Delirium presents as a significant healthcare problem due to its increased rate of occurrence, monetary effects, and adverse patient outcomes. The effects of delirium have become an increasing concern to the adult intensive care unit (ICU) population ages sixty to eighty years (Devlin et al., 2018). Delirium is seen as a frequent complication for this age group during their hospital stay (Birge & Aydin, 2017). Since the onset of delirium is considered abrupt, the healthcare team must be aware of early detection methods while having protocols in place for effective treatment.
Delirium is described as an acute disturbance of consciousness that alters the patient’s ability to focus and maintain attention (Zamoscik, Godbold, & Freeman., 2017). Patients in the ICU require regular monitoring to prevent the development of acute and irreversible complications (Dubose & Hadi, 2016). Delirium is considered one of the most harmful complications in the ICU setting, increasing the overall mortality rates (Hickin, White, & Knopp-Sihota, 2017). Over one-third of the older population is hospitalized each year, with 2.
6 million of these individuals developing delirium (Birge & Aydin, 2017). Moreover, multiple factors influence delirium development, such as environmental changes, infectious causes, acute injury, and sleep deprivation (Drouot & Quentin, 2016). The Society of Critical Care Medicine reveals that sleep deprivation is quickly becoming one of the leading causes of delirium development (Devlin et al., 2018).
This literature review completes a literary analysis that ascertains the purposed PICOT question by reviewing supporting evidence-based practice towards assessment tools and protocol development. The PICOT examined is will the initiation of set sleep protocols within adult ICU patients decrease the incidence of delirium development versus no set sleep protocols? Using a small test of change, we evaluate elements regarding a plan of action by determining what needs to be changed and how to complete this change (Christenbery, 2018).
A search of CINAHL, PUBMED, and the Cochrane Library were primary sources for this literature search. Search terms used to narrow the search were those of; ICU, delirium, sleep deprivation, measurement tools, and adult patient population. Only literature from the last five years and peer-reviewed were reviewed.
Studies had in common aspects referring to delirium development, predisposing factors, and sleep deprivation that involved the adult ICU patient population (Ashok, Pillai, & Puthenkote, 2018). Delirium affects at least eighty percent of all ICU patients (Zamoscik, Godbold, & Freeman, 2017). Moreover, delirium development causes an increased length of stay, hospital cost, and overall mortality rates (Hickin, White, & Knopp-Sihota, 2017). In the absence of validated tools and protocols, delirium goes mostly undetected in more than sixty-five percent of ICU patients (Rimen, 2017). Further data reviewed reveals the importance of early recognition with the installation of set treatment protocols that help with management and prevent further complications (Rowley-Conwy, 2018).
Delirium primarily occurs in the adult ICU patient population with core symptoms, including states of agitation and apathy (Kim, 2018). Delirium is not only a predictor of mortality but a path to potential self-harm and further complications (Knauert, Pisani & Redeker, 2019). Experts emphasize that the early detection and management of predisposing factors is directly related to the degree of education and protocol use (Rowley-Conwy, 2018).
Rowley-Conwy (2018) presents an itemized exploration of barriers to proper and timely delirium assessment with the use of the Confusion Assessment Method (CAM). Here, the authors identify multiple barriers, such as individual, patient-related, and those of the work environment. Individual barriers comprised the lack of nursing skills required for adequate patient assessments (Oxenboll-Collet et al., 2018). Core barriers dealt with the difficulties in assessing intubated and sedated patients, while a lack of effective leadership was considered a core concern within the work environment (Ashok, Pillai, & Puthenkote, 2018). Further research reveals that early delirium detection is obtained with appropriate education and assessment methods, thereby avoiding further complications (Oxenboll-Collet et al., 2018).
Studies conducted by Palacios-Cena et al. (2018) provided examples of delirium assessment and management from several focus groups. Here, the most common error was nursing’s delay in reporting delirium development. Oxenboll-Collet et al., 2018 felt that the timely detection of delirium is essential. However, without effective nursing education on assessment methods, delays in treatment continue to occur. Additional information revealed that the majority of nursing personnel lack competence in assessment methods while implicating deficiencies in set protocols to aid in treatment methods (Ashok, Pillai, & Puthenkote, 2018).
Other studies show that over fifty percent of ICU delirium is related to sleep deprivation (McAndrew, 2016). Seventy-five percent of these patients report poor sleep (Knauert, Pisani, & Redeker, 2019). A systematic review, including twelve studies, found a strong correlation between sleep deprivation and delirium occurrence (Knauert et al., 2018). It is only with the initiation of set sleep protocols that sleep within the ICU can be supported (Delaney, 2016). The use of multi-component ICU sleep bundles has been shown to improve sleep quality, thus decreasing delirium development (Knauert, Pisani, & Redeker, 2019).
ICU patients commonly report noise as the primary source of sleep disturbances. To help with these disturbances, sleep bundles encompass facets such as decreasing levels of pain, external stimuli, and other ambient stressors (Delaney, 2016). Data from non-randomized time trials showed that medical staff reported the institution of regulated quiet time was a significant factor in reducing stress levels (Pisani & D’Ambrosio, 2019). However, the most substantial evidence was from a randomized control trial that showed the reduction of noise levels had a significant impact on the occurrence of delirium development (Kawai et al., 2017). A further meta-analysis concluded the initiation of set sleep protocols resulted in reducing stress levels and delirium occurrence, thus improving the patient’s overall health outcomes (Bion, Lowe, Puthucheary, & Montgomery, 2018). Overall, each of the reviewed studies showed the importance of further education, research, and protocol development to combat delirium development within the ICU population.
The compilation of this data is to obtain a comprehensive understanding of the clinical situation at hand. In reviewing this research material, we reveal the significance of delirium within the ICU setting by showing its overall effects on the health and recovery of this patient population (Rimen, 2017). Moreover, the consideration of protocol development and effective treatment methods should be imperative to address delirium development (McAndrew et al., 2016). Strategies such as the initiation of dedicated sleep protocols should occur to improve overall aspects of sleep deprivation, thereby improving patient health outcomes and decreasing overall mortality (Sullinger, et al., 2017). Only through the use of evidence-based research will the endorsement and execution of practice change occur within the organization.
Moreover, the healthcare team should ensure that efforts are made to guarantee sufficient education, organization support, and initiation of set protocols are employed to improve delirium detection. Support is seen by making literature readily available to assist in practice change, while utilization of protocols fosters opportunities to address concerns and associated questions (Devlin et al., 2018). Furthermore, the need for continued monitoring and feedback are considered vital elements regarding change and improvement to protocol development.
Utilization of the Knowledge-to-Action Framework is the most complete and supportive framework because of its cyclic process towards making positive healthcare changes (Christenbery, 2018). The use of this model will cover all aspects required for the initiation, implementation, continued review, and supplementation of the proposed subject matter. Furthermore, this model will help reveal the cost expenditures of this project, while those costs are considered minimal compared to the estimated thirty-eight billion dollars delirium cost healthcare each year (Weinrebe, Johannsdottir, Karaman, & Fusgen, 2016).
ICU associated delirium is considered a significant healthcare concern resulting in poor patient outcomes. Outcomes that range in nature from mild to debilitating or even death. Moreover, ICU associated sleep deprivation is considered profound and quickly becoming the leading cause of delirium development (Delaney, 2016). Recognition of this issue has led to the need for further research with protocol development that aids in its detection and future prevention. In short, it is up to the healthcare team to acknowledge and embrace change to promote the best overall patient outcomes.
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