Modifying the Electronic Health Record to Facilitate the Implementation and Evaluation of a Bundled Care Program for Intensive Care Unit Delirium
Ashley CollinsworthAndrew L. MasicaElisa L. PriestCandice BerrymanMaria KouznetsovaOscar GloriosoDonna Cook Montgomery
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Electronic health records (EHRs) have been promoted as a key driver of improved patient care and outcomes and as an essential component of learning health systems. However, to date, many EHRs are not optimized to support delivery of quality and safety initiatives, particularly in Intensive Care Units (ICUs). Delirium is a common and severe problem for ICU patients that may be prevented or mitigated through the use of evidence-based care processes (daily awakening and breathing trials, formal delirium screening, and early mobility-collectively known as the "ABCDE bundle"). This case study describes how an integrated health care delivery system modified its inpatient EHR to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative.In order to facilitate uptake of the ABCDE bundle and measure delivery of the care processes within the bundle, we worked with clinical and technical experts to create structured data fields for documentation of bundle elements and to identify where these fields should be placed within the EHR to streamline staff workflow. We created an "ABCDE" tab in the existing patient viewer that allowed providers to easily identify which components of the bundle the patient had and had not received. We examined the percentage of ABCDE bundle elements captured in these structured data fields over time to track compliance with data entry procedures and to improve documentation of care processes.Modifying the EHR to support ABCDE bundle deployment was a complex and time-consuming process. We found that it was critical to gain buy-in from senior leadership on the importance of the ABCDE bundle to secure information technology (IT) resources, understand the different workflows of members of multidisciplinary care teams, and obtain continuous feedback from staff on the EHR revisions during the development cycle. We also observed that it was essential to provide ongoing training to staff on proper use of the new EHR documentation fields. Lastly, timely reporting on ABCDE bundle performance may be essential to improved practice adoption and documentation of care processes.The creation of learning health systems is contingent on an ability to modify EHRs to meet emerging care delivery and quality improvement needs. Although this study focuses on the prevention and mitigation of delirium in ICUs, our process for identifying key data elements and making modifications to the EHR, as well as the lessons learned from the IT components of this program, are generalizable to other health care settings and conditions.Keywords:
Electronic health record
Delirium is frequently observed in intensive care unit patients and its occurrence is related to increased morbidity and mortality, length of stay, functional decline and high costs. The Confusion Assessment Method for Intensive Care Unit is a tool that facilitates early identification and occurrence of delirium among intubated patients.To verify the aspects of delirium studied by means of the Confusion Assessment Method for Intensive Care Unit. A literature review was conducted in the LILACS, MedLine, PubMed and CINAHL databases, from 2001, when the Confusion Assessment Method for Intensive Care Unit was validated, to 2008. Descriptors used for LILACS, MedLine and PubMed were delirium and intensive care unit, while for the CINAHL database, delirium and intensive care were used. From 293 articles, 35 were selected. The aspects analyzed disclosed, different types of delirium in different intensive care units. Variation in sensitivity was of 93% to 100% and variation in specificity, 89% to 100% of the Confusion Assessment Method for Intensive Care Unit, an important tool for detection, characterization and control of delirium and its impact. The aspects of delirium studied by means of the Confusion Assessment Method for Intensive Care Unit were: the performance index, identification, management, cost of treatment, morbidity and mortality due to delirium.
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Delirium is a common condition in the intensive care unit (ICU). Between 16-89% of all ICU patients experience an episode of delirium during admission. Several detection tools have been developed for use specifically in the ICU. The Confusion Assessment Method for the intensive care unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) combine high sensitivity with high specificity. Treatment consists of treatment of underlying disorders, nonpharmacological measures and symptomatic drug therapy. The prognosis for ICU patients who experience delirium is worse than for those who do not. Delirious patients are more likely to develop complications, spend longer in hospital and have a higher mortality rate. In view of the high frequency, poor prognosis, high costs and lack of studies into the treatment of ICU delirium, research into the possibilities for prevention, early detection and treatment of the condition is essential.
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Delirium is a serious complication of disorders of nervous system and requires early detection for successful treatment. Confusion assessment method for intensive care unit (CAM-ICU) is a fast and reliable tool for detection of delirium. We performed screening for delirium among patients of neurological ward using CAM-ICU. Our experience showed that CAM-ICU could be used for the identification of delirium in neurological patients excluding those who suffer from severe aphasia.
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Intensive care psychosis, intensive care unit syndrome, acute confusional state and acute brain dysfunction are all delirium, a manifestation of acute brain failure associated with serious adverse outcomes. Most intensive care delirium is hypoactive and undetected. Screening for and managing delirium could significantly improve outcomes.
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. Risk factors for delirium in intensive care unit in liver transplant patients.Delirium is a disorder of the state of consciousness characterized by acute onset and temporal variability of cognitive abilities. It is frequent in intensive care unit (ICU) and it is associated with worst outcomes.To identify risk factors for the development of delirium in patients in intensive care unit (ICU) after orthotopic liver transplantation (OLTx).Observational retrospective study on all the patients undergoing OLTx between January 2014 and December 2015. The daily assessment for delirium was performed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), by nemed nurses.Of the 123 patients included, 15 (12.2%) developed post-operative delirium. The main risk factor was preoperative hepatic encephalopathy (OR = 8.80, 95% CI 2.70-28.59): the deterioration of the state of consciousness (GCS pre-OLTx score < 15) increased the risk of developing delirium (OR 6.18; IC 95% 1.51 - 25.31). A high Acute Physiologic and Health Evaluation (APACHE II) score (OR=1.29, IC 95%: 1.12-1.47) showed how patients with a more severe clinical situation at ICU admission were more likely to develop delirium.The risk factors identified predict the development of delirium in ICU. Its prevention with the implementation of pharmacological or other strategies may reduce the onset of delirium and improve the quality of care.
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Hepatic Encephalopathy
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Delirium is a serious complication that commonly occurs in critically ill patients in the intensive care unit (ICU). Delirium is frequently unrecognized or missed despite its high incidence and prevalence, and leads to poor clinical outcomes and an increased cost by increasing morbidity, mortality, and hospital and ICU length of stay. Although its pathophysiology is poorly understood, numerous risk factors for delirium have been suggested. To improve clinical outcomes, it is crucial to perform preventive measures against delirium, to detect delirium early using valid and reliable screening tools, and to treat the underlying causes or hazard symptoms of delirium in a timely manner. Keywords: Delirium; Intensive care unit; Outcome.
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Background Delirium is a common occurrence for patients in the intensive care unit and can have a profound and lasting impact on them. Few studies describe the experience of intensive care patients who have had delirium. Objective To understand the lived experience of intensive care for critically ill patients who experienced delirium. Methods The study participants consisted of 7 men and 3 women, 46 to 70 years old, who had delirium according to the Confusion Assessment Method for the Intensive Care Unit. The van Manen method of hermeneutic phenomenology was used, and data collection entailed audio recorded semistructured interviews. Results Four themes were detected: “I can’t remember,” “Wanting to make a connection,” “Trying to get it straight,” and “Fear and safety concerns.” Conclusion Nurses working in intensive care units need to assess patients for delirium, assess the mental status of patients who have delirium, and help patients and patients’ families learn about and deal with the psychological effects of the intensive care unit experience.
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