang, P., Lv, Y., & Wang, Z. (2017). Risk factors of Delirium in sequential sedation patients in Intensive Care Units. BioMed Research International. https://doi.org/10.1155/2017/3539872 Zhao, J., Duan, S., Liu, X., Han, L., Jiang, Y., Wang, J., Gao, S., & Hao, Y. (2016). Discussion on clinical application of Iowa Model in TCM nursing care, Journal of Alternative Complementary & Integrative Medicine, https://doi.org/10.24966/ACIM-756 26 Appendix A Pre-test and Post-test Questions https://docs.google.com/forms/d/e/1FAIpQLSfJJSPFrIMLfISlazEyA5HvU1pBoeA4J__i 5pqC2_XJwc23fw/viewform?usp=sf_link 1. Which statement is the most correct about the CAM screening tool? a. There are two different CAM screening methods: the CAM and the CAM-ICU b. It includes six features to assess for the presence of delirium c. You have to pair it with a RASS assessment d. Patients that are intubated can not be assessed with the CAM-ICU screening tool 2. Which of these risk factors are non-modifiable? (Select all that apply) a. Oxygen status b. Age c. Previous delirium diagnosis d. Restraints e. Drugs f. Depression 3. What is the general definition of delirium? a. Progressive neurogenerative disease 27 b. Disturbance in attention and awareness c. A condition of the peripheral nervous system d. Structural abnormalities of the central nervous system 4. How many subtypes of delirium are there? a. Four b. Two c. One d. Three 5. What interventions would you implement when considering that your patient might have delirium? (Select all that apply) a. Family and patient education on delirium b. Removing lines and drains that are not necessary c. Administering medications like melatonin and Ativan d. Restraining the patient e. Early mobilization and keeping a consistent schedule f. Clear communication Answer Key 1. There are two different CAM screening methods: the CAM and the CAM-ICU 2. Age, previous delirium diagnosis, and depression 3. Disturbance in attention and awareness 4. Three 28 5. Family and patient education on delirium, removing lines and drains that are not necessary, early mobilization and keeping a consistent schedule, and clear communication. Appendix B Education PowerPoint 29 https://1533221.mediaspace.kaltura.com/media/MSN6802RasmussenJdeliriumdeliverabl e1_29_22/1_gvoq7gvi 30 31 Figure B1. PowerPoint presentation on delirium for intensive care unit staff. 32 Appendix C Staff Survey https://docs.google.com/forms/d/e/1FAIpQLSdVZEiOGuuIr4VXCRfnxzJoE_OwK2Ocyg4Tc4EgYiQDv9cLw/viewform?usp=sf_link 1. Level of effect you put into the course 2. Level of skill/knowledge at start of course 3. Level of skill/knowledge at end of course 4. Level of skill/knowledge required to complete the course 5. Contribution of course to your skill/knowledge 6. Learning objectives were clear 33 7. Course content was organized and well planned 8. Course workload was appropriate 9. Course organized to allow all students to participate fully 10. What could be improved in the course? ______________________________________________________________________________ ______________________________________________________________________________ 34 Appendix D Staff Education Timeline 1st Month Introduce project at staff meeting 2nd Month Form a team for the change 3rd Month Creation of education module 4th Month Assign module to the staff 5th Month Interpret post-test and survey results Figure D1. Description of timeline for implementation of staff education on delirium.