Predisposition to CAM-ICU Determinacy

Running head: Predisposition to CAM-ICU Determinacy 1
Predisposition to CAM-ICU Determinacy
TRoy Coffelt
University of Oklahoma
College of Nursing

Predisposition to CAM-ICU Determinacy 2
In order to answer the question of whether or not routine assessment tools will improve
the ability to diagnose delirium in the ICU and if so, which tool to use an understanding of what
delirium is and where the question came from must first be discussed. Delirium is a brief and
severe state of confusion that cannot be attributed to a form of dementia. It attributes to
increased hospital and patient costs, increased hospital stays, poor patient/family satisfaction,
increased mortality rates, complications during hospital stays, lower staff morale, increased staff
burnout, and increased nursing home placement. Often it was determined to have been an
independent mental disorder instead of being attributed to a number of predisposing factors or
the circumstances under which a person was placed in. The predisposing and precipitating
factors are numerous, some are alcohol abuse, visual impairment, hearing loss, elevated
creatinine ratio, history of stroke, congestive heart failure, depression, dehydration, electrolyte
imbalances, hypo or hyperthyroidism, the use of analgesics, antibiotics, diuretics,
antihistamines, sedatives, steroids, adding more than three medications during a hospital stay,
and the abrupt discontinuation of long-term treatments. Many of these are situations that
patients in a hospital are subjected too or situations that they are dealing with prior to
admission.
Despite being aware that delirium is a condition it is often misinterpreted by hospital staff
and thus ignored. The three types of delirium are hypoalert-hypoactive, hyperalert-hyperactive,
and mixed. The hyperalert-hyperactive type is the easiest to notice but is often mistaken and
patients are said to crazy, combative, or to have high anxiety. The hypoalert-hypoactive is the
most difficult to notice as it has a very high rate in ventilated patients, up to 87% in some
studies, and is often mistaken for depression, apathy, and to just be an effect of the medication
as its signs are often the same such as sedated, poor attention span, and drowsiness. Mixed is
when the patient goes back and forth between the two.
An exact date for when the problem became evident was not found but impaired
cognitive function that caused abnormal behavior has been documented since ICUs came into

being in the early 1960s. It was called many things when it was documented such as ICU
psychosis and acute brail failure. The persistence of similar symptoms that lead to the same
conclusions has tied these together and generally become referred to as delirium. The poor
outcome of this issue has lead to its need to be identified so several different assessment tools
have been created and implemented as well as studies to determine who is at a higher risk for
delirium. The severity of delirium and the number of tools used to assess delirium has caused
the question of will an assessment tool help and if so, what is the best assessment tool to use
for delirium to arise.
The question originated from the ICU because it is the clinical area with the highest
incidence of delirium. This is because many of the predisposing factors mentioned earlier
coexist in large amounts in the ICU. Patients, patient families, friends, and hospital staff both in
contact with the patient and not in contact with the patient are all affected by patient delirium. It
is a problem not only because it increases hospital stays, patient fatality, staff morale, and the
other situations previously mentioned but also because it has a negative effect on anyone who
comes into contact with the people who were directly in contact with those who had the negative
experience. This can cause overall income of the hospital to decrease as business spreads by
word of mouth and the more negative things someone says about an institution the more it
spreads and the more people will utilize other facilities.
Currently nursing has increased the awareness of delirium in the ICU and has started to
devise and help devise several assessment tools to diagnose delirium. With increased
awareness of delirium the delirium can be dealt with in a more appropriate manner than simply
by complaining about the annoying patient or by letting them sink further and further into
delirium. With the implementation of the tools that have been devised delirium can be caught at
an earlier stage thus reducing the negative outcomes of delirium. With the knowledge of the
predisposing and precipitating factors those who are at a higher risk for delirium can be
determined and measures to reduce the onset of delirium can be taken.

Delirium in the Intensive Care Unit: A Review by Arend and Christensen (2009)
discussed how delirium has existed under different names for a long time and plants the term
delirium over all of them. It continues to bring to light the predisposing and precipitating factors
the contribute to a higher risk of delirium. It gives many of the adverse effects of delirium
before discussing why being adept in discovering delirium is important. This article is good
research because it gives a very detailed look at what delirium is as well as what its
predisposing factors are. If we know what contributes to the cause of delirium then we can take
steps to reduce the possibility that those at a higher risk have of developing delirium.
A Systematic Review by Steis and Fick (2008) is a systematic review over nurse
recognition of delirium. It says that nurses have barriers to recognizing delirium such as a
proper assessment tool, knowledge of the signs and symptoms of delirium, and time with the
patient. It says that hypoactive delirium is the most under recognized form of delirium. It also
says that nurses document delirium differently, which makes a case for a universal system of
documentation for delirium or a consistent tool to be used. This article is good because it
focuses on problems identifying delirium that stem from the people who spend the most time
with the patients, the nurses.
Delirium assessment in the critically ill by Devlin, Fong, Fraser, and Riker (2007)
compares six assessment tools. It says that nurses untrained in how to detect delirium have a
lower recognition rate than those who do and that a continuous screening for delirium should be
implemented. It also says that head to head comparisons of different tools need to be made.
This article is a good article because it familiarizes the reader with six different assessment
tools. It does not however pick one out and place it above the others and does not give any
other clear cut information.
Assessment of Delirium in the Intensive Care Unit: Nursing Practices and Perceptions by
Devlin et al. (2008) discusses the results of a survey that was sent to 601 nurses of which 331
responded. The study says that few of the nurses are trained to assess delirium and that over

half of them do not assess for delirium at all or only rarely. It also says that nurses' perceptions
of delirium vary. This is a good article because it discusses the issues with recognizing delirium
at their base level. The nurses and the hospital guidelines for assessing delirium.
Routine Delirium Monitoring in a UK Critical Care Unit, by Page, Navarange, Gama, and
McAuley (2009) studied 80 patients that were in one hospital's ICU. Seventy-one of these
patients' final outcomes were kept. The study was to determine the feasibility of using the CAM-
ICU assessment tool in the ICU setting. The study says that it is. This is a good article because
it focuses on the results of the assessment tool by trained nurses over a several month period of
time. It is a poor study because it only uses one tool and only uses one hospital.
The Confusion Assessment Method: A Systematic Review of Current Usage by Wei,
Fearing, Sternberg, and Inouye (2008) reviewed the CAM in 239 articles. This article only goes
over the CAM. In doing so the authors have made several recommendations for improvement
on the CAM and have said that training on how to use it is appropriate.
Large-Scale Implementation of Sedation and Delirium Monitoring in the Intensive Care
Unit: A report From Two Medical Centers by Truman et al. (2005) is over a study done in two
hospital systems. Its purpose was to see if implementing monitoring for delirium, agitation, and
sedation plus seeing if modifying ICU nurses' practice styles was feasible. This was a good
study because it used more than one institution and it was over an 18 month period of time. It
identified that observers were most likely necessary to keep sustained implementation of the
tools.
Different Assessment Tolls for Intensive Care Unit Delirium: Which Score to Use by
Luetz et al. (2010) compares the validity and reliability of three delirium assessment tools. This
study determined the CAM-ICU to be the best. It was a good study because it used a standard
to judge the assessment tools by. A downfall of the study is that one assessment tool that other
studies have said is the closest in comparison as far as reliability, the ICDSC, was not included.
Also, the assessments were performed in the same order very time.

Comparison of Delirium Assessment Tolls in a Mixed Intensive Care Unit by Eijk et al.
(2009) compared two different assessment tools and the impression of an ICU physician of the
diagnosis of a psychiatrist, neurologist, or geriatrician. The study was done in one ICU over 126
patients during an 8 month period. The study showed that the ICU physicians underdiagnosed
delirium and that the CAM-ICU was the best tool to use. The study was only done in one
hospital but it compared the two highest rated assessment tools against other professional
opinions. Another strength is that the patients studied had a variety of different diagnoses.
Several different assessment tools as well as physician and psychiatric opinion were
covered in the articles that were reviewed. Of these were the Cognitive Test for Delirium (CTD),
Confusion Assessment Method-ICU, Intensive Care Delirium Screening Checklist (ICDSC),
NEECHAM scale, the Delirium Detection Score (DDS), and the Nursing Delirium Screening
Scale (Nu-DESC). ICU physician diagnosis was also compared against these other tools.
Other factors that were taken into consideration were whether or not the nurses using these
tools had been trained in using the tools or in detecting delirium and what predisposing and
precipitating factors played a role in developing delirium.
According to the information covered the best course of action in detecting delirium
would be to implement a screening to determine who is at the highest risk of developing delirium
and then marking them in some way followed by regular screenings by personnel that have
been trained in what delirium is, what the risk factors are, how to detect it, and how to use the
assessment tool chosen. The assessment tool chosen as the best out of the ones studied is the
CAM-ICU. The runner up was the ICDSC but the CAM-ICU was determined by more than one
study to have a higher sensitivity. After delirium has been identified and the form has been
determined steps to alleviate it or prevent it from becoming worse can be taken. It is also
recommended that a universal form of screening, identifying, and caring for delirium be
implemented.

Burns' transformational leadership theory believes that leading should elevate people
from lower to higher levels of moral development. Examples of this would be to move people
into a higher part of Maslow's pyramid of hierarchy of needs or of Kohlberg's theory of moral
stages. It is a process in which the leader coexists with the followers as one unit in order to
raise each other to a higher level of morality and motivation. As with most leadership theories it
is important to lead by example. "Power, purpose, relationship, motives and values are
essential to leadership because the leader is engaged ultimately in lifting the morals of the
follower; in elevating the follower from a lower state to a higher state . . . to help develop others
to become moral leaders in the cause of achieving a collective purpose," (Fairholm, pg. 2).
Utilizing this theory it is important to maintain the moral aspect of detecting delirium as
well as the cost, patient/family satisfaction, and staff moral aspects as being important through
all steps of implementing the use of a pre screening and identification system as well as the use
of the CAM-ICU by trained nurses. It is also important to keep everyone working as a group to
obtain and maintain this effort after you have established that it is a moral duty as part of a
health care team and as a nurse to consistently implement these suggestions. First information
showing the importance of the proposed changes would need to be found and presented with
information over the feasibility of implementing and continuing the proposed changes. This
information could be presented to and discussed with the team involved in implementing the
changes. After a consensus is reached the information with a signed backing by those
implementing the change at the base level could be presented to the person in charge of the
unit. From there it would have to be cleared through the chain of command. A study could be
done during the usage of the changes, if they were implemented, could be done to compare
with previous outcomes of patients in the ICU to verify overall success of the changes in
achieving the expected outcome.
The change would affect individual nursing practice by adding another screening to be
done, way of keeping track of high risk patients, and assessment tool as well as more

documentation. Other ways it could affect it is that a better understanding of why some patients
act the way they do would come to light and through this some patients would be treated better
and staff morale may rise. The workload from individual patients on the nurse may decrease
because problems arising from the delirium may be avoided if it can be prevented or caught
early. The nurse may feel a higher sense of personal reward in helping to prevent or make
better one more issue that the patient is dealing with which results in an overall better
experience for the patient, their family, and their loved ones.
Implementation of the proposed changes may influence the organization by lowering its
overall costs, elevating its standing in public opinion, and by the workers dealing with the
patients having a heightened sense of duty and morale. The overall costs would be decreased
by the reduction of the hospital stay and resources needed by the patient. Elevation in public
opinion would be due to the overall better patient outcome achieved by the lower incidence of
delirium in the ICUs. The shortened stays in the hospital, the lower rates of those committed to
nursing homes, and the brighter demeanor of the patients and facility staff directly dealing with
the patients would help to achieve this.
The nurses, the nurse managers, and the rest of the people on the way up the chain of
command would need to be involved in this process as well as those who would be making
changes in the computer systems or providing the paperwork for the process and those who
appropriate funding to do so. Depending on how the assessments were done would depend on
what type of support would be needed. If it was a mandatory assessment that had to be
documented thoroughly then support would only be needed to get used to doing the
assessment and screening tool in order to do it correctly. Evidence based support would be
necessary for the manager and the team to get the change implemented. A study to determine
the current statistics of things that ICU delirium can cause could be done while the
implementation was being sought. This would be in order to compare post implementation data
in order to validate the change and continue it in the ICU in question. Time would be taken to

present the proposed changes to the chain of command and then to implement them into the
system and all facilities are different so it is difficult to say how long of a time frame all of this
would take. The various stages of the process would be getting the unit's nursing team involved
and interested, then taking it to the manger and on up the chain of command until it could be
implemented. After this the process of setting up the system used in the unit would happen
followed finally by the implementation of the change and the study of it to validate its overall
effectiveness.
The endpoint would be for a screening to be implemented in order to determine who is at
the highest risk of developing delirium in the ICU, for an identifier to be implemented, and for the
CAM-ICU to be used on a regular basis. Outcomes to be achieved would be lower incidents of
delirium in the ICU, shorter overall patient stay in the hospital, lower fatality rate, higher home
return rate of the patients, increased staff morale, increased patient and family satisfaction,
lower staff burnout rate, higher public opinion of the hospital, and decreased patient and
hospital costs. Successful patient outcomes would be a lower incidence of delirium, a lower
mortality rate, less complications during the hospital stay, a faster release from the hospital,
higher family and patient satisfaction with care received from the hospital. Factors that would
indicate health care personnel are satisfied with the changes would be a lack of complaining
about the perceived extra work, satisfaction with over all patient outcomes, and verbal report of
satisfaction.
Decreased hospital stay, decreased incidence of delirium, decreased complications
during the stay at the ICU, decreased unit costs, increased patient, family, and staff satisfaction,
and decreased patient costs are all ways of knowing if the solution worked. Formal outcome
measures that could be used are surveys from patients and comparisons of pre and post data
over the expected outcomes of the change. Informal measures would be observation of the
patients and staff on the unit. The impact on the individual would be that the patients have a
lower incidence of delirium. This could decrease the workload and cause for happier patients

over all. It could also decrease the stay of the patients themselves. The individual may also
gain a higher sense of self in that they had a noticeable positive effect on the patient. The
impact on the work unit would be roughly the same as it would on the individual just on a
broader scale. In addition to these unit cost may be reduced and the overall cohesiveness of
the unit may increase due to implementing such a huge change that had such a possibly
dramatic effect. The impact on the organization would be a possible higher public opinion due
to lower patient costs, shorter hospital stays, happier ICU employees talking about their
experiences, and overall lower costs for the organization as a whole.
Through the literature reviewed it was decided that the CAM-ICU was the best
assessment tool to use in the ICU and that a screening to identify those at a higher risk for
developing delirium in the ICU would be of great benefit. Outside of tools and screenings, nurse
training in order to assist in identifying delirium and how to use the screening and assessment
tools was also shown to be of benefit. It is imperative that the leader believe in the process and
not only aim to have it implemented but assist others in seeing the moral obligations that
nursing entails and how they apply to the implementation of this process. It is also important to
assist cohesiveness in the group and take into account all concerns from those who would be
implementing the interventions. Necessary information would need to be provided to the others
on the team as well as to those in management. This project has reiterated one of the key
reasons that I became a nurse. It shows that assisting the patients is at the core of everything
despite appearance and costs. It also gave me the opportunity to see that evidence based
practice is more than just a dreaded homework assignment, it is something necessary to
continue safety and to continue finding better ways to care for our patients.

References
Arend, E. & Christensen, M. (2009). Delirium in the intensive care unit: a review. British
Association of Critical Care Nurses, Nursing in Critical Care, 14(3), 145-154.
Devlin, J.W., Fong, J.J., Howard, E.P., Skrobik, Y., McCoy, N., Yasuda, C., Marshall, J. (2008)
Assessment of Delirium in the Intensive Care Unit: Nursing Practices and Perceptions.
American Journal of Critical Care, 17, 555-565.
Devlin,J. W., Fong, J. J., Fraser, G. L., Riker, R. (2007) Delirium assessment in the critically ill.
Intensive Care Med, 33, 929-940. DOI 10.1007/s00134-007-0603-5
Luetz, A., Heymann, A., Radtke, F. M., Chenitir, C. Neuhaus, U., Nachtigall, I. . . . Spies, C.
(2010). Different assessment tools for intensive care unit delirium: Which score to use.
Crit Care Med, 38(2): 409-418.
Marum, R. J., Eijk, M.J., Klijn, I. A., Wit, N., Kesecioglu, J., Slooter, A. J. (2009). Comparison of
delirium assessment tools in a mixed intensive care unit. Crit Care Med, 37(6). 1881-
1885.
Page, V.J., Navarange, S., Gama, S., McAuley, D.F. (2009). Routine delirium monitoring in a
UK critical care unit. Critical Care, 13 (1). 1-6.
Pun, B. T., Gordon, S. M., Peterson, J. F., Shintani, A. K., Jackson, J. C., Foss, J., Ely, E. W.
(2005).Large-scale implementation of sedation and delirium monitoring in the intensive
care unit: a report from two medical centers. Crit Care Med, 33(6). 1199-1205.
Steis, M.R., Fick, D.M. (2008). Are Nurse Recognizing Delirium? Journal of Gerontological
Nursing,34(9).40-47
Vanderbilt University Medical Center. (2011). ICU Delirium and Cognitive Impairment Study
Group. Retrieved from icudleirium.org: http://www.mc.vanderbilt.edu/icudelirium/
Wei, L. A., Fearing, M. A., Sternberg, E. J., Inouye, S. K., (2008). The confusion assessment
method: A systematic review of current usage. Journal of the American Geriatric Society,
56. 823-830.

Fairholm, M., R. (2001). The Themes and Theory of Leadership: James MacGregor Burns and
the Philosophy of Leadership. The George Washington University Center for Excellence
in Municipal Management. Retrieved from
http://www.unc.edu/~mmb/cemm%20web/pdf_Files/Burnsand.pdf

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