Introduction
Today, much attention is paid to a better understanding of evidence-based practice (EBP) and its effects on preventing serious diseases and conditions in patients. Nurses and other healthcare practitioners need to know the existing programs and strategies to assess problems and make sufficient decisions. One of the first common definitions of EBP was given at the beginning of the 1900s. Sackett et al. explained EBP as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patients” (cited in Reid et al., 2017, p. 1). Despite the intention to add new qualities and characteristics, the main idea of this practice remains the same today. When people address EBP, they want to integrate the best and most appropriate research evidence, resources and choices to improve care quality and knowledge.
In addition to the offered EBP principles, modern UK nurses have to follow the Code developed by the Nursing and Midwifery Council. This document consists of 25 professional standards and goals for “nurses, midwives and nursing associates” who are involved in educating and providing care to the population (Nursing and Midwifery Council, 2015, p. 3). According to the Code, healthcare practitioners must “always practise in line with the best available evidence” to maintain effectiveness and clarity of cooperation (Nursing and Midwifery Council, 2015, p. 10). Patients may not obtain enough knowledge or skills to recognise their health problems and choose proper treatment within the required deadlines. Thus, it is the responsibility of nurses to give help and share skills during practice.
There are many ways where EBP approaches are critical, and the prevention of delirium intensive care unit (ICU) patients is one of them. According to Spiegelberg et al. (2020), early identification of this condition allows for predicting serious health complications and providing patients with high-level health care delivery. Delirium is a mental health disorder characterised by cognitive impairment and affects the brain’s work. Due to multiple but unclear causes, delirium may develop in several hours or days, and nurses should use recent EBP findings to help ICU patients avoid lethal outcomes.
The prevention of ICU delirium turns out to be one of the common topics in nursing practice. Pharmacological and non-pharmacological interventions are currently discussed to offer care providers enough ideas to implement in ICUs. Occupational therapy, supportive environments, sleep quality, education, and family involvement are not all but frequently discussed preventive steps. This essay aims to discuss EBP ideas for preventing ICU delirium, addressing the current problems and available sources in the UK context.
Problem
The major problem for discussion in this project is based on understanding the reasons for preventing delirium in ICU patients. According to Ghaeli et al. (2018), delirium is a costly and damaging condition, especially for older patients who stay in hospitals for some period. For example, delirium is diagnosed in 29-64% of hospital inpatients, and about 20% include older adults (National Health Service, 2018). Disrupted circadian rhythm, sleep problems, memory impairment, disorganised thinking, and poor motor functions are the signs of this condition that remain undiagnosed (Herling et al., 2018). Patients may misunderstand or neglect their physical, mental, or behavioural changes due to their postoperative conditions and a low level of knowledge. Nurses must follow the Code and listen to people, assess their needs, cooperate, and raise concerns immediately if some vulnerability is observed (Nursing and Midwifery Council, 2015). Unfortunately, despite the level of readiness and professionalism, not all healthcare providers are able to notice the signs in the early stages.
Increased mortality rates become one of the most dramatic outcomes of underdiagnosed delirium. Hospital factors or patient gender do not affect delirium prevalence, while increased aged, dementia status, and frailty might explain some people’s vulnerability to the condition under discussion (Geriatric Medicine Research Collaborative, 2019). Therefore, it is recommended for nurses to initiate regular screening for delirium among patients aged 65 and older and communicate with other practitioners who cooperate with ICU patients. Sometimes, if a nurse spends several extra minutes with a patient, this decision will reduce hospital stay length or unnecessary treatment interventions.
In ICUs, nurses are obliged to observe and assess patients regularly to predict the development of health complications that lead to financial and emotional burdens. The report by the Nursing and Midwifery Council (2015) shows that delirium affects about 80% of ICU patients and provokes additional healthcare costs like £13,000 per admission. On the one hand, it seems unclear why people cannot predict the possibility of this condition while being aware of such negative outcomes. Hospitals report increased lengths of stay and the growth of pressure sores in older patients with delirium (Nursing and Midwifery Council, 2015). On the other hand, certain improvements and positive shifts should be recognised. Health and medicine scholars and researchers continue investigating the field and offering solutions for hospitals. Lange et al. (2022) admit that the most effective EBP analyses do not contain effective pharmacological interventions to prevent ICU delirium, while non-pharmacological strategies need to be developed. Communication, education, and cooperation are the areas of nursing practice where innovations and new guidelines are developed, improved, and introduced quickly. Thus, delirium itself is not the only problem; the challenge is to find and utilise credible information.
Taking into consideration the offered statistics, the description of symptoms, and current findings, the problems of ICU patient delirium prevention have several roots, namely awareness, education, and practice. First, one should understand that delirium is a serious mental condition, but it can be predicted. Second, nurses have to improve their awareness of delirium among ICU patients in particular. Finally, delirium prevention may include pharmacological and non-pharmacological solutions. The essence of EBP is to gather credible facts, evaluate professional opinions and guidelines, and provide nurses with clear guidelines to provide patients with timely and high-quality care. Besides, treatment with respect and dignity should be promoted following the principles of the Nursing and Midwifery Council’s Code.
Solutions
People need to maintain consciousness and cognition to make decisions, take care of themselves, and cooperate with others properly. Delirium in the ICU is a terrible condition when patients are not able to recognise physiological or mental threats and have to live underdiagnosed. With time, they face additional problems related to increased healthcare costs, prolonged hospitalisation, and challenged socialisation. The major risk factors of delirium may be predisposing like smoking, sepsis, and hypertension or precipitating like mechanical ventilation, immobility, and other metabolic disturbances (Mart et al., 2021). Patients or nurses can modify some of them, including smoking control, environment, pain, or drug use, while many factors like illness severity or frailty are hard to modify (Mart et al., 2021). Thus, preventing delirium is a sound idea for the ICU to be implemented, and EBP findings enhance the quality of care and individual professionalism. EBP principles that can be applied to put the guidance into practice are quality improvement, cooperation, leadership, and environment.
Pharmacological Strategies
Nurses should be aware of how to predict delirium symptoms in ICU patients by offering effective and non-harmful pharmacological treatment plans. They have to control the alterations of dopaminergic and cholinergic pathways by prescribing sedatives, opioids, and melatonin antagonists (Barbateskovic et al., 2019). Haloperidol is commonly supported by many international guidelines and used for analysis in many trials and study groups (Al‐Qadheeb, 2016, cited in Burry et al., 2019). Some studies show positive results in reducing the duration of delirium in ICU patients, but most of them were of small size, which requires additional work and discussion. However, in most cases, Burry et al. (2019). agree that despite the preferred drug class, there is no or small difference with placebo in terms of cognitive outcomes, mortality rates, or coma. Thus, these findings prove the observation mentioned by Krupa et al. (2019) (cited in Lange et al., 2022) that there are no effective pharmacological interventions for the prevention of delirium. As such, non-pharmacological treatment remains one of the most preferred strategies for nurses to rely on in their intention to predict the possibility of delirium among ICU patients.
Non-Pharmacological Strategies
Delirium in ICU patients is preventable, and non-pharmacological strategies are commonly practised in many UK hospitals and worldwide. The diversity of services is impressive, and nurses follow the Code to ensure they properly complete single tasks or multi-component assignments. The essence of such interventions is not to rely on drugs and other pharmacological products but focus on interpersonal relationships, create supportive environments, and gather information via communication, reports, and observations. Modern authors conduct library and online research, analyse trials, and introduce their experiments to prove the effectiveness of non-pharmacological nursing care. Among the existing variety of approaches, such ideas as light or music therapy, hydration, the ABCDEF bundle, the Hospital Elder Life Program (HELP), and sleep improvement. There are no clear rules to using one component or combining several options. Therefore, nurses and other care providers must address the Code, preserve safety, work effectively, prioritise people, and promote trust (Nursing and Midwifery Council, 2015). ICU patients are challenged by delirium, and these EBP preventive steps are characterised by positive outcomes and changes in nursing practice.
Delirium is associated with circadian rhythm changes, and light therapy is one of the options to improve this rhythm. There are many control trials to check the effectiveness of this intervention because light helps to stabilise circadian rhythm, lessen restless behaviours, and reduce confusion at night time (Ghaeli et al., 2018; Lange et al., 2022). Bright lighting systems are installed in patient rooms and controlled by nurses. In addition, it is recommended to remove unnecessary noise with the help of earplugs, so patients are not confused with external sources (Lange et al., 2022; Salvi et al., 2020). When possible, nurses try to use natural light that is favourable for ICU patients. There is usually a poor light-dark transition in rooms, and human eyes need to make some effort to accept the change. Thus, nurses who follow this intervention reduce unnecessary disturbances and delirium incidence. As a rule, this strategy is supported by additional steps, including cooperation and communication between nurses, colleagues, patients, and families.
Today, people use music for different purposes to improve their mood, find additional sources for inspiration, complete specific tasks, and express emotions. However, not many individuals believe in the effectiveness of music therapy that affects brain work and manages mental health problems. Addressing the trial by Cetinkaya (2019) (cited in Burton et al., 2021) and Salvi et al. (2020), music interventions are used to reduce delirium incidence. Still, the effects of the condition’s severity, duration, and relation to hospital stay are poorly reported. Lange et al. (2022) offer music as a part of an environmental intervention together with bright lighting and earplugs to reduce delirium in ICU patients. This approach focuses on lowering anxiety and avoiding confusion provoked by physical changes, inabilities, weaknesses, and other unpleasant moments (Ghaeli et al., 2018). The improvement of some physiological parameters cannot be ignored as the possible effects of music on heart rate, blood pressure, and skin condition. ICU nurses care for patients with different conditions, and it is their responsibility to control music volume, quality, and choice and not to create unnecessary discomfort.
Dehydration is one of the most evident predictors and outcomes of delirium that affects the human brain and cognition. Physiological and metabolic functions are distorted, provoking behavioural and mental changes (Ghaeli et al., 2018). Nurses need to ensure that patients get access to fundamental care that usually includes nutrition and hydration (Nursing and Midwifery Council, 2015). Thus, hydration interventions are critical for all patients, including those from ICUs. Although they are associated with a probable reduction in delirium incidence, there are no harmful outcomes that might challenge human health (Burton et al., 2021). Therefore, the use of dehydration interventions to prevent delirium in ICU patients is justified with the help of EBP studies and aligns with the nursing Code to preserve the safety and effective care.
Another EBP solution to prevent ICU delirium is to follow the ABCDEF bundle. Its idea lies in the necessity to take several steps to improve patient care quality and examine the current condition to predict the progress of new challenges. A single-centre, prospective randomised controlled trial was introduced by Sosnowski et al. (2021) to show the effectiveness of the assessment, breathing trials, choice of sedation, delirium management, early mobility, and family engagement. In the study, 150 participants randomly perceived the ABCDEF bundle together with standard nursing and medical healthcare (Sosnowski et al., 2021). As a rule, each element of this intervention has to be prescribed separately by an interdisciplinary team member and completed within two hours (Sosnowski et al., 2021). The offered EBP project is characterised by rather positive outcomes measured by a reliable assessment tool. When family members are involved in a caring process, and a number of aspects are regularly monitored, nurses get good chances to recognise alarming signs and prevent delirium.
HELP (Hospital Elder Life Program) has already been proven as a successful intervention in many hospitals where elderly patients receive care. Using the findings by Inouye et al. (2000) and Zolfaghrani et al. (2012) (cited in Ghaeli et al., 2018), researchers continue concluding that HELP allows preventing cognitive disorders and functional defects in elderly patients. Nurses are involved in different reorientation therapeutic activities, encourage early mobilisation among patients, and provide vision/hearing aid (Salvi et al., 2020). Regarding the fact that delirium is more common among older patients, the offered intervention turns out to be a good solution for nurses who have to work with ICU patients. Still, HELP is usually supported by volunteers, and the number of people who are ready to spend time on education and evaluation of the programs is limited (Salvi et al., 2020). More evidence is required to support this approach and involve more nurses on a voluntary basis.
Finally, the prevention of delirium is closely related to the possibility of managing patient sleep habits. Many studies from different parts of the world prove the effectiveness of sleep improvement interventions either introduced independently or as a part of multi-component approaches (Burton et al., 2021; Salvi et al., 2020). According to the International Statistical Classification of Diseases (cited in Burton et al., 2021), a disturbed sleep-wake cycle is included as one of the risk factors. Therefore, nurses who focus on preventing delirium or other cognitive disorders have to ensure that ICU patients get access to appropriate sleep hygiene behaviours. A healthy sleep environment is a part of an ICU delirium management process when nurses control how patients get care. When a person does not sleep well, an alert mental state emerges and provokes memory problems. Nurses cannot directly promote high-quality sleep, but they are responsible for supporting the conditions under which patients take rest.
Conclusion
In general, attention to EBP for preventing ICU delirium is critical for nurses and healthcare providers. This approach allows to understand what steps have already been made in this field and see what results have been achieved. Nurses use EBP to improve their practice environments, make sufficient decisions, and achieve positive patient outcomes. In addition, this practice strengthens nurses’ knowledge and introduces alternatives for decision-making in various directions. The spheres of nursing and health care undergo multiple changes because individuals get access to new technologies and exchange their experiences worldwide. Therefore, it is important for nurses to check recent achievements and adjust their practice, addressing available resources and knowledge obtained. It is better for participants to cooperate and discuss their steps, but individual practice and progress are also encouraged. EBP enables students and practitioners to learn the risks in their work and define how to help patients or support families.
At this moment, many pharmacological and non-pharmacological interventions exist to prevent ICU delirium. Nurses are properly educated to choose the solutions that correspond to their goals and obligations. The Nursing and Midwifery Council Code cannot be ignored when preventive interventions are applied. Thus, nurses who use haloperidol or other allowed drugs to improve patients’ mental well-being follow the principles of safety and effective care. Besides, treating patients with respect, dignity, compassion, and kindness become the core aspects of most non-pharmacological interventions. Such solutions as the ABCDEF bundle, HELP, dehydration, music or light therapy, and sleep hygiene remain effective for preventing delirium, stabilising people’s mental health, and reducing cognitive and functional impairments. Delirium can be prevented, and the application of EBP ideas is one of the best options for nurses to consider in the UK and across the globe. Cooperation, risks minimisation, communication, and mutual support promote EBP in the context of ICU delirium prevention.
Reference List
Barbateskovic, M. et al. (2019) ‘Pharmacological interventions for prevention and management of delirium in intensive care patients: a systematic overview of reviews and meta-analyses’, BMJ Open, 9(2).
Burry, L. et al. (2019) ‘Pharmacological interventions for the treatment of delirium in critically ill adults’, Cochrane Database of Systematic Reviews, 9.
Burton, J. K. et al. (2021) ‘Non‐pharmacological interventions for preventing delirium in hospitalised non‐ICU patients’, Cochrane Database of Systematic Reviews, 7(7).
Geriatric Medicine Research Collaborative (2019) ‘Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day’, BMC Medicine, 17(1).
Ghaeli, P. et al. (2018) ‘Preventive intervention to prevent delirium in patients hospitalized in intensive care unit’, Iranian Journal of Psychiatry, 13(2), pp. 142-147.
Herling, S. F. et al. ‘Interventions for preventing intensive care unit delirium in adults’, Cochrane Database of Systematic Reviews, 11.
Lange, S. et al. (2022) ‘Non-pharmacological nursing interventions to prevent delirium in ICU patients – an umbrella review with implications for evidence-based practice’, Journal of Personalized Medicine, 12(5).
Mart, M. F. et al. (2021) ‘Prevention and management of delirium in the intensive care unit’, Seminars in Respiratory and Critical Care Medicine, 42(1), pp. 112-126.
National Health Service (2018) Delirium curriculum for acute hospital staff. Web.
Nursing and Midwifery Council (2015) The code. Web.
Reid, J. et al. (2017) ‘Enhancing utility and understanding of evidence based practice through undergraduate nurse education’, BMC Nursing, 16(1), pp. 1-8.
Salvi, F. et al. (2020) ‘Non-pharmacological approaches in the prevention of delirium’, European Geriatric Medicine.
Sosnowski, K. et al. (2021) ‘Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomised controlled trial with embedded process evaluation’, BMJ Open, 11(7).
Spiegelberg, J. et al. (2020) ‘Early identification of delirium in intensive care unit patients: improving the quality of care’, Critical Care Nurse, 40(2), pp. 33-43.