Implementation of Delirium Screening in a Community-based Pediatric Intensive Care Unit

Jennifer C. DeLozier Smith, DNP, RN, CNS, CPNP-PC, CPNP-AC; Jonathan D. Feldman, MD; Nancy Crego, PhD, RN, CCRN Alumnus, CHSE

Disclosures

Pediatr Nurs. 2022;48(4):197-203. 

In This Article

Abstract and Introduction

Abstract

The presence of delirium and its sequelae in critically ill pediatric patients is increasingly being recognized. Validated bedside screening tools nurses use have emerged to assist pediatric providers in the early identification of delirium. Nurses' compliance and scoring accuracy of delirium screening tools have improved following education and an increased understanding of delirium. The aims of this project were to increase nurses' knowledge of pediatric delirium and implement twice-daily delirium screening using the Cornell Assessment of Pediatric Delirium (CAPD) screening tool in a community-based pediatric intensive care unit (PICU). Nursing knowledge was evaluated using a pre-/post-survey of pediatric delirium following a didactic delirium lecture and case study activity. Following the implementation of the CAPD tool into the electronic health record (EHR), twice-daily delirium screening was implemented and measured for screening compliance. Nursing knowledge decreased between the two measurement periods, although not significantly. Complete delirium screens, defined as screening occurring after the first ICU day, on non-sedated or lightly sedated patients at the end of the nursing shift occurred in 60% of scoring opportunities.

Introduction

Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as an acute disturbance of cognition, attention, and awareness that occurs over a short period, fluctuates in severity, and is not attributable to another medical condition or coma (American Psychiatric Association, 2013). Delirium in children is increasingly recognized as a potentially avoidable complication of critical illness and intensive care stays (Garcia Guerra et al., 2016; Traube & Greenwald, 2017). Most delirium in pediatric patients occurs within intensive care unit (ICU) settings (Holly et al., 2018; Malas et al., 2017). Delirium in pediatric patients affects morbidity during hospitalization (Dervan et al., 2020; Traube, Silver, Gerber et al., 2017). Traube, Silver, Gerber, and colleagues (2017) found children with delirium experienced significantly increased pediatric ICU (PICU) and hospital length of stays and prolonged duration of mechanical ventilation. Study results have not consistently established a significant association between delirium and mortality. One single-center cohort study by Traube, Silver, Gerber, and colleagues (2017) of 1,547 critically ill children found delirium to be an independent predictor of mortality (adjusted odds ratio = 4.4). However, a more recent single-center cohort study by Dervan and colleagues (2020) of 2,446 children in a PICU did not find a statistically significant association between children who had experienced delirium and mortality. The reported incidence of pediatric delirium in PICUs varies widely but is consistently reported to be at least 20% to 30% (Cano Londoño et al., 2018; Dervan et al., 2020; Silver et al., 2015; Simone et al., 2017; Traube, Silver, Gerber et al., 2017; Traube, Silver, Reeder et al., 2017).

Recognition of delirium among critically ill pediatric patients is an important first step to mitigating modifiable risk factors that may contribute to the development of delirium. The American Association of Critical-Care Nurses (AACN) (2016) issued a Practice Alert in 2016 calling for nursing practice to assess critically ill patients for delirium using validated tools. In 2016, the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) published guidelines recommending delirium screening every shift (Harris et al., 2016). Despite evidence and recommendations for delirium screening in pediatric critically ill patients, a survey by Kudchadkar and colleagues (2014) of 341 PICU providers both nationally and internationally revealed only 2% reported screening all children at least once per shift in their PICUs. A survey of PICU intensivists in Canada found 78% of PICUs do not use delirium scoring (Garcia Guerra et al., 2016). As members of the multidisciplinary ICU team, nurses are integral players to help recognize and screen for the presence of delirium in the PICU (Rohlik et al., 2018). Nursing lack of knowledge and inconsistent and incorrect use of screening tools are identified as challenges to implementing nurse-administered delirium screening (Flaigle et al., 2016; Oosterhouse et al., 2016). Nursing knowledge, perception, and screening tool use consistently improve following interventions focused on increasing nurses' knowledge of delirium (Gesin et al., 2012; Hickin et al., 2017; Norman & Taha, 2019).

Elements of education, screening, and rounding are integral aspects of identifying and intervening early in the management of delirium in critically ill children to reduce associated morbidities and improve outcomes in this population. The nursing staff of the small, eight-bed, community-based PICU did not previously receive formal delirium education. Additionally, the PICU did not implement a validated delirium screening tool or engage in routine discussions of delirium during daily rounds. Consequently, there was a high likelihood delirium was occurring in the PICU without being recognized. Aims of this project were to 1) increase PICU nursing staff knowledge of delirium in childhood, including identification, assessment, and documentation using the Cornell Assessment of Pediatric Delirium (CAPD) scoring tool after attending a unit-based education program; and 2) implement and document twice-daily nurse-administered delirium screening using the CAPD tool on all PICU patients at least 90% of the time.

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