What are we asking for when requesting "Specialling" for the confused hospitalised older person? A concept analysis.

BACKGROUND AND/OR RATIONALE: "Specialling" is a common nursing practice in hospitals which entails the allocation of extra staff to be with an older person who is confused to maintain safety. Despite ongoing use, this practice has little evidence of effectiveness. To facilitate further investigation, a concept analysis of "specialling" was undertaken. AIMS: The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital. METHODS: This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding. FINDINGS: A total of (n = 43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities. DISCUSSION: The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study. IMPLICATIONS FOR PRACTICE: Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.

Differentiation of delirium, dementia and delirium superimposed on dementia in the older person.

Delirium is an acute clinical emergency that requires prompt clinical intervention. A predisposing factor for delirium is dementia, and delirium may highlight the vulnerability of a patient to developing dementia. However, delirium also occurs during an acute illness in patients diagnosed with dementia; this is classified as delirium superimposed on dementia. This complex interplay of both dementia syndromes and the condition of delirium has been extensively studied. However, delirium continues to be under-recognised in the acute setting, which impacts negatively on patient outcomes. Nurses are the health professionals best placed to recognise a change in a patient's cognitive symptoms, but nurses caring for the older person have suggested the identification of and differentiation between delirium, dementia and delirium superimposed on dementia remains very confusing. A need for further education with supportive guidelines and protocols is required to empower nurses caring for an older person to verbalise changes in patients' cognitive status in a reliable, robust and systematic manner.

Delirium em Unidade de Terapia Intensiva: implicações para o cuidado de Enfermagem ao adulto e idoso / Delirium in intensive care units: implications to nursing care of adults and elderly

Introdução: Delirium ou Confusão Mental Aguda refere-se a uma síndrome de início súbito, curso flutuante e comprometimento das funções cognitivas, distúrbio da atenção, do ciclo sono-vigília e das atividades psicomotoras anormalmente elevadas (forma hiperativa) ou diminuídas (forma hipoativa). Apesar da significativa prevalência em pacientes internados em Unidades de Terapia Intensiva (UTI) e do relevante impacto no prognóstico desses pacientes, ainda é consideravelmente subdiagnosticado, o que repercute nas taxas de morbimortalidade e prolonga o período de internação. Nos pacientes críticos, a forma mais comum é a hipoativa, caracterizada por sonolência ou torpor. Objeto da pesquisa: Delirium em pacientes adultos e idosos internados em UTI. Objetivo geral: Investigar a ocorrência de delirium nos pacientes adultos e idosos internados na UTI. Objetivos específicos: 1) Descrever, a partir da observação direta, a realidade contextual do processo de trabalho da equipe de enfermagem da UTI; 2) Descrever as características sociodemográficas e clínicas dos pacientes internados na UTI; 3) Quantificar a ocorrência de delirium nos pacientes internados na UTI por meio da aplicação do Método de Avaliação de Confusão em Unidades de Cuidados Intensivos Flowsheet (CAM-ICU); 4) Identificar as variáveis clínicas e os fatores associados ao delirium. Metodologia: Trata-se de um estudo de caso. Foi utilizado o Fluxograma do Método de Avaliação de Quadros Confusionais em UTI para investigar a ocorrência de delirium nos pacientes internados na UTI do Hospital Estadual Azevedo Lima, respeitando os seguintes critérios de inclusão: pacientes com idade igual ou superior a 18 anos; permanência sob cuidados intensivos no período mínimo de 24 horas; capacidade de comunicação; ausência de sedação profunda. A coleta de dados ocorreu entre Junho e Agosto de 2015, com total de 142 pacientes. A amostra foi constituída subtraindo-se os pacientes que não atenderam aos critérios de inclusão, e os que tiveram seu instrumento de coleta extraviado. O projeto foi aprovado pelo Comitê de Ética e Pesquisa da Universidade do Estado do Rio de Janeiro, sob CAAE no 46748115.5.0000.5282. Resultados: Dos 92 pacientes analisados, 16 (17.39%) tiveram delirium detectado, totalizando 104 episódios encontrados. A média de idade foi de 64.5 anos, com predominância do sexo feminino (52.7%). O tempo médio de internação na UTI foi de 37.1 dias para os pacientes com delirium, e de 23.6 para os pacientes sem o diagnóstico. Em relação aos fatores associados predominantes, os pacientes com delirium foram submetidos a: polifarmácia (média de 60.8 dias); cateteres vasculares (média de 58.5 dias); prótese ventilatória (média de 37 dias); e contenção mecânica (média de 24.8 dias). Conclusão: Os resultados apontaram que os profissionais detectaram apenas a forma hiperativa de delirium, demonstrando a necessidade da implementação de um protocolo para sua prevenção na UTI estudada.

Introduction: Delirium or Acute Mental Confusion refers to a syndrome with an acute onset, fluctuations in awareness and compromising of cognitive functions, attention or sleeping cycle disturbance and of the abnormally elevated (hyperactive form) or diminished (hypoactive form) of psychomotor activities. Although significantly prevalent amongst patients in Intensive Care Units (ICU's) and of the relevant impact in these patient's prognosis, it's still considerably under diagnosticated generating repercussions in morbidity/mortality rates and prolonging admission periods. In critical patients, the most common form is the hypoactive, characterized by somnolence or torpor. Research Object: Delirium in adult and elderly patients admitted into the ICU. General Objective: Investigate the occurrence of delirium in adult and elderly patients admitted in the ICU. Specific Objectives: 1) Describe the contextual reality of the ICU's nursing team's work process through direct observation; 2) Describe sociodemographic and clinical characteristics of patients admitted into the ICU; 3) Quantify the occurrence of delirium in patients admitted into the ICU by applying the Confusion Assessment Method ­ Intensive Care Unit Flowsheet (CAM-ICU); 4) Identify the clinical variables associated to delirium. Methodology: This is a case study utilizing CAM-ICU to investigate the occurrence of delirium in patients admitted into Azevedo Lima State Hospital's ICU respecting the following inclusion criteria: patients aging equal or above 18 years; intensive admittance for at least 24 hours; capacity to communicate; absence of profound sedation. Data collection occurred between June and August 2015 with a total of 142 patients. The sample was constituted by subtracting the patients that didn't comply with the inclusion criteria and those whose data collection was lost. The project was approved by the Ethics and Research Committee of Rio de Janeiro's State University under CAAE no 46748115.5.0000.5282. Results: Out of 92 analysed patients, 16 (17.39%) were detected with delirium, totalizing 104 episodes. Age average was found at 64.5 years with a predominance of the female sex (52.7%). Average admittance time in the ICU was 37.1 days for patients with delirium and 23.6 for patients with no such diagnosis. In regards to predominant associated factors, patients with delirium were submitted to: polypharmacy (average 60.8 days); vascular catheters (average 58.5 days); IMV's (average 37 days) and mechanical restraints (average 24.8 days). Conclusion: Results indicated that professionals detected only the hyperactive form of delirium, demonstrating the necessity of implementing a protocol for its prevention in the studied ICU.

Confusion reigns on who cleans up.

Guidance on the cleaning responsibilities of nursing and domestic staff must be communicated clearly, the RCN said.

Reliability and validity assessment of the Japanese version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

OBJECTIVE: Delirium may lead to adverse outcomes in patients with serious conditions, but is often under-diagnosed due to inadequate screening. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is an established method for assessing delirium in the ICU. The validity and reliability of the Japanese version of the CAM-ICU has not, however, been verified, and we undertook this study to verify these parameters. RESEARCH METHODOLOGY: CAM-ICU validity and reliability were assessed in two Japanese ICUs. Using the evaluation of the DMS-IV-TR in the psychiatrists group as the standard criteria for delirium diagnosis, we compared the evaluation of the Japanese version of the CAM-ICU between the research nurses group and the staff nurses group. RESULTS: According to DSM-IV-TR criteria, the prevalence of delirium was 22.0%, and according to CAM-ICU delirium was found in 22.0% with Research Nurses and 19.5% with Staff Nurses. CAM-ICU sensitivity ratings were 83% and 78%, while their specificity ratings were 95% and 97%, respectively. The Kappa inter-rater reliability was good (κ=0.85), and Cronbach's alpha coefficient was 0.69 (95% CI: 0.57-0.79). Mean rating time for the CAM-ICU was 2.5-2.8 minutes for Research Nurses and Staff Nurses, respectively. CONCLUSION: The Japanese version of the CAM-ICU has comparable validity and reliability as a delirium assessment tool in surgical patients in two Japanese ICUs. With training, CAM-ICU can be incorporated into daily clinical practice.

A new tool to asses risk of wandering in hospitalized patients.

This article describes the development and implementation of a wandering screening and intervention program based on identifying hospitalized patients with impaired cognition and mobility. A wandering screening tool developed by a multidisciplinary team was linked to appropriate levels of interventions available in the electronic health record. Advanced practice nurses (APNs) confirmed the accuracy of screening and interventions by bedside nurses for all patients who screened positive. Of 1,528 patients hospitalized during a 3-week period, 48 (3.1%) screened positive for wandering. At-risk patients were older (age ≥ 65) (66.7%), those admitted to surgical units (41.7%), Caucasian (89.6%), and men (58.3%). Thirteen (27.1%) had dementia and 45 (93.8%) had impaired cognition. Of those patients who screened positive for wandering, the APNs agreed with the bedside nurses' assessment in 79.2% of cases (38/48) about wandering risk and 89.5% (34/38 true positives) for the interventions. A two-item wandering screening tool and intervention was feasible for use by bedside nurses. Further studies are needed to determine whether this tool is effective in preventing wandering.

Safety incidents involving confused and forgetful older patients in a specialised care setting--analysis of the safety incidents reported to the HaiPro reporting system.

AIMS AND OBJECTIVES: To describe the safety incidents involving confused and forgetful older patients in a specialised care setting entered in the HaiPro reporting system. BACKGROUND: About 10% of patients experience a safety incident during hospitalisation, which causes or could cause them harm. The possibility of a safety incident during hospitalisation increases significantly with age. A mild or moderate memory disorder and acute confusion are often present in the safety incidents originating with an older patient. DESIGN: The design of the study was action research with this study using findings from one of the first-phase studies, which included qualitative and quantitative analysed data. METHODS: Data were collected from the reporting system for safety incidents (HaiPro) in a university hospital in Finland. There were 672 reported safety incidents from four acute medical wards during the years 2009-2011, which were scrutinised. Seventy-five of them were linked to a confused patient and were analysed. RESULTS: The majority of the safety incidents analysed involved patient-related accidents. In addition to challenging behaviour, contributing factors included ward routines, shortage of nursing staff, environmental factors and staff knowledge and skills. Nurses tried to secure the patient safety in many different ways, but the modes of actions were insufficient. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Nursing staff need evidence-based information on how to assess the cognitive status of a confused patient and how to encounter such patients. The number of nursing staff and ward routines should be examined critically and put in proportion to the care intensity demands caused by the patient's confused state. The findings can be used as a starting point in the prevention of safety incidents and in improving the care of older patients.

Management of acute confusion in patients with CNS infections.

This article discusses the management of acute confusion and aggression in patients with infections of the central nervous system (CNS). The issues discussed are applicable to the management of acute confusion of any cause and the principles of care apply to all confused patients. The article addresses many of the challenges encountered by nurses caring for confused patients, including the recognition of acute confusion, use of screening tools, and the management and treatment of these patients.

[The confused elderly patient]. / Le sujet âgé confus.

Mental confusion has long-time been likened to dementia, while it is in fact an acute disturbance of a person's alertness and attention capacities. Generally reversible and temporary, it is brought on by high levels of stress. Nursing care is an essential element of its treatment.

Toward the development of a nursing practice for older persons with acute confusional state (ACS).

Surgery unit nurses often deal with older people in an acute confusional state (ACS). To care for them, nurses must resort to different patterns of knowing, including empirical, esthetic, ethical, personal and emancipatory. According to Chinn and Kramer (2008), it is by consciously and deliberately asking themselves critical questions about specific clinical situations that nurses can enhance their knowledge and improve practice. In this regard, narrative pedagogy developed by Diekelmann (2001), which encourages sharing lived experiences and seeking other possibilities for the future, seems a well suited approach. This article presents the theoretical bases of narrative pedagogy and the grounds for an intervention inspired by this approach and intended for nurses who must care for hospitalized older people in an ACS. This innovative pedagogical intervention, which encourages nurses to participate actively in their learning, is consistent with recent empirical works on continuing education of health professionals.

Using Diffusion of Innovations Theory to implement the confusion assessment method for the intensive care unit.

Routine screening of mechanically ventilated patients for delirium is essential for prompt recognition and management; however, this represents a change in practice. Rogers' Diffusion of Innovations Theory can be useful as a strategy to facilitate adoption of a practice change. This case study describes the effectiveness of identifying barriers to a change in practice and developing strategies, specific to Rogers' innovation decision process, for implementing the Confusion Assessment Method for the intensive care unit.

[Research study regarding the benefits of nursing care in the twilight syndrome]. / Studio di ricerca sui benefici dell'assistenza infermieristica nell'insorgenza della sindrome del tramonto.

The twilight syndrome manifests with the appearance of a severe confusional state which damages the patient's cognitive potential. The aim of this study was to evaluate whether nursing care focused on the patient's space-time orientation could reduce or even prevent the onset of this syndrome. The study comprised 48 patients, 17 in the action group and 31 in the control group. The results of the study showed that the nursing strategies implemented, aimed at maintaining the patient's cognitive, perceptive and orientation functions, not only slowed down the progression of the syndrome but also made early recognition possible.

Transferring from an acute hospital and settling into a subacute facility: the experience of patients with dementia.

BACKGROUND: In a Melbourne metropolitan health network, patients with dementia can have difficulty settling into a subacute rehabilitation facility after transfer from the acute hospital. AIMS AND OBJECTIVES: To understand how older patients with mild to moderate dementia experienced the transfer from acute to subacute care and settling-in period. DESIGN: A descriptive design was used. Eight patients with mild to moderate dementia were recruited, one to 5 days after transfer. METHOD: A qualitative method using in-depth interviews was used. The data were analysed using content analysis. RESULTS: Four main themes were identified: 'Settling into a new environment', 'staff attitudes to people with dementia', 'loss of control' and 'family support'. CONCLUSIONS: Person-centred care that comes from the perspective of respect for the individual transcends all these issues. People with dementia require more support to settle after transfer. Family involvement can assist in facilitating a smooth transition. IMPLICATIONS FOR PRACTICE: Nurses who understand the specific needs of patients with dementia can develop ways of working with patients to ensure person-centred care. More conversations with people with dementia are needed to investigate how this can be achieved. Orientation procedures should ensure that support for people with dementia is optimized during the settling-in phase.