AACN Practice Alert: Delirium Assessment and Monitoring

AACN Practice Alert: Delirium Assessment and MonitoringSuad Ali, Nicki Croel, Vaughn Lovell & Chelsey Treglia

ObjectivesReview the background of AACN standards and practice alertsProvide an overview of AACN ICU Delirium Practice AlertDefine evidence-based nursing interventions for ICU delirium Discuss improving quality and safety and the influence of standards of care

The AACNAmerican Association of Critical-Care NursesPatients and their families rely on nurses at the most vulnerable times of their lives. Acute and critical care nurses rely on AACN for expert knowledge and the influence to fulfill their promise to patients and their families. AACN drives excellence because nothing less is acceptable (American Association of Critical-Care Nurses [AACN], 2014).

Levels of evidenceLevel A-E, & M

AACN represents more than 500,000 nurses working with acutely and critically ill patients. Providing knowledge and resources to the members is one of the major goals of AACN.There are 6 AACN levels of evidence that describe the research and recommendations, with level A being the strongest research study and level M being the weakest.

Practice Alert SummaryDelirium is an acute change in consciousness that is accompanied by inattention and either a change in cognition or perceptual disturbance (AACN, 2014).

Expected Practice:Implement delirium assessment for all critically ill patients using validated tools such as the Confusion Assessment Method for the ICU (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) (Level B)Create strategies to decrease delirium risk factors, including early exercise (Level B)Be cautious with benzodiazepine use, giving only what is needed (Level C)Consider whether to adopt a core bundle like the ABCDE bundle (Level E)

Hyperactive delirium includes agitation, restlessness, attempting to remove catheters, and/or emotional lability.Hypoactive delirium includes flat affect, withdrawal, apathy, lethargy, and/or decreased responsiveness.Combination- Includes both hyperactive and hypoactive delirium behaviors.Impact- affects up to 80% of ICU pts & increases length of stay in both hospitals and ICU, time on vent, mortality, and long-term neuropsychological deficits Delirium is also estimated to cost between $4-16 billion in ICU costs annually.Influence on Standards of Care

Assessment PlanningInterventions Collaboration

The AACN practice alert on delirium stresses the importance of assessing patients thoroughly to determine patients at risk for delirium and for continued assessments for early recognition of delirium

If it is found that the pt is at high risk for delirium based on the assessment the critical care nurse will be able to plan accordingly and individualize pts care to prevent delirium

AACN suggested implementing the ABCDE bundle which is a model of care that combines multiple evidence based practice strategies to improve overall outcomes. It will improve the Quality and effectiveness of nursing practice. The ABCDE Bundle is:

o Awakening and Breathing Trial Coordination (the Wake Up and Breathe Protocol)o Choice of Sedativeo Delirium Detectiono Early Progressive Mobility and Exercise

Improving Quality & Safety of Healthcare DeliveryTHIINK mnemonic for early recognition of causeToxic SituationHypoxia, Infection / sepsisImmobilizationNonpharmacologic InterventionsK+ (Potassium or electrolyte problems)

Reliable and valid assessment toolsMedication precautions and reviewsImplementation of ABCDE bundle

SummaryThe complications associated with delirium are serious and can be debilitatingPractice alerts give guidelines to critical care nurses by enabling them to use current recommendations and best practice when providing care.

ReferencesAmerican Association of Critical Care Nurses. (2013). History of AACN. Retrieved from http://www.aacn.org/wd/mainpages/content/aboutus.content?menu=AboutUsAmerican Association of Critical Care Nurses. (2013). Delirium assessment and management. Retrieved from http://www.aacn.org/wd/practice/content/practicealerts/delirium-practice-alert.pcms?menu=practice