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Evaluation of an Educational Intervention Utilizing Nurse "Champions" and Nurses' Documentation of Intensive Care
Christine E DeForge1, Natalie H Yip, Amy L Dzierba
1Christine E. DeForge, MSN, RN, CCRN, is a PhD student at Columbia University School of Nursing, New York, NY and a staff nurse at New York-Presbyterian/Columbia University Irving Medical Center, New York, NY. Her research and clinical interests include adult critical care nursing and long-term outcomes for critically ill patients. Natalie H. Yip, MD, is an assistant professor of medicine and associate director of Medical Intensive Care Units and Medical Critical Care Service, New York Presbyterian/Columbia University Irving Medical Center, New York, NY. Her research and clinical interests include health services research in critical care. Amy L. Dzierba, PharmD, is a clinical pharmacist and program director of the Critical Care Pharmacy Residency at New York-Presbyterian/Columbia University Irving Medical Center, New York, NY. Her research and clinical interests include sedation/analgesia/delirium in mechanically ventilated patients, pharmacotherapy for the management of ARDS, pharmacokinetic changes in critically ill patients receiving extracorporeal membrane oxygen support, and treatment of patients with pulmonary hypertension. Patrick G. Ryan, MA, MS, RN, NP-C, CNS, CWOCN, CCRN, is a critical care clinical nurse specialist at New York Presbyterian/Columbia University Irving Medical Center, New York, NY. His background is in pulmonary critical care nursing, and has extensive experience with acute respiratory distress syndrome treatment modalities including ECMO and prone positioning. His interests also include strategies to reduce hospital-acquired conditions with concentrations on central line associated blood stream infections and pressure injuries. Elaine L. Larson, RN, PhD, is Anna C. Maxwell Professor Emerita and Special Lecturer, Columbia University School of Nursing, New York, NY, Professor of Epidemiology Emerita, Mailman School of Public Health, Columbia University, New York, NY, and Scholar in Residence at the New York Academy of Medicine, New York, NY. Her research is primarily in infection prevention and control. She was the editor of the American Journal of Infection Control for 25 years.
Background:
Delirium is a common, underdetected problem that has short- and long-term negative sequelae for critically ill patients. Prompt and accurate delirium identification by nurses can ensure early intervention and treatment to help minimize adverse outcomes.
Objectives:
To evaluate the relationship between an educational program and the accuracy of registered nurses' (RNs') documentation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a delirium screening tool.
Methods:
In a medical ICU at a tertiary academic medical center from September 2015 to March 2016, RNs were reinstructed on use of the CAM-ICU. Registered nurse assessment data were collected retrospectively for 12 months before and after intervention and were compared against the CAM-ICU algorithm using χ analysis.
Results:
A total of 10 736 RN assessments in 1020 patients preintervention and 11 068 in 951 patients postintervention were evaluated. Overall RN accuracy improved from 78% to 80% (P = .054). The algorithm determined delirium to be present in 32% versus 30% of all patients preintervention and postintervention, respectively; there was no difference in rate of nurse detection of delirium preintervention and postintervention (54% vs 55%, not statistically significant). The percentage of "inappropriate unable to assess" ratings by nurses decreased from 42% to 37% postintervention (P < .05).
Conclusions:
After a comprehensive training initiative, there was no significant improvement in CAM-ICU documentation and no improvements in patient delirium identification. Future quality improvement efforts should target reducing the number of assessments that RNs judge to be "unable to assess." Clinical practice must evolve to routinely incorporate RN delirium assessments into the patient's plan of care.