Recognizing the Signs and Symptoms of Delirium

In 2016, Lauren Bruwer, BSN, RN, PCCN, joined the neuromedicine unit at Cleveland Clinic’s main campus as a clinical nurse specialist intern. Later that fall, the unit launched a delirium demonstration project to elevate the practice of clinical nurses related to the signs and symptoms of hypoactive and hyperactive delirium.

“After meeting with the nurse manager and making observations on the unit, it was obvious that we needed to do a better job identifying delirium in the neurological patient population,” says Bruwer. “Our delirium scores were well below the national average – only about 3.6 percent for recognizing delirium accurately. Yet many of our patients were confused, restrained or needed sitters.” Delirium occurs in up to 25 percent of hospitalized patients, according to a joint study by the American Nurses Association and the American Delirium Society.

Bruwer recruited Nakiaa Robinson, MEd, BSN, RN, a clinical nurse on the 50-bed unit, to help spearhead the project with the goal of increasing the unit’s delirium prevalence rate so it was representative of the patient population.

Interventions to improve delirium screening and recognition

Bruwer and Robinson implemented the following interventions as part of the neuromedicine unit’s delirium demonstration project:

• Utilization of a geriatric resource nurse – Prior to the project, the unit didn’t have a geriatric resource nurse (GRN), so Robinson volunteered to become one. Her preparation included training on the Brief Confusion Assessment Method (bCAM), the evidence-based screening tool used to identify and recognize delirium in patients. Robinson then began monthly delirium rounding on all patients 65 years and older, as well as patients of any age who came into the unit with a mental status change. She completed the bCAM on patients meeting those criteria and shared her findings with clinical nurses. “That gave me the opportunity to identify areas where the assessment wasn’t being completed or wasn’t accurate,” says Robinson. “The primary issue was nurses not recognizing a fluctuation in mental status.”
• Daily rounding by the CNS intern – Bruwer began daily rounding on patients using a tool she created that formalizes the process. The tool considers some of the following questions: Was the bCAM screen positive or negative? Does the patient display signs of inattention? Is the screening score accurate? Is the correct order set being used for the patient? What interventions have been put in place? Are the caregivers using the nursing delirium protocol? The rounding tool provided valuable data: During a five-month period in 2017, Bruwer conducted 152 patient assessments. She discovered 66 bCAM negative screens that were positive upon reassessment, and discussed 121 cases with clinical nurses.
• Nurse education – Rounding by both Robinson and Bruwer led to one-on-one conversations with clinical nurses not only about individual patients, but about delirium signs and interventions. They talked to nurses about factors that increase the risk of delirium, such as age, lengthy surgeries, immobility and dehydration. Robinson and Bruwer also created an eight-minute educational video about the appropriate use of delirium screening tools and the importance of accurate handoff reports at shift changes. The video is posted online on the hospital’s delirium resource site for easy access at any time. “We now give each other information in handoff reports about whether or not a patient is delirium positive, and that wasn’t happening before,” says Robinson.
• Family education – While it’s critical to educate nurses, it’s equally important to make sure families understand delirium too. The neuromedicine unit now engages families by providing them with an educational brochure.

Outcomes of the delirium demonstration project

Prior to the project, Bruwer says nurses were hesitant to label a patient as delirium positive. “Once they understood the benefits of recognizing delirium – that it impacts the point of care before the situation escalates – it boosted the nurses’ confidence in their practice,” she says. “Now, they will call it delirium when they see it. They recognize a set of symptoms and bring it to the attention of people that have the authority to devise a plan to manage the patient either pharmacologically or through interventions.”

Prevalence rates on the neuromedicine unit have risen, from 3.6 percent before the project began to 18.9 percent in November 2017. The unit has sustained those numbers. The prevalence rate was 19.5 percent in January 2018 and 17 percent in March 2018.

A result of more accurate delirium screenings has been decreased patient length of stay (LOS) on the unit. When the project began, the unit’s average LOS for patients with delirium was eight days. Now it is four days. “We attribute that to intervening sooner, which helps avoid the use of physical restraints and patient companions,” says Bruwer. “Those two things are direct barriers to getting our patients transferred to the next level of care.”

Bruwer and Robinson shared the success of the neuromedicine unit’s delirium demonstration project in a poster presentation at the 2018 American Delirium Conference.