Knowledge-to-Action Case Report: Improving ICU Delirium Management at the Point of Care Allana LeBlanc, BScN, RN, CNCC(C), Vininder K. Bains, BScN, RN, CNCC(C), Simmie Kalan, BSN, RN, Christina Choung BScN, RN. INTRODUCTION & BACKGROUND
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Although delirium is associated with increased morbidity and mortality in critically ill patients, it is often unrecognized and untreated in practice1. Nurse-led activities such as regular screening, pain management, early mobilization, and sleep promotion are recognized best practices. The knowledge-to-action process2 conceptualizes the relationship between knowledge creation and action. The knowledge-to-action cycle (KTA Cycle) represents activities that may be used to apply knowledge in practice. Our aim is to engage the VGH ICU team in an action cycle that translates current knowledge and best practices for ICU delirium into practice. Prior research3,4 has revealed that the of difficulty evaluating sedated and ventilated patients, lack of knowledge about delirium, and physician indifference are barriers to uptake of best practice recommendations for delirium management in critically ill patients In 2010, the VGH ICU began adapting this knowledge to its local context by using the Intensive Care Delirium Screening Checklist (ICDSC)5. It also offered in-services and a multidisciplinary education day regarding the importance of delirium in critical care in order to keep up to date with current, best-practice guidelines.
Figure A. Experiences from a Post-ICU Syndrome and PTSD victim. Retrieved August 15th, 2013, from: www.nancyandrews.net
METHODS AND MATERIALS ABOUT THE VGH ICU The Vancouver General Hospital (VGH) Intensive Care Unit (ICU) is a 27-bed teaching unit that provides specialized care to patients who are severely ill, suffering from multi-organ failure and/or require ventilation. Specialized quaternary services include care for spinal injuries, neurosurgery, transplants, major burns, plastics, and trauma. A quaternary care referral centre for all of British Columbia, the nursing ratio is generally 1:1.
ACKNOWLEDGEMENTS We would like to thank the VGH ICU staff RNs, Patient Services Manager, nursing leadership team, and physicians, and the Foundations of Knowledge Translation Course Team, St. Michael's Hospital, Toronto, for their generous support of this project.
CONTACT Allana LeBlanc Email: Allana.Leblanc@vch.ca
To assess local barriers to knowledge use, a needs assessment survey was conducted. A total of 186 VGH ICU nurses were invited to participate in an anonymous electronic survey on nurses' knowledge and perspectives about delirium assessment and management in the VGH ICU. The survey was available to participants on a Canadian website accessible from inside or outside the hospital. Questions were adapted from previously published surveys or developed by the project team. The survey was divided into three categories: knowledge, perspectives, and feedback/opinion. Multiple choice knowledge questions measured familiarity with the ICDSC. Perspective questions used the Likert scale and addressed users’ values and comfort regarding both their own and other team members’ delirium assessments. Feedback/opinion questions were open-ended and addressed the issue of identifying delirium management practices, and existing barriers and facilitators, directly from VGH ICU’s point-of-care nurses. The project team analyzed 74 responses (40% response rate) to assess barriers to and facilitators of knowledge use. For Likert-scale and multiple-choice questions, summary statistics were employed. Thematic analysis was used to identify themes common to the open-ended questions. ICDSC scores were obtained from VGH ICU's database for the previous two years.
RESULTS Based on a stable two-year period for ICDSC compliance and scoring, results from the VGH ICU’s database indicate that current compliance rates for ICDSC completion are low. Needs assessment survey results indicate the following: Knowledge: • Nurses possess good general knowledge of the ICDSC. • Some respondents demonstrated gaps in knowledge concerning sleep, mood, and speech. • Many participants expressed difficulty in identifying hypoactive delirium.
Perspectives: Though many nurses felt confident in completing the ICDSC, many respondents questioned the impact of daily screening on patient care.
Figure C. Summary analysis of participants’ responses to each of the survey’s perspectives questions4,6
Figure B. Summary of participants’ responses to question 1 of the survey
Opinions: Themes from free-text responses: • Rounds – reporting of ICDSC score, rounds checklist, sleep, pain management • Sleep Hygiene – education about importance and routine, environmental modification • Pain Management – patient experience, assessment, optimizing management • Consistent Communication – ICDSC completion, reporting, documentation • ICDSC – education regarding effectiveness, importance, specific patient populations • Pharmacology – minimize polypharmacy, appropriate use of PRNs, PPOs/protocols • Buy-In – address clinician indifference, normalization of delirium, prioritization
Figure D. Wordle created from the answers to question 15 of the survey: “In your opinion, how can we improve delirium prevention, assessment, and/or management in VGH ICU?”
CONCLUSIONS
Figure E. The KTA Cycle. Blue bubbles indicate project team’s activities to date.
REFERENCES
1. Barr, J., et al. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263-306. 2. Straus, S., Tetroe, J., Graham, I., (2009). Knowledge translation in health care: Moving from evidence to practice. West Sussex: Wiley Blackwell 3. Devin, J., et al. (2008). Assessment of delirium in the intensive care unit: Nursing practices and perceptions. American Journal of Critical Care, 17(6), 555-566. 4. Law et al., (2012). A survey of nurses’ perceptions of the intensive care delirium screening checklist. Dynamics, 23(4), 18-24. 5. Bergeron, N., et al. (2001). Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Medicine, 6(5), 859-864. 6. Soja, S., et al., (2008). Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients. Intensive Care Medicine, 34, 1263-1268.
Our survey results suggest that individual and environmental factors impact nurses’ ability to translate knowledge into practice. The knowledge-to-action process has proven useful as a way to continue the process of translating knowledge into practice, and is applicable to quality improvement for ICU delirium management. Drawing on survey and database results, we conclude that survey respondents have a strong foundational knowledge of how to use the ICDSC, though there may be a minor knowledge deficit with regards to sleep. Nurses feel comfortable and confident that they can complete the ICDSC accurately, but do not feel that the tool is valued by physicians. Nurses have insights to offer on how to improve delirium management. The survey also revealed barriers and facilitators related to knowledge use similar to those discussed in previous research in the field. The next step in our project is to select, tailor, and implement interventions beginning in September 2013. Based on survey results, our priorities will be: 1) Teamwork and communication within the multidisciplinary team, with a focus on rounds. 2) Education about the importance and effectiveness of the ICDSC with regards to delirium. 3) Education surrounding sleep hygiene, pain management, and pharmacology.