This is a sub-analysis of a prospective, international prevalence survey conducted on WDAD, an annual international day to increase awareness of delirium amongst healthcare professionals, patients, and caregivers.¹² Fourteen units at two hospitals: a 652-bed Level-1 tertiary research and academic medical centre and a 207-bed community hospital participated in the WDAD Prevalence Study. Of 11 General Units, seven belong to the community hospital; 4 remaining were from the tertiary hospital. Two High Acuity Units were from a community hospital, and 1 was from a tertiary hospital. General units include medical-surgical, neurology, and orthopedic units, whereas High Acuity Units include step-down and intensive care units (ICU). Approval was received from the Advocate Health Wake Forest University Institutional Review Board (Protocol # IRB00092271).

Twenty Clinical Nurse Leaders (CNL) from all specialties at two hospitals were invited to complete a web-based survey during the WDAD; 11 (55%) completed the survey. The WDAD Prevalence survey contains 39 “select all that apply” questions assessing the characteristics of respondents, hospitals, units, structures, delirium prevention and management processes, and barriers to implementing delirium evidence-based strategies (Online Supplemental Table 1). In addition, three open-ended questions asked for recommendations for delirium care and future research. To answer the survey questions, these CNLs must have reviewed the unit census and electronic healthcare record (EHR) of patients aged 18 and older at 8 A.M (+/-4hrs) and 8 P.M (+/-4 hrs) on March 15, 2023, to identify the number of patients on the unit, the number of CAM assessments, and positive CAM screening. A patient was defined as having delirium if their EHR documentation reflected at least one occurrence of a positive CAM. All surveys had to be returned to the study team by March 17, 2023, or were excluded. Permission was granted from the international study team to perform this sub-analysis.

Categorical survey data were reported as numbers and percentages. Comparative analysis between the two-unit groups (General and High Acuity) was performed using Fisher’s exact test. Continuous data associated with delirium assessments were assessed for normality, and either an unequal sample t-test or Wilcoxon rank-sum test was performed as appropriate to the data. Means and standard deviations were reported. Radar graphs were generated to visualise the Non-pharmacological treatment and Barriers against implementation data.

Data for the variables for Non-pharmacological prevention and treatment, Pharmacological treatment, and Barriers against implementation and/or use of evidence-based strategies are… were assessed and grouped by the variable designating unit type. Percentages were created where the denominator was the number of patients present in their respective units at the AM and PM times indicated on the survey, and the numerators were patients assessed positive by CAM; creating four variable types: AM Patients Assessed Percentage, PM Patients Assessed Percentage, AM Patients Positive Percentage, and PM Patients Positive Percentage. All data were analysed by Stata 17 (College Station, TX: StataCorp LLC) and p<.05 was considered statistically significant.

For the tertiary hospital, 137 patients were present on the unit at 8 A.M, 70 (51%) CAM assessments were documented. At 8 P.M of 137 patients, 64 (47%) CAM assessments were performed. At the community hospital, of the 191 patients on the unit at 8 A.M, 154 (81%) CAM assessments were documented, and at 8 P.M, 168 patients were present on the unit, 130 (77%) CAM assessments were documented. Among CAM assessments, positive CAM screening was 2% and 3% (5 CAM assessments at 8:00 A.M. and 8:00 P.M.), respectively. The overall average number of patients assessed for delirium was higher in the morning (AM: 17.5 vs. PM: 14.5), though when stratified by unit type, this pattern was not found in the High Acuity Unit (AM: 10.7 vs. PM: 11.3). There were no significant differences between the unit types in percentage of patients either assessed for, or positive for delirium in either AM or PM (Table 1). However, while not significant at a p<.05 level, the average AM percentage of patients positive for delirium in the General Units trended towards a much lower than average AM percentage of patients positive in the High Acuity Units (General: 0.35% vs. High Acuity: 7.4%, p=.066).

There was a significant difference in the use of multiprofessional daily goals between the two-unit types as a non-pharmacologic intervention for delirium (General: 0% vs. High Acuity: 100%, p=.003) (Online Supplemental Table 2). The General Units reported family information, mobilisation, pain management, avoidance of catheters, family engagement, adequate fluids, and verbal re-orientation at frequencies greater than 90%. The High Acuity Units also reported mobilisation, pain management, adequate fluids, and verbal re-orientation at high frequencies; however, the difference from the General Unit was they also reported open visiting times, cognitive stimulation, ear plugs, and multiprofessional daily goals at high-frequency utilisation (Figure 1). As for pharmacologic interventions, there were no significant differences between the two unit types (Table 2).

The High Acuity Units reported “Patients who are difficult for assessment” as a barrier significantly more than the General Units (General: 9.1% vs. High Acuity: 100%, p=.011) (Table 3). The General Units reported a lack of knowledge about delirium and a lack of awareness in frequencies above 90%, and the High Acuity Units also reported these barriers in high frequency, with the addition of shortage of personnel, communication gaps between professionals, and patients who are difficult to assess (Figure 1).

The survey respondents recommended frequent delirium education, focusing on how to use the CAM tool to increase accuracy. One respondent wrote, staff needs more education on CAM scores. Current scoring may not be appropriate/accurate. Additionally, non-pharmacological interventions such as providing vision and hearing aids, day and nighttime rhythm, multidisciplinary rounds, and patient education are essential in preventing and managing delirium. However, as shown in Figure 1, these interventions are seldom being provided, which may be due to a lack of time and resources. A participant wrote, non-pharmacological interventions can be effective but can take more time. Most units are also not stocked with activities for patients. Participants also suggested leveraging the EHR to increase delirium assessment by linking the delirium assessment admission checklist, or shift required actions; otherwise, CAM is not assessed regularly. Based on the participant’s perspective, integrating this simple reminder will help nurses remember to assess and document delirium in the EHR. Overall, the survey respondents expressed motivation to do the right thing for their patients, as a healthcare provider, I am motivated to promote awareness and education of delirium. However, staff will need support such as enhancing EHR tools, access to delirium prevention supplies, receive continuing delirium education, and ensure adequate staffing.

Several limitations to this study prevent generalising results. The small sample and cross-sectional nature of the assessment timeframes may cause assessments performed at other times during the day to be overlooked. The use of survey-based data may produce bias results, and inability to acquire participant-level data, potentially impacting data quality. Additionally, location limits the generalisation of these results to nurses’ delirium assessments at other facilities. Low CNL participation at the tertiary hospital limits CAM assessments to 5 units, affecting the true assessment compliance and recognition rates. Additionally, only CAM and CAM-ICU tools were utilised in this study. Finally, a recent transition to a new EHR limits the nurses’ familiarity and compliance with necessary documentation.

Clinical implications of this work point to the need for more education and training regarding delirium assessment, interventions, and interprofessional collaboration. Delirium does not occur solely in the morning hours; hence, compliance with delirium assessment per shift and as needed is critical for early detection and intervention. Findings revealed the need for resources to help appropriately assess patients and document this assessment correctly. Assessment documentation is critical for interprofessional teammates managing the care of the patients in future shifts. Future research surrounding the use of the EHR to support compliance and documentation of delirium would provide insight into how nurses can be better supported in an assessment that is known to be difficult, further highlighted in this study.

Future studies should also explore the clinical practice differences between the two types of units. Here, the High Acuity Units experienced a higher percentage of positive CAM assessments. Interestingly, the use of non-pharmacological interventions and the barrier of personnel shortages were noted within the High Acuity Units compared to the General Units meaning that while High Acuity Units noted staffing barriers, they still used more non-pharmacological interventions than the General Units. Could staffing issues or acuity levels contribute to the differences between the two-unit types?

All authors declare that they have conflict of interest.