Occurrence of delirium is severely underestimated in the ICU during daily care

Delirium is associated with prolonged intensive care unit (ICU) stay and higher mortality. Therefore, the recognition of delirium is important. We investigated whether intensivists and ICU nurses could clinically identify the presence of delirium in ICU patients during daily care. All ICU patients in a 3-month period who stayed for more than 48 h were screened daily for delirium by attending intensivists and ICU nurses. Patients were screened independently for delirium by a trained group of ICU nurses who were not involved in the daily care of the patients under study. The Confusion Assessment Method for the ICU (CAM-ICU) was used as a validated screening instrument for delirium. Values are expressed as median and interquartile range (IQR; P25-P75). During the study period, 46 patients (30 male, 16 female), median age 73 years (IQR = 64-80), with an ICU stay of 6 days (range 4-11) were evaluated. CAM-ICU scores were obtained during 425 patient days. Considering the CAM-ICU as the reference standard, delirium occurred in 50% of the patients with a duration of 3 days (range 1-9). Days with delirium were poorly recognized by doctors (sensitivity 28.0%; specificity 100%) and ICU nurses (sensitivity 34.8%; specificity 98.3%). Recognition did not differ between hypoactive or active status of the patients involved. Delirium is severely under recognized in the ICU by intensivists and ICU nurses in daily care. More attention should be paid to the implementation of a validated delirium-screening instrument during daily ICU car

Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit

BACKGROUND: Delirium is a frequently missed diagnosis in the intensive care unit (ICU). Implementation of the Confusion Assessment Method for the ICU (CAM-ICU) may improve recognition of delirium. However, the ICU team may be reluctant to adopt daily assessment by a screening tool. This report focusses on the obstacles and barriers encountered with respect to organisational context and prevailing opinions and attitudes when implementing the CAM-ICU in daily practice in a Dutch ICU. METHODS: A structured implementation process was set up comprising four phases: (1) assessing the current situation to understand behaviour towards delirium; (2) the identification of barriers to the implementation of the CAM-ICU; (3) preparation of the ICU team for a change in attitude; and (4) evaluation of the effects of implementation. RESULTS: Phase 1 demonstrated that there was no delirium protocol available; it was left to the attending physicians when and how to diagnose delirium in each individual patient. In addition, nurses acted on delirium in a non-structured way; nurses thought implementation of the CAM-ICU would be very time-consuming and would not add to their ability in recognising delirium. In Phase 2, several barriers to implementation were addressed. Firstly, all nurses had to be convinced that delirium is an important problem and, secondly, logistics had to be put in place, for example, picture cards at every bedside, communication between daily nurses and a delirium working group had to be improved. In Phase 3, 10 nurses were educated to perform the CAM-ICU through several training sessions which included videos to illustrate different delirium states; these trained nurses educated all other nurses. A check box in the daily records was introduced to denote whether the CAM-ICU had been performed. In Phase 4, after a training period and 2 months of actual routine bedside CAM-ICU performance, evaluation demonstrated that frequency of assessments on un-sedated patients had increased from 38% to 95% per nursing shift. A short survey amongst the ICU nurses also showed that awareness of delirium and appreciation of the clinical problem had markedly increased. CONCLUSION: Implementation of the CAM-ICU in daily critical care is feasible. A structural training programme is probably helpful for success of implementatio