Recognizing the Signs and Symptoms of Delirium
Delirium is grossly under recognized in hospitals. Nurses on a neuromedicine unit at Cleveland Clinic created a multi-pronged approach to recognizing delirium and improving patient care and outcomes.
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.
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“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.
Bruwer and Robinson implemented the following interventions as part of the neuromedicine unit’s 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.