Author(s): Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC,
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Abstract OBJECTIVE: To implement sedation and delirium monitoring via a process-improvement project in accordance with Society of Critical Care Medicine guidelines and to evaluate the challenges of modifying intensive care unit (ICU) organizational practice styles. DESIGN: Prospective observational cohort study. SETTING: The medical ICUs at two institutions: the Vanderbilt University Medical Center (VUMC) and a community Veterans Affairs hospital (York-VA). SUBJECTS: Seven hundred eleven patients admitted to the medical ICUs for >24 hrs and followed over 4,163 days during a 21-month study period. INTERVENTIONS: Unit-wide nursing documentation was changed to accommodate a sedation scale (Richmond Agitation-Sedation Scale) and delirium instrument (Confusion Assessment Method for the ICU). A 20-min introductory in-service was performed for all ICU nurses, followed by graded, staged educational interventions at regular intervals. Data were collected daily for compliance, and randomly 40\% of nurses each day were chosen for accuracy spot-checks by reference raters. An implementation survey questionnaire was distributed at 6 months. MEASUREMENTS AND MAIN RESULTS: The implementation project involved 64 nurses (40 at VUMC and 24 at York-VA). Sedation and delirium monitoring data were recorded for 711 patients (614 at VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation Scale was 94.4\% (21,931 of 23,220) at VUMC and 99.7\% (5,387 of 5,403) at York-VA. Compliance with the Confusion Assessment Method for the ICU was 90\% (7,323 of 8,166) at VUMC and 84\% (1,571 of 1,871) at York-VA. The Confusion Assessment Method for the ICU was performed more often than requested on 63\% of shifts (5,146 of 8,166) at VUMC and on 8\% (151 of 1871) of shifts at York-VA. Overall weighted-kappa between bedside nurses and references raters for the Richmond Agitation-Sedation Scale were 0.89 (95\% confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95\% confidence interval, 0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses and reference raters using the Confusion Assessment Method for the ICU was 0.92 (95\% confidence interval, 0.90-0.94) at VUMC and 0.75 (95\% confidence interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to implementation were physician buy-in and time. CONCLUSIONS: With minimal training, the compliance of bedside nurses using sedation and delirium instruments was excellent. Agreement of data from bedside nurses and a reference-standard rater was very high for both the sedation scale and the delirium assessment over the duration of this process-improvement project.
This article was published in Crit Care Med
and referenced in Journal of Gerontology & Geriatric Research