An Advanced Practice Provider-Led Initiative for Delirium Screening and Management in an Oncologic ICU

Abstract

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: Delirium occurs in 30-80% of patients admitted to the Intensive Care Unit (ICU) and is associated with increased morbidity and mortality, mechanical ventilator-days, hospital and ICU length of stay (LOS), costs, and long term cognitive impairment. Most cases of delirium are missed by ICU clinicians. The Confusion Assessment Method for the ICU (CAM-ICU) is one of the few validated tools for the assessment of delirium in the critically-ill population. However, routine use of CAM-ICU by nurses alone does not improve delirium recognition and management. We hypothesize that an Advanced Practice Provider (APP) led initiative can close additional gaps in knowledge and improve accuracy of and compliance to CAM-ICU screening and overall delirium management. METHODS: As part of a larger multidisciplinary delirium quality improvement project, a small group of APPs created a comprehensive training program that targeted nurse practitioners (NPs), physician assistants (PAs) and critical care fellows working in the ICU at Memorial Sloan Kettering Cancer Center. The educational sessions included formal didactic lectures, open discussions, and a multi-item questionnaire to capture participants’ demographics, knowledge, and comfort level with the use of CAM-ICU and with delirium management. CAM-ICU administration and delirium pathophysiology, assessment, management and impact were discussed. All participants were provided electronic tablets and completed the questionnaire before and after each educational session. Delirium rates and both compliance to and accuracy of CAM-ICU were recorded before and after the intervention. Survey responses were compared between pre- and post-training using McNemar’s test for categorical variables and Wilcoxon Signed Rank test for continuous variables. Data are presented as absolute numbers, percentages, and medians with first and third interquartile ranges. A p value of < 0.05 was statistically significant. RESULTS: Thirty one ICU practitioners participated in the training program: 8 critical care fellows, 20 board-certified NPs and 3 board-certified PAs with a median of 6 (2.5-10) years ICU experience. Of the 31 practitioners, 5 (16%) had participated in a delirium screening and treatment program prior to our intervention and 13 (41%) had never used CAM-ICU in practice. Scores on the 15-item questionnaire improved from a baseline of 76% to 86% (p < 0.0001). Comfort level with CAM-ICU administration increased from 16% to 61% (p < 0.0001) while comfort level with delirium management increased from 35% to 68% (p = 0.0001). Finally, post-intervention audits revealed compliance to CAM-ICU screening of 99% from a baseline of 60%, accuracy of CAM-ICU results of 90-95% from a pre-training rate of 50-60%, and an increase in ICU delirium rates from 18.3% in the fourth quarter of 2015 to 30% in the fourth quarter of 2016. CONCLUSIONS: An APP-led initiative successfully improved knowledge of delirium prevention and management by physicians, NPs and PAs working in a medical-surgical ICU. The post-training adherence to CAM-ICU screening increased. CLINICAL IMPLICATIONS: Our intervention supports the need for identification of APP delirium champions to lead educational programs for their colleagues in the ICU. DISCLOSURE: The following authors have nothing to disclose: Sarah Rebal, Caroline Shirzadi, Jennifer Agatep, Konstantina Matsoukas, Kate Tayban, Heidi Yulico, Kay See Tan, Kenneth Seier, Yesne Alici, Beatriz Korc-Grodzicki, Louis Voigt No Product/Research Disclosure Information