Preventing Delirium in Critically Ill Children

Abstract

Category/Date Emerging Knowledge for Clinical Practice Podium Presentations focusing on the Research Agenda Priority of Pediatric Research: Chronic Illness, Presented at NAPNAP's 40th National Conference on Pediatric Health Care, March 8, 2019, New Orleans, LA. Purpose The purpose of this study was threefold: 1.) initiate routine screening for delirium in the Pediatric Intensive Care Unit (PICU), 2.) implement and evaluate a delirium education program designed for pediatric nurses, and; 3.) characterize the PICU setting as it relates to the prevention of delirium. Background and Significance Delirium in critically ill children increases PICU length of stay, duration of mechanical ventilation, and mortality. Unfortunately, studies suggest 25% of critically ill children suffer from delirium. Moreover, the incidence of delirium nearly doubles after five days of PICU hospitalization. Consequently, Cornell University investigators recognized the need to screen for delirium in critically ill children and developed the Cornell Assessment for Pediatric Delirium (CAPD). Problem Statement Since few pediatric centers routinely screen for delirium in critically ill children, this descriptive study was designed to assist pediatric nurses in the prevention, recognition and treatment of delirium in critically ill children. Methods Following Institutional Review Board (IRB) approval, this descriptive study: 1)Used bedside audits to characterize the PICU setting 2)Delivered tutorials designed to enhance nurses’ knowledge of pediatric delirium 3)Collected pre and post-test surveys that measured nurses’ delirium knowledge The pre-test/ post-test survey was a 15 item self-reported instrument. The first 5 items dealt with demographic data while the 10 remaining questions were used to assess participant's knowledge of delirium in critically ill children. Results The sample was predominately female (96.3%), white (90.7%) and baccalaureate educated (90.7%). Nearly two-thirds of the sample was less than thirty years of age (64.8%), of which most fell within the 22 to 25 year range (35.3%). Overall, the sample was inexperienced, with the majority having less than two years of critical care experience (53.7%). The bedside audits (n=119) suggested the PICU environment is not conducive to preventing critically-ill children's delirium. For instance, 92.4% of the children did not have daily schedules of care posted in their rooms. In nearly two-thirds of the cases care was not clustered (64.7%) and bathing was performed after 10PM (62.4%). Room noise levels were not kept to a minimum (52.9%) and familiar music was not incorporated into care (52.1%). Of the 75 surveys launched, 54 were returned. The response rate was 72%. Pre (64.0%) and post-test composite scores (90.0%) of the ten knowledge-based questions were compared. Overall, post-test scores improved 40.6%. A rank order comparison of pre-test/post-test means and standard deviations showed that nurses’ knowledge of age groups at heightened risk for delirium increased more than any other category (453.3%). Knowledge of the medications used to treat delirium also increased significantly (112.8%). Discussion This study has clinical, educational and research implications. The CAPD, designed to identify delirium in children, is an easily used bedside tool and should be included as a standard of care for all critically ill children. Enhanced nurse knowledge of at-risk groups and medications that treat delirium increases the likelihood of prevention, recognition and appropriate treatment of delirium. Additional studies to determine the prevalence of pediatric delirium are needed. Emerging Knowledge for Clinical Practice Podium Presentations focusing on the Research Agenda Priority of Pediatric Research: Chronic Illness, Presented at NAPNAP's 40th National Conference on Pediatric Health Care, March 8, 2019, New Orleans, LA. The purpose of this study was threefold: 1.) initiate routine screening for delirium in the Pediatric Intensive Care Unit (PICU), 2.) implement and evaluate a delirium education program designed for pediatric nurses, and; 3.) characterize the PICU setting as it relates to the prevention of delirium. Delirium in critically ill children increases PICU length of stay, duration of mechanical ventilation, and mortality. Unfortunately, studies suggest 25% of critically ill children suffer from delirium. Moreover, the incidence of delirium nearly doubles after five days of PICU hospitalization. Consequently, Cornell University investigators recognized the need to screen for delirium in critically ill children and developed the Cornell Assessment for Pediatric Delirium (CAPD). Since few pediatric centers routinely screen for delirium in critically ill children, this descriptive study was designed to assist pediatric nurses in the prevention, recognition and treatment of delirium in critically ill children. Following Institutional Review Board (IRB) approval, this descriptive study: 1)Used bedside audits to characterize the PICU setting 2)Delivered tutorials designed to enhance nurses’ knowledge of pediatric delirium 3)Collected pre and post-test surveys that measured nurses’ delirium knowledge The pre-test/ post-test survey was a 15 item self-reported instrument. The first 5 items dealt with demographic data while the 10 remaining questions were used to assess participant's knowledge of delirium in critically ill children. The sample was predominately female (96.3%), white (90.7%) and baccalaureate educated (90.7%). Nearly two-thirds of the sample was less than thirty years of age (64.8%), of which most fell within the 22 to 25 year range (35.3%). Overall, the sample was inexperienced, with the majority having less than two years of critical care experience (53.7%). The bedside audits (n=119) suggested the PICU environment is not conducive to preventing critically-ill children's delirium. For instance, 92.4% of the children did not have daily schedules of care posted in their rooms. In nearly two-thirds of the cases care was not clustered (64.7%) and bathing was performed after 10PM (62.4%). Room noise levels were not kept to a minimum (52.9%) and familiar music was not incorporated into care (52.1%). Of the 75 surveys launched, 54 were returned. The response rate was 72%. Pre (64.0%) and post-test composite scores (90.0%) of the ten knowledge-based questions were compared. Overall, post-test scores improved 40.6%. A rank order comparison of pre-test/post-test means and standard deviations showed that nurses’ knowledge of age groups at heightened risk for delirium increased more than any other category (453.3%). Knowledge of the medications used to treat delirium also increased significantly (112.8%). This study has clinical, educational and research implications. The CAPD, designed to identify delirium in children, is an easily used bedside tool and should be included as a standard of care for all critically ill children. Enhanced nurse knowledge of at-risk groups and medications that treat delirium increases the likelihood of prevention, recognition and appropriate treatment of delirium. Additional studies to determine the prevalence of pediatric delirium are needed.