Review
Barriers to delirium assessment in the intensive care unit: A literature review

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Abstract

Background

Delirium is a common syndrome that has both short and long-term negative outcomes for critically ill patients. Many studies over several years have found a knowledge gap and lack of evidence-based practice from critical care personnel, but there has been little exploration of the reasons for this.

Aim

To identify the perceived barriers to delirium assessment and management among critical care nurses.

Method

A literature review of published studies to examine barriers to effective delirium assessment using a comprehensive search strategy. Five relevant studies identified for review.

Results

Few studies have investigated barriers to delirium assessment and management, but several themes reoccur throughout the literature. The perceived time consuming nature of the assessment tools is cited by many, as is the lack of medical prioritisation of results. Lack of education on delirium appears to be a significant factor and reinforces some of the stated misconceptions.

Conclusion

Many barriers exist to prevent effective assessment and management of delirium, but several of these are due to a lack of understanding or unfamiliarity with the condition and the assessment tools as well as lack of medical prioritisation of the results. Further research is needed on this topic.

Introduction

Intensive care unit (ICU) delirium is defined as an altered state of consciousness featuring disordered attention, impaired cognition, altered psychomotor activity (increased or decreased) and disorder of the sleep-wake cycle (Borthwick et al., 2006, Tait, 2016). It has an acute onset and is thought to be reversible (Borthwick et al., 2006), although Morandi et al. (2012) state that long-term cognitive impairment is common after diagnosis of ICU delirium. Delirium is associated with poorer outcomes, higher costs and increased mortality (Chevrolet and Jolliet, 2007, National Institute for Health and Care Excellence, 2010). Incidence varies widely but it is thought to affect from 18% to 82% of critically ill patients (Ely et al., 2004, Morandi et al., 2012). There are three subtypes: hyperactive, characterised by hallucinations and agitation; hypoactive, where the patient is withdrawn and inattentive; and mixed delirium, which fluctuates between the two (Page and Ely, 2015). Assessment is crucial for effective management, and many studies have identified a deficit in assessment practice such as using clinical observation rather than validated tools (MacSweeney et al., 2010) or lack of routine assessment for all ICU patients (Patel et al., 2009). However, there have been no previous reviews of the barriers to delirium assessment in critical care nurses, and this review aims to explore and establish the reported barriers to recommended practice.

Section snippets

Aim

To identify the perceived barriers to Intensive Care Unit (ICU) delirium assessment and management among critical care nurses.

Search strategy

A literature search was conducted by the author to obtain relevant material pertaining to the topic. All search words were set to be recognised within the article title, abstract and/or keywords, and combined using Boolean operators [OR] or [AND] (see Table 1). CINAHL headings were also searched in the CINAHL database, with MESH headings searched in the Pubmed and Cochrane databases. ‘Backward chaining’ of reference lists of the included studies was done to ensure no pertinent or seminal data

Results

From a total of 136 articles, five were found to meet the aims of the review (see Fig. 1).

Discussion

Although the studies provided varied methodologies and results, it is possible to use thematic analysis to categorise the identified barriers to delirium assessment into three broad themes: individual barriers; patient-related barriers; and working environment barriers.

Limitations

Limitations of this review include the small number of studies looking at barriers to delirium assessment in critical care. The included studies used variable items and the questionnaires were constructed differently and thus, although thematic analysis is possible and shows similar findings across the studies, comparison is difficult. Several of the studies used a small sample size, or had low response rates, which affects the generalisability of the findings.

Conclusion

There are very few studies that investigate the barriers to delirium assessment, and future research could address this issue on a larger scale to clarify the reasons for this. The results of this review give some insight into the reasons why nurses do not perform delirium assessment, and the barriers they perceive. It is clear that effective leadership and organisational support would remove some of the described barriers, and many of the rest could be addressed by ensuring more comprehensive

Conflicts of interest

As this study was a systematic review, no ethical approval was required.

Ethical approval

As this study was a systematic review, no ethical approval was required.

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