Relationship Between Delirium and Ventilatory Outcomes in the Medical Intensive Care Unit.

BACKGROUND: Delirium is a common neuropsychiatric diagnosis in intensive care units and often leads to extended hospital stays and an increased rate of complications. Delirium can be classified as hypoactive, hyperactive, or mixed. Hyperactive delirium is often accompanied by agitation, which is a predictive factor for unplanned extubation. Hypoactive delirium does not include outward agitation; its incidence and relationship to ventilatory outcomes, specifically unplanned extubation and duration of mechanical ventilation, are relatively unexplored. OBJECTIVE: To determine the occurrence rate of each delirium type in the first 7 days after intensive care unit admission and explore the relationship between delirium type and ventilatory outcomes. METHODS: This was a retrospective cohort study that enrolled adult patients consecutively admitted to a medical intensive care unit over 12 months. Data were abstracted on patient demographic variables, daily clinical variables (morning and evening delirium, coma, and sedation scores), and outcome variables (unplanned extubation, length of stay, and duration of mechanical ventilation). RESULTS: We enrolled 171 patients in the study. Hypoactive delirium occurred in up to 44% of patients. Of 25 instances of unplanned extubation, up to 74% of patients had hypoactive delirium. Delirium was not a predictor of unplanned extubation; smoking history, chronic obstructive pulmonary disease, and failed breathing trials best predicted unplanned extubation (odds ratios = 3.2, 5.2, and 12.6, respectively; P < .05). CONCLUSIONS: Hypoactive delirium is common among intensive care unit patients and may precede unplanned extubation. Patient history and comorbidities remain the strongest predictors of unplanned extubation.

Hyperactive Terminal Delirium in Hospice Patients: A Retrospective Cohort Study.

Terminal delirium is a common occurrence in patients at the end of life, and its presence is widely accepted as a poor prognostic indicator. The hyperactive subtype is characterized by psychomotor agitation that is distressing to patients, caregivers, and providers. The purpose of this study was to determine whether physical, psychosocial, or spiritual data collected at hospice admission are associated with development of hyperactive terminal delirium. In this retrospective cohort study, 154 patients were assigned to one of two cohorts depending on whether or not they had signs of hyperactive terminal delirium. Hospice admission data from the Hospice Item Set, psychosocial assessment, and spiritual assessment were analyzed using descriptive statistics, inferential statistics, and logistic regression. Although there were no statistically significant relationships among the physical, psychosocial, and spiritual variables and hyperactive terminal delirium, there were some findings that are clinically significant for nurses caring for patients at the end of life. Specifically, this study highlights the importance of ongoing physical, psychosocial, and spiritual assessment throughout the end-of-life trajectory, as well as prompt management of symptoms.

Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit.

AIMS AND OBJECTIVES: To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit. BACKGROUND: Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence-based practice or custom and culture. STUDY DESIGN: Integrative review. METHOD: Seven health sciences databases were searched to identify published and grey literature (1995-2019), with additional hand-searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken. RESULTS: A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint. CONCLUSIONS: There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision-makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated. RELEVANCE TO CLINICAL PRACTICE: Delirium and agitation pose a potential threat to patient safety and the maintenance of life-preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence-based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.

A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care Unit.

BACKGROUND: In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment. OBJECTIVES: The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes. METHODS: Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved. RESULTS: Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001). CONCLUSIONS: The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.

Multiprofessional care for delirium patients in intensive care: integrative review. / Cuidados multiprofissionais para pacientes em delirium em terapia intensiva: revisão integrativa.

OBJECTIVE: To describe the multiprofessional care for the management of critical patients in delirium in the ICU from the evidences found in the literature. METHODS: This integrative review was carried out in the period from February 1 to June 30, 2016 through searches on PubMed, Scopus, Web of Science, and CINAHL, with the following descriptors: delirium, critical care e intensive care units, which brought up 17 original papers. RESULTS: A bundle and a guideline, two systematic reviews, evidence 1a and four clinical trials, evidence 1b and 2b, cohort and observational studies were found. The multiprofessional care was presented to better understand the diagnosis of delirium, sedation pause, early mobilization, pain, agitation and delirium guidelines, psychomotor agitation, cognitive orientation, sleep promotion, environment and family participation. CONCLUSION: The care for delirium is wide and not specific, which determines its multifactorial aspect.

Paroxysmal Sympathetic Hyperactivity Syndrome Following Traumatic Brain Injury.

Paroxysmal sympathetic hyperactivity (PSH) is a syndrome classified by episodic presentation of abnormal sympathetic and motor symptoms observed in patients with acquired brain injuries. Although the exact physiologic mechanism of PSH is not fully understood, its clinical significance has been well-established. PSH diagnosis depends on the identification of symptom presence, severity, and patterns. Treatment of PSH is rooted in pharmacologic management of targeted symptoms. Although complex, recognition and management of PSH has meaningful implications on the hospitalization and recovery trajectory for adult patients with traumatic brain injuries.

Evaluation of Richmond Agitation Sedation Scale (RASS) in Mechanically Ventilated in the Emergency Department.

The purpose of this study was to assess Richmond Agitation Sedation Scale (RASS) goal implementation in mechanically ventilated patients sedated in the emergency department (ED), compliance with RASS, and goal achievement. This study was a retrospective chart review at a large Level I trauma academic medical center. Patients who were intubated in the ED or en route to the ED between October 1, 2013, and October 1, 2014, were eligible for inclusion if they met the following criteria: aged 18 years or older, 24 hr or more on mechanically ventilated support receiving continuous sedation and/or analgesia during the first 48 hr of admission, and a hospital stay of 6 days or more. There were 205 patients identified; 104 failed inclusion, 101 were enrolled, and 62 were excluded. Thirty-nine patients (94.9%) had an RASS goal implemented in the ED, of which 37 patients (81.1%) had an RASS goal set by an ED physician. Assessment of the RASS was found to be inconsistent, as 56.8% of patients were evaluated by an ED nurse within 1 hr of sedative initiation. Of the 37 patients who had an RASS goal in the ED, 18.9% achieved their goal in the ED. A review of sedation prescribing revealed that 39% received a regimen of varied combinations of continuous infusions of propofol, dexmedetomidine, and midazolam throughout admission, 33% received a regimen of 2 of the aforementioned drugs, and 28% received only propofol. Median extubation time was 129 hr. Seven patients expired within 180 days of admission. The assessment of the RASS was a common practice, but there were inconsistencies in measurement. A limited number of patients achieved their RASS goal in the ED. These results support a provider and nursing knowledge deficit regarding RASS goal setting, proper documentation of RASS measurement, and the need for appropriate assessments.

Designing a nurse-delivered delirium bundle: What intensive care unit staff, survivors, and their families think?

BACKGROUND: Implementation of quality improvement interventions can be enhanced by exploring the perspectives of those who will deliver and receive them. We designed a non-pharmacological bundle for delirium management for a feasibility trial, and we sought to obtain the views of intensive care unit (ICU) staff, survivors, and families on the barriers and facilitators to its implementation. OBJECTIVE: The objective of this study is to determine the barriers and facilitators to a multicomponent bundle for delirium management in critically ill patients comprising (1) education and family participation, (2) sedation minimisation and pain, agitation, and delirium protocol, (3) early mobilisation, and (4) environmental interventions for sleep, orientation, communication, and cognitive stimulation. METHODS: Nine focus group interviews were conducted with ICU staff (n = 68) in 12 UK ICUs. Three focus group interviews were conducted with ICU survivors (n = 12) and their family members (n = 2). Interviews were digitally recorded, transcribed, and thematically analysed using the Braun and Clarke framework. RESULTS: Overall, staff, survivors, and their families agreed the bundle was acceptable. Facilitating factors for delivering the bundle were staff and relatives' education about potential benefits and encouraging family presence. Facilitating factors for sedation minimisation were evening ward rounds, using non-verbal pain scores, and targeting sedation scores. Barriers identified by staff were inadequate resources, poor education, relatives' anxiety, safety concerns, and ICU culture. Concerns were raised about patient confidentiality when displaying orientation materials and managing resources for early mobility. Survivors cited that flexible visiting and re-establishing normality were important factors; and staff workload, lack of awareness, and poor communication were factors that needed to be considered before implementation. CONCLUSION: Generally, the bundle was deemed acceptable and deliverable. However, like any complex intervention, component adaptations will be required depending on resources available to the ICU; in particular, involvement of pharmacists in the ward round and physiotherapists in mobilising intubated patients.

Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial.

BACKGROUND: Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost. METHODS AND FINDINGS: This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group. CONCLUSIONS: These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting. TRIAL REGISTRATION: ISRCTN Registry ISRCTN62237498.

Patient agitation and its management in adult critical care: A integrative review and narrative synthesis.

AIMS AND OBJECTIVE: To critically review the evidence relating to the management of agitation within the Adult Critical Care Unit environment and identify any risks and benefits of current management strategies. BACKGROUND: Admission to an Adult Critical Care Unit can be traumatic and potentially life altering for the patient. Patient agitation is common in Adult Critical Care Units and is associated with the potential for harm. Despite inherent safety risks, there is a paucity of evidence-based guidance underpinning the care of agitation in patients with critical illness. STUDY DESIGN: Integrative review and narrative synthesis. METHODS: A systematic procedure for searching and selecting the literature was followed and applied to databases including CINAHL, British Nursing Index, Cochrane Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts were analysed using a structured narrative review approach. RESULTS: A total of 208 papers were identified and following a systematic deselection process 24 original articles were included in the review. It was identified that agitation in the setting of Adult Critical Care Unit is associated with high-risk events such as unplanned removal of life-supporting devices. There were consistent links to sepsis, previous high alcohol intake and certain medications, which may increase the development of agitation. Prompt assessment and early liberation from mechanical ventilation was a major contributing factor in the reduction in agitation. Administration of antideliriogenic mediation may reduce the need for physical restraint. There was repeated uncertainty about the role of physical restraint in developing agitation and its effective management. CONCLUSIONS: Our review has shown that there is a dearth of research focusing on care of agitated patients in the Adult Critical Care Unit, despite this being a high-risk group. There are dilemmas for clinical teams about the effectiveness of applying physical and/or pharmacological restraint. The review has highlighted that the risk of self-extubation increases with the presence of agitation, reinforcing the need for constant clinical observation and vigilance. RELEVANCE TO CLINICAL PRACTICE: The importance of ensuring patients are re-orientated regularly and signs of agitation assessed and acted upon promptly is reiterated. Early identification of specific patient profiles such as those with previous high alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the restriction of ventilation and encouragement of family or loved ones involvement in care need to be considered.

Management of behavioural and psychological symptoms of dementia by an aroma-massage with acupressure treatment protocol: A randomised clinical trial.

AIMS AND OBJECTIVES: This study evaluates the clinical effectiveness of a multicomponent aroma-massage with an acupressure treatment protocol and compared it to cognitive training for the management of behavioural and psychological symptoms of dementia. BACKGROUND: Pharmacological interventions have been unsatisfactory in managing behavioural and psychological symptoms of dementia; thus, complementary and alternative medicine has been extensively researched to identify an adjunct safe and cost-effective intervention. DESIGN: This randomised clinical trial utilised a three-arm parallel group design. Cognitive training was used as a conventional intervention to manage behavioural and psychological symptoms of dementia, whereas exercise was considered "treatment as usual" in this study; both were used as comparisons with the experimental protocol. There were three treatment groups: Group 1: aroma-massage with acupressure + exercise, Group 2: cognitive training + exercise and Group 3: aroma-massage with acupressure + cognitive training. METHOD: Sixty older adults were recruited and randomly assigned to the three groups (20 each). Using the 29-item Chinese Version of the Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, Mini-mental State Examination and Barthel Index-20, the outcome measures were assessed at preintervention, postintervention and the 3-month follow-up to assess behaviour, Activities of Daily Living, cognition, and behavioural and psychological symptoms of dementia severity and distress. Multiple comparisons performed through repeated measures were analysed to detect between-group differences and within-subject differences, as well as the interaction effects between groups and times. RESULTS: The Group 1 and 3 participants showed a significant reduction in the severity and distress caused by behavioural and psychological symptoms of dementia, whereas Group 2 did not demonstrate similar effects. CONCLUSIONS: This clinical study suggests that aroma-massage with acupressure is as effective as cognitive training and can enhance cognitive training in reducing the severity and distress of behavioural and psychological symptoms of dementia. RELEVANCE TO CLINICAL PRACTICE: Aroma-massage with acupressure may serve as an adjunct therapy to reduce behavioural and psychological symptoms of dementia. This therapy is safe, cost-effective and can be implemented by caregivers and family members who are not professionally trained.

Feasibility of a Nurse-Managed Pain, Agitation, and Delirium Protocol in the Surgical Intensive Care Unit.

BACKGROUND: Society of Critical Care Medicine guidelines recommend the use of pain, agitation, and delirium protocols in the intensive care unit. The feasibility of nurse management of such protocols in the surgical intensive care unit has not been well assessed. OBJECTIVES: To evaluate the percentage of adherent medication interventions for patients assessed by using a pain, sedation, and delirium protocol. METHODS: Data on all adult patients admitted to a surgical intensive care unit from January 2013 through September 2013 who were assessed at least once by using a pain, sedation, and delirium protocol were retrospectively reviewed. Protocol adherence was evaluated for interventions implemented after a nursing assessment. Patients were further divided into 2 groups on the basis of adherence, and achievement of pain and sedation goals was evaluated between groups. RESULTS: Data on 41 patients were included. Of the 603 pain assessments, 422 (70.0%) led to an intervention adherent to the protocol. Of the 249 sedation assessments, 192 (77.1%) led to an adherent intervention. Among patients with 75% or greater adherent pain interventions, all interventions met pain goals with significantly less fentanyl than that used in interventions that did not meet goals. Despite 75% or greater adherence with interventions for sedation assessments, only 8.7% of the interventions met sedation goals. CONCLUSIONS: A nurse-managed pain, agitation, and delirium protocol can be feasibly implemented in a surgical intensive care unit.

[From constraint to containment through the nursing link]. / De la contention à la contenance par le lien soignant.

The implementation of a sufficiently strict, adapted care setting provides constructive support for a move away from isolation and restraint towards new spaces of freedom. The account of the evolutive management of a patient by a nursing team in Bourg-en-Bresse, presents possible therapeutic strategies.

Reading as a Nursing Intervention for Agitation in Patients With Anoxic Brain Injury.

PURPOSE: The purpose of this article is to describe and recommend reading as a nursing intervention for agitated patients with anoxic brain injury. DESIGN: The design of this study is a case report of the results from reading to an agitated patient with anoxic brain injury. METHODS: Observation of the effects of reading to an agitated patient. FINDINGS: Fifteen minutes of reading to an agitated patient during the evening hours had a calming effect. CONCLUSIONS: Reading to agitated patients is an additional nursing intervention with little risk and represents efficient, patient-centered care. CLINICAL RELEVANCE: Reading is a successful nursing intervention that has a calming effect on agitated patients.

CE: Assessing and Managing Pain, Agitation, and Delirium in Hospitalized Older Adults.

: In the acute care setting, pain, agitation, and delirium (PAD) often occur as interrelated parts of a syndrome rather than as separate entities. Because the three facets of PAD may be similar in presentation, it is often difficult for clinicians to recognize the syndrome and to assess and treat it. The challenge is particularly great in older patients, who are more likely than their younger counterparts to have such comorbid conditions as dementia, which may impair the ability to report pain, or age-related physiologic changes that may affect the metabolism and clearance of certain medications. This article provides an overview of each aspect of PAD, discusses clinical considerations related to the assessment and treatment of the syndrome in older adults receiving acute care, and illustrates the application of published PAD guidelines through the use of a hypothetical patient scenario.

Sensory stimulation for persons with dementia: a review of the literature.

AIMS AND OBJECTIVES: To provide an overview of available sensory stimulation interventions, and their effect on persons with dementia and to present theoretical and methodological characteristics of the studies included. BACKGROUND: Different sensory stimulation interventions are used for persons with dementia to increase alertness, reduce agitation and improve quality of life. However, the effect of these interventions is not clear, neither are their characteristics. DESIGN: A systematic search and review of the literature with description of the content and an evaluation of theoretical and methodological approaches. METHODS: Systematic searches in CINAHL, PubMed (Medline), The Cochrane library and PsycINFO. Studies included have been subject to quality assessment by means of Critical Appraisal Skills Programme. RESULTS: Fifty-five studies were included and thirty of these documented significant effect. The effect of the sensory stimulation interventions mainly reported on negative behaviours, except from five studies assessing quality of life and well-being. The majority of the studies had methodological limitations. The different sensory stimulation interventions were organised into eight categories: music, light therapy, acupressure/reflexology, massage/aromatherapy and doll therapy/pet therapy/toy therapy, the Sonas programme and Snoezelen. CONCLUSIONS: More studies are needed to clarify appropriate substantial background for the specific interventions. However, most of the studies based their interventions on a theoretical foundation. Furthermore, more research is needed to measure the effect of sensory stimulation on communication as well as quality of life. In addition, studies are to focus on whether the effect depends on the stage of dementia. RELEVANCE TO CLINICAL PRACTICE: Nurses are to be aware of sensory stimulation as a possible intervention to improve persons' quality of life.