Rapid Handheld Continuous Electroencephalogram (EEG) Has the Potential to Detect Delirium in Older Adults.

BACKGROUND: Delirium-related biochemical derangements lead to electrical changes that can be detected in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. Studies using limited lead EEG show a large difference between patients with and without delirium while discriminating delirium from other causes. Handheld rapid EEG devices may be capable of detecting delirium before symptom onset, thus providing an objective physiological method to detect delirium when it is most amenable to interventions. OBJECTIVE: The aim of this study was to explore the potential for rapid EEG to detect waveform pattern changes consistent with delirium status. METHODS: This prospective exploratory pilot study used a correlational design and mixed models to explore the relationships between handheld portable EEG data and delirium status. RESULTS: While being under powered minimized opportunities to detect statistical differences in EEG-derived ratios using spectral density analysis, sleep-to-wake ratios tended to be higher in patients with delirium. CONCLUSIONS: Limited lead EEG may be useful in predicting adverse outcomes and risk for delirium in older critically ill patients. Although this population is at the highest risk for mortality, delirium is not easily identified by current clinical assessments. Therefore, further investigation of limited lead EEG for delirium detection is warranted.

Is Perception Reality? Using Person-in-Context Simulation to Promote Empathic Understanding of Dementia Among Nurse Practitioner Students.

ABSTRACT: This one-group nonexperimental pretest/posttest repeated-measures design plus interpretative phenomenological analysis explored nurse practitioner students' perceptions of dementia using virtual simulation. Perceptions of dementia and its associated challenges differed after the simulation. A critical theme that emerged was "developing empathic understanding"; the two subthemes were "mirroring dementia behaviors" and "provoking emotions." Virtual dementia simulation is an inexpensive, low-fidelity strategy to challenge assumptions and preconceived belief systems about dementia. Person-in-context experiential learning is valuable in nurse practitioner education for facilitating empathic understanding. Further research is needed to explore the correlation between empathic understanding and altruistic helping behaviors in professional practice.

Delirium Screening of Patients on a Neuroscience Step-Down Unit.

This project aimed to identify patients who had experienced a stroke and were at risk for delirium earlier, and implement evidence-based protocols to reduce overall length of stay and mortality. Nurses were motivated to perform screening and implement strategies that benefit patients who had experienced acute stroke. Results suggest early identification and treatment of delirium, use of prevention strategies, and treatment of the underlying etiology can improve patient outcomes and reduce cost of care.

Fronto-temporal dementia: a case study and strategies and support for caregivers.

Fronto-temporal dementia, also known as fronto-temporal lobular degeneration, is the second most common form of early-onset dementia with a prevalence equal to Alzheimer's dementia. Behavioural variant fronto-temporal dementia primarily involves the frontal and temporal lobes of the brain. Myelination of nerve fibres in these areas allow for highly synchronized action potential timing. Diagnosis is often significantly delayed because symptoms are insidious and appear as personality and behavioural changes such as lack of inhibition, apathy, depression, and being socially inappropriate rather than exhibiting marked memory reductions. In this article, a case study illustrates care strategies and family education. Management of severe behavioural symptoms requires careful evaluation and monitoring. Support is especially important and beneficial in the early to middle stages of dementia when nursing home placement may not be required based on the individual's condition.

Detecting Delirium Using a Physiologic Monitor.

For the past 2500 years, delirium has been described based on the presence of behavioral symptoms. Each year, as many as 1 in 5 acute care and 80% of critically ill patients develop delirium. The United States spends approximately $164 million annually to combat the associated consequences of delirium. There are no laboratory tools available to assist with diagnosis and ongoing monitoring of delirium; therefore, current national guidelines for psychiatry, geriatrics, and critical care strongly recommend routine bedside screening. Despite the significance, health care teams fail to accurately identify approximately 80% of delirium episodes.The utility of conventional electroencephalogram (EEG) in the diagnosis and monitoring of delirium has been well established. Neurochemical and the associated neuroelectrical changes occur in response to overwhelming stress before behavioral symptoms; therefore, using EEG will improve early delirium identification. Adding EEG analysis to the current routine clinical assessment significantly increases the accuracy of detection. Using newer EEG technology with a limited number of leads that is capable of processing EEG may provide a viable option by reducing the cost and need for expert interpretation. Because EEG monitoring with automatic processing has become technically feasible, it could increase delirium recognition. Electroencephalogram monitoring may also provide identification before symptom onset when nursing interventions would be more effective, likely reducing the long-term ramifications. Having an objective method that nurses can easily use to detect delirium could change the standard of care and provide earlier identification.

Methods of identifying delirium: A research protocol.

Delirium is an acute disorder affecting up to 80% of intensive care unit (ICU) patients. It is associated with a 10-fold increase in cognitive impairment, triples the rate of in-hospital mortality, and costs $164 billion annually. Delirium acutely affects attention and global cognitive function with fluctuating symptoms caused by underlying organic etiologies. Early detection is crucial because the longer a patient experiences delirium the worse it becomes and the harder it is to treat. Currently, identification is through intermittent clinical assessment using standardized tools, like the Confusion Assessment Method for ICU. Such tools work well in clinical research but do not translate well into clinical practice because they are subjective, intermittent and have low sensitivity. As such, healthcare providers using these tools fail to recognize delirium symptoms as much as 80% of the time. Delirium-related biochemical derangement leads to electrical changes in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. However, continuous EEG monitoring is not feasible due to cost and need for skilled interpretation. Studies using limited-lead EEG show large differences between patients with and without delirium while discriminating delirium from other causes. The Ceribell is a limited-lead device that analyzes EEG. If it is capable of detecting delirium, it would provide an objective physiological monitor to identify delirium before symptom onset. This pilot study was designed to explore relationships between Ceribell and delirium status. Completion of this study will provide a foundation for further research regarding delirium status using the Ceribell data.

Conducting a Device Feasibility Study.

Feasibility studies are often the first attempt researchers use to test whether a new process or part of a process is practical for use in a clinical setting or a device will provide the desired information. When conducting a device feasibility study there are several unique considerations that must be addressed. This manuscript describes the processes and considerations.

Choosing the Right Delirium Assessment Tool.

Delirium is an increasing concern with current combined annual costs for the United States and Europe of approximately $350 billion. Although standardized definitions and diagnostic criteria exist, more than 80% of delirium in the acute care setting is overlooked or misdiagnosed. Delays in identification result in increases in severity and mortality and a reduction in quality of life. Selecting an assessment tool is the first step toward improving recognition.

Pathophysiology Review: Seven Neurotransmitters Associated With Delirium.

Delirium affects 70% to 80% of intensive care unit patients and is associated with a 10-fold increase in rates of cognitive impairment at discharge and a 3-fold increase in mortality rates. Estimated costs are $152 billion in Medicare charges annually, 17.5 million inpatient days, and 30-day postdischarge costs of $238 726 per patient. Delirium is an acute disorder of attention and global cognitive function characterized by fluctuating symptoms occurring in the face of an underlying organic cause. As patients adapt to physiological stressors, neurotransmitter changes lead to electroencephalogram pattern changes. The ability to compensate for the chemical (neurotransmitter) imbalances is surpassed, causing the behavioral symptomatology we know as delirium. This article seeks to describe the pathophysiology behind the behavior core to the prevention and management of delirium.

Monitoring peripheral edema of heart failure patients at home: Device, algorithm, and clinic study.

Continuous monitoring of heart failure (HF) patients is desirable in order to better manage their illness and reduce unnecessary hospitalization. A comprehensive cloud-based HF patient management system is proposed to collect patients' health status information and provide just-in-time intervention. To date, an HF patient edema monitoring system prototype, including the device and its algorithm, has been developed. The hardware features multiple sensors whose data are fused using an edema classification algorithm based on a standard linear solid (SLS) edematous tissue model. Clinical data have been collected and analyzed to verify the effectiveness of the hardware and software. While the analysis results show some promise, full validation of the device and the algorithm warrant further study.

What's Your Position? Strategies for Safely Reaching Patient Comfort Goals After Cardiac Catheterization via Femoral Approach.

BACKGROUND: Patients frequently complain of back pain after cardiac catheterization, and there is a lack of evidence to guide practice regarding patient comfort while maintaining hemostasis at femoral access site after cardiac catheterization. OBJECTIVE: The aim of this study was to examine if frequent position changes affect a patient's pain level or increase incidents of bleeding in the recovery period after cardiac catheterization. METHODS: A quasi-experimental pretest/posttest design was used to evaluate a patient's reported pain levels and positioning changes during bed rest period postprocedure. Twenty charts were reviewed to note documentation of patient position, self-reported pain rating related to pain relief goals, and occurrence of bleeding at the procedure site. A survey was conducted to reveal nurse attitudes, knowledge, and beliefs regarding positioning and pain management for patients in the post-cardiac catheterization period. Results from this survey were used to develop education and data collection tools. Education regarding perceived barriers and importance of maximizing activity orders for patient comfort was provided to nursing staff. After nurse education, an additional 20 charts were reviewed to note if increasing frequency of position change affects pain levels reported by patients or if any increased incidence of bleeding was noted with greater frequency of position change. RESULTS: Data were analyzed using correlation analyses. Greater levels of pain were associated with higher pain ratings (r = 0.796, P < .000). Use of position change only as a comfort measure was negatively associated with pain ratings; in other words, lower patient pain ratings were associated with use of positioning only without addition of medications to address complaint (r = -0.493, P < .023). There was a significant increase in number of pain management goals met from before to after education intervention (P < .046). DISCUSSION: Nurse concern for increased bleeding was found to be the most common barrier for use of position changes for comfort after cardiac catheterization. This initial analysis suggests position changes in conjunction with pain medication are beneficial in managing pain after cardiac catheterization. There was no increase in bleeding or complications reported; however this study had a small sample size, and caution should be used regarding generalization of findings.

Design of peripheral edema measurement device for home use.

Due to improvements in cardiovascular care, more patients are living longer but ultimately developing heart failure. It is important for patients with chronic conditions, like heart failure, to self-manage and monitor their symptoms. One symptoms that can be indicative of worsening heart failure is peripheral edema. Therefore, we present a concept for a HeartSMART system capable of edema measurement in the home with remote connection to and feedback from providers. The goal of the system is to provide a tool for heart failure patients to manage their disease. The work presented herein describes the system design and preliminary testing using simulated edema models. The system uses displacement and force sensors and mimics the gold standard finger indentation performed by care providers. The results for the edema models (foam) show increasing displacement with edema severity.

Is Nursing Care Missed? A Comparative Study of Three North Carolina Hospitals.

Results of a survey measuring frequency, types, and reasons for missed care at three acute care hospitals in North Carolina are described. Results also are compared to those of a previous, similar study in the midwestern United States.

Vulnerability of older patients in critical care.

One of the patient characteristics in the AACN Synergy Model is vulnerability. Vulnerability is defined in the model as the susceptibility to actual or potential stressors that may adversely affect patients' outcomes. The risk of vulnerability increases in older patients in critical care units.

Care redesign: a higher-quality, lower-cost model for acute care.

OBJECTIVE: The aims of this study were to design, pilot, and evaluate a care team model of shared accountability on medical-surgical units. BACKGROUND: American healthcare systems must optimize professional nursing services and support staff due to economic constraints, evolving Federal regulations and increased nurse capabilities. METHODS: A redesigned model of RN-led teams with shared accountability was piloted on 3 medical/surgical units in sample hospitals for 6 months. Nursing staff were trained for all functions within their scope of practice and provided education and support for implementation. RESULTS: Clinical outcomes and patient experience scores improved with the exception of falls. Nurse satisfaction demonstrated statistically significant improvement. Cost outcomes resulted in reduced total salary dollars per day, and case mix-adjusted length of stay decreased by 0.38. CONCLUSION: Innovative changes in nursing care delivery can maintain clinical quality and nurse and patient satisfaction while decreasing costs.

Ethnogeriatrics in critical care.

This article discusses the increased diversity of older adults expected to be treated in intensive care units over the next 10 years. The importance of the integration of an ethnogeriatric assessment to include ethnicity, level of acculturation, religion/spirituality, preferred interaction pattern, facilitation of communication, and physical examination constraints due to ethnicity are discussed.

Critical care visitation: nurse and family preference.

PURPOSE: The purpose of the study was to explore the satisfaction of patients' families and nurses with visitation guidelines in the 5 critical care units at a 435-bed acute care hospital in the southeastern part of the United States. PROBLEM STATEMENT: The restriction of visitation hours for intensive care unit patients has significant implications for the health and well-being of the patient and their family. Although traditionally both facilities and staff have cited reasons to restrict family visitation, research indicates that these practices may have a detrimental effect on the overall health of the patient. METHODS: A descriptive correlational design is utilized in this study. Subjects consisted of family members of patients in 1 of the 5 critical care units and nurses providing care in these units. Family and nurses completed a questionnaire on their perspective of the critical care visiting hours. RESULTS: The majority of families visiting patients in the critical care setting followed the posted guidelines and were very satisfied with the guidelines. The hours most convenient for families to visit at the bedside were from 4 to 8 PM. The majority of nurses wanted to keep visiting hours during day-shift hours; family members were divided on having all hours available for visitation. Nurses had varied perspectives on whether visitation should be allowed as a restraint alternative, when family is out of town, patient emotional needs, eminent death, at time of discharge instructions, and to speak with a physician. CLINICAL IMPLICATIONS: Family member visitation in the intensive care unit setting should be flexible and open. This may include tailoring a plan on admission with the family to allow open access to the patient during times when they are most available; thus, each family has a plan that suits its unique dynamics.

Inpatient fall prevention: use of in-room Webcams.

OBJECTIVES: Patient falls are a challenging safety and quality issue in acute care settings. This study compared inpatient falls on medical-surgical units with and without Webcams and assessed the Morse Risk Assessment (MRA) for effectiveness in identifying fall risk. METHODS: Ten hospitals in one health system that exceeded the benchmark for falls were chosen for a 6-month study. One medical-surgical unit in each of the 10 hospitals was randomly assigned to an intervention or control group. The intervention group used Webcams that viewed the bed with a central monitoring system. A "virtual bed rail" function was used for those patients with a Morse Risk Assessment (MRA) of greater than 25. RESULTS: Consent rate was 20.7% for the intervention group. A significant difference (P ≤ 0.05) between groups was found in fall rate per 1000 admissions, but no significant difference was found in fall rate per 1000 patient days. The Morse Risk Assessment was a significant predictor of risk. CONCLUSIONS: Webcams are one option to increase surveillance for high-risk patients. The use of the MRA with a 50+ score for high risk is recommended. More research is needed on patient acceptance of this form of intervention and effectiveness in preventing falls on various inpatient units or with specific age groups.

Hearing loss in older critical care patients: participation in decision making.

Older adults with hearing loss who receive care in the noisy environment of a critical care unit can be disadvantaged in their ability to understand speech, thus limiting their participation in decision making. Providing optimal outcomes for such patients can be understood through use of the American Association of Critical-Care Nurses Synergy Model. When older adults are admitted to a critical care unit, their spouses, children, and friends are in positions to participate in the patients' care. The AACN Synergy Model patient characteristic of participation in care is useful in enhancing optimal outcomes for older patients.