An Early Rehabilitation QI Program Promotes CAM-ICU Delirium Screening

Delirium is common in the intensive care unit (ICU) and is associated with worse long-term physical and mental health outcomes.¹ It is important to determine a patient’s delirium status for both ICU clinical practice and quality improvement (QI) projects. The Confusion Assessment Method for the ICU (CAM-ICU) is a validated tool that screens for four features of delirium²:
 

1. Change from baseline mental state or fluctuation in mental status in the past 24 hours
2. Inattention
3. Altered level of consciousness
4. Disorganized thinking

A patient is considered to have delirium when both features 1 and 2 are present in addition to either feature 3 or 4.

ICU early rehabilitation interventions can help prevent and treat delirium, but delirium itself can be a barrier to implementing active rehabilitation interventions.³ Complete and accurate delirium screening ensures that patients’ delirium status is correctly determined. Potential challenges in routine clinical delirium screening include missing and/or incomplete screening, inappropriate screening when a patient is deeply sedated (i.e., comatose), and errors in scoring and summarizing the four features of the CAM-ICU.

At the Johns Hopkins Hospital medical ICU (MICU) in Baltimore, Maryland, USA, nurses screen for delirium at least once during each day shift and each night shift. MICU nurse preceptors train new MICU nurses on how to conduct CAM-ICU screening. Thereafter, MICU nurse leaders provide one-on-one feedback to nurses, focused CAM-ICU retraining, and just-in-time education.

Tracking and Reviewing Delirium Screening
In 2008, the Johns Hopkins Hospital MICU established its hospital-funded Critical Care Physical Medicine and Rehabilitation (CCPM&R) QI program. Trained program assistants review every MICU patient’s electronic medical record (EMR) daily for appropriateness and safety of physical therapy, occupational therapy, and/or speech-language pathology consultations. Program staff also coordinate weekly multidisciplinary meetings to review each patient’s rehabilitation consultations in addition to rehabilitation goals, barriers, and progress. 

Program staff monitor MICU nurses’ completion of CAM-ICU delirium screening and then review each documented CAM-ICU screening in the EMR for completeness and potential errors. Every day, excluding weekends, CCPM&R program assistants provide day shift nurses real-time feedback and education on any missed, incomplete, or possibly inaccurate screening based on their EMR review of CAM-ICU documentation. Since CCPM&R staff do not monitor nurse assessments in person, they cannot assess all aspects of CAM-ICU accuracy. For example, they cannot monitor the quality of screening for CAM-ICU features 2 and 4, but they can assess aspects such as errors in scoring feature 1 or inappropriately assessing CAM-ICU features when patients are comatose. 

At the end of each month, the CCPM&R program generates a report summarizing the number, percentage, and types of potential errors and identifies nurses with relatively high rates of potential errors. A synthesis of this report is provided to the MICU nurse educator and clinical nursing leaders to use in conjunction with one-on-one feedback and education to MICU nurses. The CCPM&R medical director and program staff meet with nursing leaders monthly to discuss delirium screening metrics within the larger context of nurse-based mobility efforts that are part of the CCPM&R program.

This clinical program uses structured, data-driven QI methods to monitor and improve delirium screening documentation in the ICU and improve completeness and accuracy for both patient care and QI projects. This approach has been an important foundation for improving clinical practice and patient outcomes.⁴ This multidisciplinary program exemplifies the benefits of integrating delirium screening within a comprehensive, early rehabilitation program.