Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings.

BACKGROUND: Nurses play a key role in recognition of delirium, yet delirium is often unrecognized by nurses. Our goals were to compare nurse ratings for delirium using the Confusion Assessment Method based on routine clinical observations with researcher ratings based on cognitive testing and to identify factors associated with underrecognition by nurses. METHODS: In a prospective study, 797 patients 70 years and older underwent 2721 paired delirium ratings by nurses and researchers. Patient-related factors associated with underrecognition of delirium by nurses were examined. RESULTS: Delirium occurred in 239 (9%) of 2721 observations or 131 (16%) of 797 patients. Nurses identified delirium in only 19% of observations and 31% of patients compared with researchers. Sensitivities of nurses' ratings for delirium and its key features were generally low (15%-31%); however, specificities were high (91%-99%). Nearly all disagreements between nurse and researcher ratings were because of underrecognition of delirium by the nurses. Four independent risk factors for underrecognition by nurses were identified: hypoactive delirium (adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age 80 years and older (OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2; 95% CI, 1.2-4.0), and dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition by nurses increased with the number of risk factors present from 2% (0 risk factors) to 6% (1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk factors; P(trend)<.001). Patients with 3 or 4 risk factors had a 20-fold risk for underrecognition of delirium by nurses. CONCLUSIONS: Nurses often missed delirium when present, but rarely identified delirium when absent. Recognition of delirium can be enhanced with education of nurses in delirium features, cognitive assessment, and factors associated with poor recognition.

Outcomes following physical restraint reduction programs in two acute care hospitals.

BACKGROUND: Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS: The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS: Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION: Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY: Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

The relationship of sedation to deliberate self-extubation.

STUDY OBJECTIVES: To evaluate the relationship between sedative therapy and self-extubation in a large medical-surgical intensive care unit (ICU). DESIGN: Retrospective, case-controlled study. SETTING: Large teaching hospital. PATIENTS: All adult patients who underwent unplanned self-extubation during a 12-month period (n = 50). Each patient was matched to two control patients who did not self-extubate based on age, gender, dates in hospital and diagnosis. INTERVENTIONS: none. MEASUREMENTS: Data collected included time to self extubation, dosages and types of benzodiazepines, opioid analgesics, antipsychotics, and hypnotics. Data on the degree of agitation as assessed by nursing staff also were obtained. MAIN RESULTS: When compared to controls, patients in the self-extubation group were more likely to have received benzodiazepines (59% vs. 35%; p < 0.05), but equally likely to have received opioids and/or paralytic drugs. Patients who self-extubated were twice as likely as controls to be agitated (54% vs. 22%; p < 0.05). Use of benzodiazepines was more common in agitated patients than in nonagitated patients (62% vs. 35%; p < 0.02). Among nonagitated patients who self-extubated, increased use of benzodiazepines (57% vs. 29%; p < 0.05) was noted when compared to nonagitated controls. CONCLUSIONS: In intubated ICU patients, benzodiazepines may not consistently treat agitation effectively or prevent self-extubation. Such an effect may be due to paradoxical excitation, disorientation during long-term administration, or differences in drug administration between ICU and operating room (OR) environments.

Interrater reliability of 2 sedation scales in a medical intensive care unit: a preliminary report.

BACKGROUND: Critical care nurses must assess the effectiveness of sedatives and analgesic agents in order to titrate doses. OBJECTIVES: To measure the interrater reliability of 2 sedation scales used to assess patients in medical intensive care units. METHODS: The interrater reliabilities of the Motor Activity Assessment Scale and the Luer sedation scale were compared prospectively in 31 patients receiving mechanical ventilation in an 18-bed medical intensive care unit of a tertiary care institution. Three registered nurses, 1 clinical pharmacist, and 1 physician simultaneously and independently followed a standardized procedure to rate each patient by using the 2 scales. Scales were randomly ordered to counteract ordering effect. Analysis of variance with post hoc Duncan multiple range tests was used to detect bias; a correlation coefficient matrix was used to examine degree of association among raters; and the intraclass correlation coefficient was measured to control for multiple raters. RESULTS: No significant bias was detected with either scale. The Motor Activity Assessment Scale had less variation (Pearson r = 0.75-0.92) than did the Luer scale (Pearson r = 0.37-0.94) and had a stronger intraclass correlation coefficient (0.81 vs 0.79). CONCLUSIONS: The Motor Activity Assessment Scale showed the highest consistency among raters.

Ending a nurse practitioner-patient relationship: uncovering patients' perceptions.

DATA SOURCES: Seventy-nine patients assigned to the care of a nurse practitioner (NP) were interviewed to explore reactions to ending a yearlong therapeutic relationship at the conclusion of a clinical trial. Three researchers identified, reviewed and CONCLUSIONS: Of the total 79 patients, 22 (28%) spontaneously discussed perceptions and feelings about the termination of their relationship with the NP, Qualitative analysis of their statements identified future concerns about continuity of care and emotional themes ranging from gratitude, regret, and anxiety to grief. IMPLICATIONS FOR PRACTICE: Changes in health care coverage often result in abrupt termination of patient-provider relationships. The involuntary termination of a patient-provider relationship may have significant negative consequences on patients with substantial influence on physical and emotional health. Awareness and anticipatory counseling may be useful in stemming these effects.

Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: the SIGNET model.

Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve case finding of at-risk older adults and provide comprehensive assessment in the ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at-risk older ED patients, (2) improve care planning and referral for those returning home, and (3) create a coordinated network of existing medical and community services. The four sites are a 1,000-bed teaching center, a 700-bed county teaching hospital, a 400-bed community hospital, and a health maintenance organization (HMO) ED site. Ten community agencies also participated in the study: four agencies associated with the hospital/HMO sites, two nonprofit private agencies, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical nurse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary physicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully implemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding and community linkage programs for at-risk older adults are feasible in the ED setting.

Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation.

BACKGROUND: Although popular, clinical practice guidelines are not universally accepted by healthcare professionals. OBJECTIVES: To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use. METHODS: Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use. RESULTS: Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation. CONCLUSIONS: Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.

Sensitivity and specificity of the Braden Scale in the cardiac surgical population.

PURPOSE: A descriptive study was conducted to investigate the sensitivity and specificity of the Braden Scale for Predicting Pressure Ulcer Risk in a cardiac surgical population. PATIENTS AND SETTING: A convenience sample of 337 pressure ulcer-free patients undergoing cardiothoracic surgery at a large midwestern national referral center were enrolled in the study. METHODS: Systematic skin and Braden Scale assessments were completed independently on the day of surgery and on postoperative days 1, 3, and 5. The presence of a pressure ulcer was determined and classified using the 4-stage scale developed by the WOCN Society. RESULTS: Sixteen patients (4.7%) developed a total of 22 pressure ulcers. Sensitivity and specificity of Braden scores were calculated for the day of surgery and for postoperative days 1, 3, and 5. The established Braden "cutoff" score of < or = 16 to identify those "at risk" had poor specificity and sensitivity in this patient population. The appropriate cutoff score varied by hospital day. A preoperative Braden score of 22 correctly classified 50% of the pressure ulcer-positive patients. The appropriate cutoff scores on postoperative day 1, 3, and 5 were 13, 14, and 20, respectively. Those scores correctly classified 67% of the pressure ulcer-positive patients on postoperative day 1, 57% on postoperative day 3, and 50% on postoperative day 5. CONCLUSION: These results illustrate that optimum prediction of pressure ulcer risk can only be accomplished with reassessments and determination of the Braden cutoff score or scores that are reflective of the patient's changing clinical condition throughout the hospitalization.

Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence.

OBJECTIVE: To determine physician and nurse adherence with sedative, analgesic, and neuromuscular blocking agent guidelines in the management of mechanically ventilated patients in a medical intensive care unit. DESIGN: Prospective cohort study. SUBJECTS: One hundred consecutively admitted patients to a medical intensive care unit who required mechanical ventilatory support. A sample of 29 nurses, residents, and attending physicians were interviewed regarding their attitudes and perceptions of the guidelines. MEASUREMENT: Data were collected from concurrent medical records and included the following: demographic characteristics; clinical variables; physician prescriptions of sedative, analgesic, and/or neuromuscular blocking agents; nurse administration of these medications; documentation of monitoring; and assessment of patient hemodynamic status and behaviors. A semistructured interview was elicited from both nurses and physicians about their rationale for the use or nonuse of the guidelines. RESULTS: Patients ranged in age from 24 to 87 yrs, mean 60.7 (+15.3) yrs. Admission Acute Physiology and Chronic Health Evaluation III scores ranged from 36 to 192, mean 93.8 ( 30.5) and median 88. Length of mechanical ventilatory support ranged from 1 to 112 days, mean 14.8 ( 20.0) days, and median 8 days; medical intensive care unit length of stay ranged from 1 to 46 days, with a mean of 9.8 ( 8.1) days and a median of 8 days. Of the 100 patients, 47% died, 28% returned home, and 25% were discharged to a nursing facility. Eighty-five patients were administered one or more sedative, analgesic, and/or neuromuscular blocking agent, range 1-9 drugs, mean 2.5 (+1.5) drugs. Physicians prescribed 14 different medications; the most commonly administered drug was lorazepam (n = 71), followed by morphine (n = 39). Physicians and nurses had partial or total adherence to the guidelines in 58% of patients. The initial choice of the drug followed the guidelines in 60% of patients; the overall guideline was followed in 23% of patients. The most common rationales for nonadherence to the guidelines stated by both physicians and nurses were patient-specific factors, resident guideline learning curve, and physician medication preferences. CONCLUSION: Most patients required treatment for agitated behaviors. The majority of treatment regimens partially or totally adhered to the guidelines. Factors such as patient-specific disease states, resident guideline learning curve, and physician preferences of medications may have decreased adherence. Improving adherence to the guidelines is essential to assess their effectiveness in improving clinical outcomes.

Substance abuse and the hospitalized elderly.

Health care professionals frequently fail to recognize and address the misuse and abuse of alcohol and drugs in the elderly. Estimates of alcohol abuse in the older adult population range from 4% to 20% in the community dwelling elderly and up to approximately 25% among hospitalized older adults (Adams & Cox, 1995; Adams & Kinney, 1995; Beresford et al., 1990). In addition, the present population of older adults consumes 2-3 times more psychoactive medications than younger age groups (Sheahan et al., 1995). The effects of alcohol and substance abuse in older adults are influenced by physical, developmental, and psychosocial changes that occur with aging. Identification of alcohol and substance abuse presents a challenge for health care providers as older adults often present with atypical symptoms. Accurate diagnosis allows for the initiation of interventions for both immediate and long-term treatment.

Help the health care team release its hold on restraint.

As part of a three-site cooperative physical restraint reduction program in acute-care hospitals, a multidisciplinary team created a survey instrument to measure staff's knowledge, unit beliefs about practice patterns, ethical concerns, and more.

Standard of practice protocol: acute confusion/delirium. NICHE Faculty.

Acute confusion, also known as delirium, is a prevalent disorder that contributes to poor outcomes of care. Because of their inability to think clearly, delirious patients are unable to care for themselves and often exhibit unsafe behaviors, resulting in an increased use of physical and pharmacologic restraints. Consequently, the goal of this article is to delineate prevention and treatment guidelines for acutely confused patients and thereby improve nursing care for this vulnerable patient population.

Prevalence and patterns of physical restraint use in the acute care setting.

Nurse executives usually have the principal responsibility to respond to the national movement to reduce physical restraint use in hospitals. The results of this three-site, interdisciplinary, prospective incidence study (based on more than 49,000 observations collected on 18 randomly selected days) reveal new patterns in the rationale and types of restraints used. The authors discuss how the results can be used in measuring success and allocating resources for restraint reduction programs.

Physical restraints in the acute care setting: issues and future direction.

The pattern and prevalence of physical restraint in hospital settings have changed over the past decade. The challenge to health professionals who wish to reduce or eliminate the use of restraints includes clinical, ethical, and legal concerns. Factors that influence health care providers' decisions regarding whether to use physical restraints include organizational characteristics and systems of care, environmental characteristics, and specific clinical guidelines or protocols, as well as individual patient characteristics. To reduce the incidence of physical restraint, hospital professionals need to develop and test feasible alternative practices using an interdisciplinary approach that addresses organizational, environmental, and patient-specific factors.

Developing better critical paths in healthcare: combining 'best practice' and the quantitative approach.

Critical paths are tools to manage healthcare delivery and ensure favorable patient outcomes. Unfortunately, many of these paths are not evaluated or revised after their initial development. One potential problem faced by nursing managers is that critical paths may lose relevance in a rapidly changing healthcare environment. The authors suggest one strategy to strengthen existing critical paths in a way that is responsive to these changes.

A nonpharmacologic sleep protocol for hospitalized older patients.

OBJECTIVES: To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative-hypnotic drug (SHD) use. DESIGN: Prospective cohort study. SETTING: A 34-bed general medical unit in a university-affiliated teaching hospital. PARTICIPANTS: A total of 175 consecutive admissions aged 70 years or older. INTERVENTION: A nonpharmacologic sleep protocol consisting of a back rub, warm drink, and relaxation tapes was administered by nursing personnel to patients who complained of difficulty initiating sleep or who requested a SHD. After 1 hour, if the patient still requested it, the nurse administered the SHD. MEASUREMENTS: The main outcomes of sleep quality and SHD use were measured by patient interview and chart abstraction. Feasibility and adherence to the protocol were tracked daily by patient and nurse interviews and chart abstraction. RESULTS: A cohort of 111 patients, mean age 79.3 (+/- 6.4), 68% women, received the sleep protocol. Patients required the protocol for a mean of 4.9 days per patient, totalling 539 patients-days. The overall adherence rate was 400/539 (74%) patient-days. The rate of complete nonadherence was 139/539 (26%), with reasons for nonadherence including nurse nonadherence in 30 (6%), patient refusal in 104 (19%), and medical contraindications in five (1%). The quality of sleep correlated strongly with the number of parts of the protocol received, suggesting a dose-response relationship, with the highest correlation for receiving two to three parts (p = .64, P < 0.001). The sleep protocol was successful in reducing SHD use from the baseline preintervention rate of 51/94 (54%) to 34/111 (31%) (P < .002). The sleep protocol had a stronger association with quality of sleep (p = .75, P = .001) than did SHDs (p = .07, P = .45). However, chronic SHD users were more likely to refuse the protocol than nonusers (64% vs 41%, P < .03) and received SHDs 4.5 times more often than nonusers (67% vs 15%, P = .001). CONCLUSION: The nonpharmacologic sleep protocol provides a feasible, effective, and nontoxic alternative to SHDs to promote sleep in older hospitalized patients. Use of the protocol can substantially decrease use of SHDs.

Characteristics and outcomes of patients who self-extubate from ventilatory support: a case-control study.

OBJECTIVE: To identify factors associated with the occurrence of deliberate self-extubation and to describe associated patient outcomes. DESIGN: Case-control study. SETTING: ICUs of a national referral, tertiary medical center. PARTICIPANTS: Fifty adult, intubated patients who had self-extubated from mechanical ventilatory support. Two control subjects who had not self-extubated were matched to each case based on age, gender, primary discharge diagnosis, and time hospitalized (within same quarter). MEASUREMENTS: Standardized coding of medical record information, including demographic characteristics, clinical information, intubation and mechanical ventilation characteristics, medications, and selected laboratory indexes. RESULTS: As compared to the control subjects, patients who self-extubated were more likely to be medical than surgical patients (p<0.001) and have a current history of smoking (p<0.05). Prior to the self-extubation, patients had a greater likelihood of hospital-acquired infections (p<0.001) or other hospital-acquired adverse events (p<0.001), abnormal (<10, >50 mg/dL) BUN (p<0.05), and abnormal (<20, >50 mm Hg) PaCO2 (p<0.05); they also were more likely to be restless or agitated (p<0.001), and more likely to be physically restrained (p<0.001). A logistic regression model demonstrated that presence of restlessness or agitation and presence of a hospital-acquired adverse event were independently associated with self-extubation from mechanical ventilatory support. In examining outcomes, as compared to the control subjects, those who self-extubated had longer lengths of stay in ICU and hospital, were more likely to need reintubation, and were more likely to suffer complications from intubation. However, none of the cases died within 48 h of self-extubation. CONCLUSION: The results underscore the need for clinical guidelines for weaning and for monitoring patients at risk of self-extubation.

Evaluation of an orientation system for newly employed registered nurses.

In this article, the authors discussed the successful evaluation of an orientation system for newly employed registered nurses in a large teaching hospital using the IOP model. This methodology can be successfully applied to any educational program that is consolidated into an organization's goals. Although not well examined, orientation has been reported to be costly (Bethel, 1992; del Bueno, Weeks, Brown-Stewart, 1987). The system presently used at this hospital uses at least 1 week of a nurse educator's time, 3-10 weeks for a newly employed registered nurse, and 3-10 weeks for a preceptor RN. Such an investment of personnel resources mandates examination of the processes and outcomes of the program to ensure newly employed RNs become competent practitioners as efficiently as possible. The use of the IOP model particularly was useful in examining a complex orientation system in a multicentered hospital. Use of this systematic program evaluation separated the overall orientation process into workable components. Tools, such as the algorithm, allowed for easy visualization and comprehension of the process steps. This was indispensable because of the number and scope of people involved in the orientation program. The evaluation process was impartial and focused on the program steps, not on the individuals. Because of this impartiality, people were able to gather and work cohesively to improve the overall program. Use of the IOP model assisted the nurse educators in determining that PBDS was not achieving the goal of identifying individual learning needs. Rather, PBDS was a useful tool in establishing baseline competency of newly employed RNs. The system clearly identified those individuals who had above average knowledge bases and those individuals who had more learning needs. For those with more learning needs, PBDS provides a starting point for planning a structured orientation. Thus, a Phase II PBDS assessment could be used as a more unit-specific assessment to validate whether the RN has achieved the orientation objectives. Although the IOP model is not a strict research methodology, it is appropriate for examination of a program as fluid and ongoing as this. Finally, ongoing run charts or statistical trends will assist the nurse educators in monitoring the quality and effectiveness of the orientation program.

Improving care givers' satisfaction with information received during hospitalization.

As competition for patient volume escalates among hospital providers, administrators must identify ways to attract new patients and maintain or increase patient volume. Family care givers are known to greatly influence individuals' choices in these matters of selection of healthcare services and providers. The results of a successful nurse-initiated daily phone calls program, designed to improve family care giver satisfaction by enhancing the provision of patient-specific information, are presented. The components of the program, associated costs, and implications on delivery of care are discussed.