Delirium Prevention, Identification and Management in the Oncology Setting: A Unique Partnership with Patients and Their Family Caregivers

Significance & Background: Delirium affects a significant number of hospitalized adults each year resulting in negative patient outcomes and family caregiver distress. Clinical identification of delirium by nurses and use of family caregivers as part of a multicomponent delirium prevention strategy are not consistently implemented in the practice setting despite being best practice.Purpose: An interdisciplinary team in this 800 bed level one trauma center has been created to create and implement this best practice delirium protocol. The purpose of this initiative was to incorporate the family caregiver into this existing multicomponent delirium prevention, detection and management protocol. Interventions: Consistent implementation of basic care interventions and personalized care for at risk patients can help to prevent delirium in the acute care setting. The team has focused on staff education on the use of the CAM (confusion assessment method) as a consistent delirium-screening tool as well as early implementation of the protocol. Use of non-pharmacological interventions can be effective in the prevention of delirium as well as in reduction of the episode if it does occur. Family caregivers can be educated and engaged by the nurse to help create a personalized plan of care. Evaluation: Evaluation of the protocol has been measured by hospital safety and quality metrics such as falls, length of stay, mortality rates as well as patient experience scores.Discussion: Oncology patients are at high risk for delirium and require a team approach to identify this medical emergency early and to begin evidenced based interventions. Cancer care is most often done in the out patient setting making partnerships with family caregivers even more critical. Non-pharmacological interventions are simple and easily taught to family caregivers. These interventions include encouragement of food and drink, ambulation, cognitive stimulation/orienting strategies and protected rest. This opportunity of partnership is missed by nurses and contributes to poor outcomes.Innovative: The identification and treatment of delirium is becoming an international priority as its negative impact to quality of life and the bottom line become undeniable. This medical emergency requires a team approach that includes the family caregiver and a personalized plan of care. The oncology nurse is poised to be an important team member to create positive outcomes

Using Simulated Family Presence to Decrease Agitation in Older Hospitalized Delirious Patients: A Randomized Controlled Trial

Background: Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed. Objectives: To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients. Design: Single site randomized control trial, 3 groups x 4 time points mixed factorial design conducted from July 2015 to March 2016. Setting: Acute care level one trauma center in an inner city of the state of Connecticut, USA. Participants: Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n = 126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia. Methods: Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30 minutes following the intervention. Results: Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p \u3c .001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p \u3c .001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p \u3c .001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p = .001) between family video(60%) and usual care (35.1%) immediately following the intervention Conclusion: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia