Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients
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To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients.
Design and setting
Prospective, observational study in a level 1 trauma unit of a tertiary care, university-based medical center.
Acutely injured patients admitted to the trauma unit between 1 February 2006 and 16 April 2006.
Measurements and results
Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period the nurses completed a postimplementation survey. The expert evaluator performed 1,011 random CAM-ICU assessments within 1 h of the bedside nurse's assessments. Nurses completed the CAM-ICU assessments in 84% of evaluations. Overall agreement (κ) between nurses and expert evaluator was 0.77 (0.721–0.822; p < 0.0001), in TBI patients 0.75 (0.667–0.829; p < 0.0001) and in mechanically ventilated patients 0.62 (0.534–0.704; p < 0.0001). The survey revealed that nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training that they received. It also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium.
The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.
KeywordsDelirium Trauma Critical care Implementation Monitoring Confusion Assessment Method for the Intensive Care Unit
- 1.American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DCGoogle Scholar
- 2.Jacobi J, Fraser GL, Coursin DB, Riker R, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke S, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA, Murray MJ, Peruzzi WT, Lumb PD (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30:119–141PubMedCrossRefGoogle Scholar
- 3.Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Dittus R (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286:2703–2710PubMedCrossRefGoogle Scholar
- 8.Bland M (1987) An introduction to medical statistics. Oxford University Press, OxfordGoogle Scholar
- 9.Young GB, Bolton CF, Archibald YM, Austin TW, Wells GA (1992) The electroencephalogram in sepsis-associated encephalopathy. J Clin Neurophysiol 91:145–152Google Scholar
- 10.Ely EW (2005) Delirium in the intensive care unit. In: Hall JB, Schmidt GA, Wood LDH (eds) Principles of critical care, 3rd edn. McGraw-Hill, New York, pp 975–984Google Scholar
- 12.Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y (2006) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 32:66–73Google Scholar