ReviewDelirium screening in intensive care: A life saving opportunity
Introduction
A primary nursing concern is the provision of high quality and skilled evidence based care (NMC, 2015). Nowhere is this more apparent than in the intensive care environment, where arguably the hospital’s sickest patients are found, often supported with one to one care (Woodrow, 2002). It is an area where dedicated and expert interventions are needed in order to improve health outcomes. The Scottish Intensive Care Safety Audit Group (SICSAG) (SICSAG, 2015) have recently outlined a number of key indicators to improve and ensure patient safety. In this article we focus on the risk of delirium; an acute fluctuating deterioration of cognition (Manning et al., 2012) and a widely recognised hazard for people cared for in Intensive Care Units (ICU) that leads to increased morbidity and mortality (Woodrow, 2002). Delirium is a condition requiring daily risk assessment (SICSAG, 2015).
‘Think delirium’ is a policy created in line with the most recent recommended clinical guidelines (NICE, 2010) which promotes the rapid diagnosis and effective treatment of an episode of delirium. If delirium is effectively identified and treated, significant financial and human cost could be saved (NICE, 2014). Current NICE (2010) guidelines recommend screening for those with risk factors such as being 65 or older, cognitive impairment or severe illness. SICSAG (2015) however recommend blanket screening in an ICU environment to address the needs of the critically ill and negate the significant risk of a patient slipping through the cracks.
This review of best practice was undertaken as part of an undergraduate nursing assignment to explore the topic of delirium in contemporary critical care [Box 1]. A literature search was carried out using MEDLINE and CINAHL and databases. Wider searching generated numerous hits [Box 2]. From reading and expert discussions, issues to do with effective assessment and barriers to assessment were identified as contemporary issues. This was supported by the literature (Page et al., 2009, Scott et al., 2013, Elliott, 2014). A further hand search of this literature yielded five pathophysiology results, assessment tool papers and three papers regarding barrier for consideration in depth. What follows is a narrative review which aims to present a rigorous synthesis of best practice.
Section snippets
Pathophysiology of delirium
Delirium was first described over 2500 years ago however its exact pathophysiology is poorly understood (Inouye et al., 2014). Its medical sequelae are still often misconstrued as a psychiatric condition. This poses particular risk in the acute care setting where less regard may be paid to such conditions and thus crucial diagnoses could be missed. Delirium is referred to as acute brain failure (Inouye et al., 2014) and constitutes a medical emergency (Manning et al., 2012). Even one episode of
ICU Delirium Screening Tools
Whilst not utilised routinely, tools exist which can aid healthcare professionals in screening for delirium in ICU: Scott et al., 2012) however barriers exist [Box 4]. NICE (2010) guidelines recommend delirium screening using the CAM-ICU tool when indicators of delirium are present. Two small studies were selected because they considered use of delirium screening tools on a daily basis.
van Eijk et al. (2009) conducted a prospective study based in a mixed critical care setting in the
Barriers to routine delirium screening
SICSAG outlines a number of recommendations for best practice in intensive care settings. Their recent guidelines state that “All patients in Critical Care will be screened for delirium at least once per day using a standardised screening tool” (SICSAG, 2015 pp. 10). It is clear that routine screening is recommended in Scottish hospitals, yet literature indicates practice to the contrary (Mac Sweeney et al., 2010). The very nature of intensive and critical care means there is a need for
Conclusion
One limitation of this review is that it focuses on westernised literature. It is recognised that definitions of delirium vary in different countries and contexts. International guidelines on the recognition and management of delirium are urgently required. However this review illuminates best practice within the author’s clinical context.
SICSAG suggests routine daily screening for delirium (2015). This recommendation is complemented by NICE guidelines (2010) when considering the patient with
Conflict of interest
The authors state no conflict of interest.
Funding
No funding was sought for this work.
Ellen Lamond is a final year student nurse on the BSc Hons Nursing programme at Queen Margaret University who became interested in delirium screening in ICU while studying about recognition and management of deteriorating patients in theory and in clinical practice placement.
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Ellen Lamond is a final year student nurse on the BSc Hons Nursing programme at Queen Margaret University who became interested in delirium screening in ICU while studying about recognition and management of deteriorating patients in theory and in clinical practice placement.
Scott Murray is Liaison Psychiatry Nurse Specialist, Borders General Hospital, Melrose and Associate Lecturer, QMU, Edinburgh.
Caroline Gibson is Senior Lecturer in Nursing, QMU Edinburgh.