Stop. Think. Delirium! A quality improvement initiative to explore utilising a validated cognitive assessment tool in the acute inpatient medical setting to detect delirium and prompt early intervention.

AIMS AND OBJECTIVES: The paper examines the ability of nursing staff to detect delirium and apply early intervention to decrease adverse events associated with delirium. To characterise nursing practices associated with staff knowledge, delirium screening utilising the Modified Richmond Assessment Sedation Score (mRASS), and multicomponent interventions in an acute inpatient medical unit. BACKGROUND: Delirium incidence rates are up to 60% in frail elderly hospitalised patients. Under-recognition and inconsistent management of delirium is an international problem. Falls, restraints, and increased hospital length of stay are linked to delirium. DESIGN: A descriptive study. METHODS: Exploration of relationships between cause and effect among cognitive screening, knowledge assessment and interventions. RESULTS: Success in identifying sufficient cases of delirium was not evident; however, multicomponent interventions were applied to patients with obvious symptoms. An increase in nursing knowledge was demonstrated after additional training. Delirium screening occurred in 49-61% of the target population monthly, with challenges in compliance and documentation of screening and interventions. Technological capabilities for trending mRASS results do not exist within the current computerised patient record system. CONCLUSIONS: Delirium screening increases awareness of nursing staff, prompting more emphasis on early intervention in apparent symptoms. Technological support is needed to effectively document and visualise trends in screening results. The study imparts future research on the effects of cognitive screening on delirium prevention and reduction in adverse patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Evidence-based literature reveals negative patient outcomes associated with delirium. However, delirium is highly under-recognised indicating future research is needed to address nursing awareness and recognition of delirium. Additional education and knowledge transformation from research to nursing practice are paramount in the application of innovative strategies. Focus is placed on nursing staff because nurses are at the bedside and are able to identify early signs of delirium.

Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial.

BACKGROUND: Inadequate blood pressure control is a persistent gap in quality care. OBJECTIVE: To evaluate provider and patient interventions to improve blood pressure control. DESIGN: Cluster randomized, controlled trial. SETTING: 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System. PATIENTS: 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent. INTERVENTION: Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education); provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education). MEASUREMENTS: Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication. RESULTS: Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62]; P = 0.012). LIMITATIONS: Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control. CONCLUSIONS: A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.