Unlike some other studies, which identified delirium based only on physician assessments, our initiative utilized the CAM performed by floor nurses to identify delirium. While this method may have affected the sensitivity and specificity of the CAMs, it also conferred the advantage of recognizing, documenting, and intervening on delirium in real time, given that bedside nurses are often the first to encounter delirium. Furthermore, nurses were instructed to notify a physician if a patient had a new positive CAM, as reflected in Table 1.
Our study demonstrated an increase in the overall compliance with the CAM screening during the postintervention period, which is significant given the under-recognition of delirium by health care professionals.20 We attribute this increase to greater realized importance and a higher level of confidence from nursing staff in recognizing and addressing delirium, as supported by survey data. While the increased screening of patients should be considered a positive outcome, it also poses the possibility that the observed decrease in delirium incidence in the postintervention group was in fact due to more CAMs performed on patients without delirium. Likewise, nurses may have become more adept at recognizing true delirium, as opposed to delirium mimics, in the latter period of the study.
Perhaps the greatest limitation of our study is the variability in performing and recording CAMs, as some patients had multiple CAMs recorded while others did not have any CAMs recorded. This may have been affected in part by the increase in COVID-19 cases in our hospital towards the latter half of the study, which resulted in changes in nursing assignments as well as patient comorbidities in ways that cannot be easily quantified. Given the limited size of our patient cohorts, certain outcomes, such as the use of sitters, physical restraints, and in-hospital mortality, were unable to be assessed for changes statistically. Causative relationships between our interventions and associated outcome measures are necessarily limited in a binary comparison between control and postintervention groups.
Within these limitations, our study demonstrates promising results in core dimensions of patient care. We anticipate further quality improvement initiatives involving greater numbers of nursing staff and patients to better quantify the impact of nonpharmacologic nursing-centered interventions for preventing hospital delirium.
Conclusion
A multimodal strategy involving nursing-focused training and nonpharmacologic interventions to address hospital delirium is associated with improved patient care outcomes and nursing confidence. Nurses play an integral role in the early recognition and prevention of hospital delirium, which directly translates to reducing burdens in both patient functionality and health care costs. Education and tools to equip nurses to perform standardized delirium screening and interventions should be prioritized.
Acknowledgment: The authors thanks Olena Svetlov, NP, Oscar Abarca, Jose Chavez, and Jenita Gutierrez.
Corresponding author: Jason Ching, MD, Department of Neurology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048; jason.ching@cshs.org.
Financial disclosures: None.
Funding: This research was supported by NIH National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881.