A SURVEY OF NURSES' OPINIONS ABOUT DELIRIUM IN ICU

1* 2 3 4 Nikeshmani Rajbhandari , Naba Raj Koirala , Lalit Kumar Rajbanshi , Batsalya Arjyal 1540 ISSN: 2542-2758 (Print) 2542-2804 (Online) Birat Journal of Health Sciences Vol.6/No.2/Issue 15/May-Aug., 2021 Received : 15 June, 2021 Accepted : 15 July, 2021 Published : 04 November 2021 Original Research Ar cle


Introduc on
Delirium is under diagnosed especially in ICU. In a study done in the Netherlands inves gators found not only ICU nurses but also intensivists had difficulty in diagnosing delirium. With the impact that delirium has on pa ents' health, its monitoring and detec on should be considered an integral part of pa ent care in cri cal care medicine, Knowledge and a tude are one of the primary unmet needs regarding early detec on and treatment of delirium. Since nurses are the first line assessors in any ward we would like to carry out this cross-sec onal survey on a group of nurses.

Objec ve
To assess the nurses' knowledge about delirium & to compare the knowledge between those that have worked in ICU or cri cal care to those who haven't.

Methodology
This was a cross-sec onal survey carried out at Birat medical college and teaching hospital. Here all nurses were requested to fill a ques onnaire that consisted of 15 ques ons. A me-frame of 1 week was taken to gather the data.

Result
We collected data from 124 nurses, who had varying educa onal degrees, Eighty-four were currently working in an ICU and 32.5% of those not working had previously worked in an ICU. Over all knowledge level for nurses was poor where 94 of 124 nurses had less than 50% scores. About 27% of those who had worked in an ICU se ng had good knowledge compared to 17.5% of those who had not.

Conclusion
Training regarding delirium is required to increase iden fica on and adequate management to decrease morbidity due to delirium.

INTRODUCTION
Delirium is an acute brain dysfunc on characterized by cogni ve impairment, that is fluctua ng, and disturbance in 1 consciousness. It has many e ologies, all of which result in a similar pa ern of symptoms and signs, which are related to cogni on and consciousness. Usually delirium has a rapid onset and a brief and fluctua ng course, with rapid improvement on removal of causa ve factor. It is a common condi on and affects about 15% of pa ents in general 2 medical and surgical wards. Though the incidence of delirium is up to 40% to 60% in the ICU it is an under diagnosed condi on in intensive care unit or cri cal care unit. Lack of awareness about the need to diagnose and treat delirium is 2,3 probably the major factor. Delirium causes burden to the hospital and society. It increases hospital mortality by three folds, while also increasing length of stay in the ICU and 3 consequently increases hospital stay. Associa on between delirium and early deaths, func onal disability, admission to residen al care, and increased burden to caregivers have 3,4 also been seen. With delirium having such a huge impact on pa ents there is a budding conscience that it is a public health problem. Data have shown that even though most health care workers deem delirium as an important health issue, few actually monitor it, are able to detect it and hence 4 it remains largely under diagnosed. With the impact that delirium has on pa ents' health, its monitoring and detec on should be considered as an integral part of pa ent care in cri cal care medicine, where 5 the prevalence of delirium is highest. There should be guidelines in place in all ICU's around the country to monitor 5 delirium. But for implementa on of such guidelines and hence its success, it is important to know the views of healthcare workers about delirium. Knowledge and a tude are one of the primary unmet needs regarding early detec on and treatment of delirium. Since nurses are the first line assessors in any ward we would like to carry out this cross-sec onal survey on a group of nurses. In a study done in the Netherlands inves gators found not only ICU nurses but also intensivists had difficulty in diagnosing delirium. Without help of reliable, validated diagnos c tool only 35% of ICU delirium were recognized by 1 nurses. A Swedish na on-wide survey of ICU head-nurses of the 58 respondents only one reported using a validated delirium screening tool and almost half reported using clinical judgement to diagnose delirium. The study also concluded that awareness of delirium is low and most 2 centers lacked use of validated tools for delirium screening. Another survey carried out amongst 912 health professional about their opinions of delirium observed though most of them considered delirium to be a common and serious problem that was under diagnosed, few actually took steps 3 to monitor the problem. In comparison to altered level of consciousness, presence of pain, or improper placement of an invasive device only 3% of 331 nurses from 16 different intensive care units ranked delirium as most important 5 condi on to evaluate. A simple educa onal interven on can improve the capacity of ICU nurses in detec ng delirium 6 early. Hence through this study we wished to assess the nurses' knowledge about delirium and addi onal to compare the knowledge between those that have worked in ICU or cri cal compared to those who haven't.

METHODOLOGY
This was a cross-sec onal survey carried out at Birat Medical College and Teaching Hospital. A total of 200 nurses who worked at Birat Medical College and Teaching Hospital, were requested to fill a ques onnaire that consisted of 15 ques ons. The ques onnaire was developed by the authors following an itera ve process of item genera on, construc on and refinement. Sample size was calculated assuming views of the nurses comes true as 50%. Using the 2 2 formula n= (Z *p*q)/d , where d was considered as absolute difference, and considering for 20% non-response we calculated a sample size of 116. A me-frame of 1 week was taken to gather the data, during which those that responded were included in the study. Sta s cal analysis was using SPSS v.22.

RESULTS
We collected data from 124 nurses, who had varying educa onal degrees, rest did not want to par cipate in the study. There was only one par cipant who had completed Masters in Science (Nursing) and most (72%) of the par cipants had a degree in cer ficate level nursing, the rest (27%) had received a bachelor's degree in nursing. The mean age of par cipants was 23.96±4.224 years, with minimum age being 19 years and maximum 50 years. Almost 64% (79) of the par cipants were between 21-25 years of age, 23 (18.5%) between 26-30 years, 17 (13.7%) were 20 years or less and 5 (4%) were 31 years or more.
Among the 124 nurses about 89% had been working since 1-5 years, minimum dura on of work experience being 1 month and maximum 20 years with a mean dura on of 2.617±3.2 years. Eighty-four (67.7%) par cipants said that they currently worked in an intensive care unit (ICU)or cri cal care unit as compared to the 40 that did not. Of those who were not presently working in an ICU or cri cal care, 32.5% reported that they had previously worked in such a se ng. More than 74% of the par cipants said that they had not received any specific training on delirium and only 43% par cipants said that delirium was regularly screened at their centre 31% said it was not screened for and 25% did not know whether delirium was screened at their place of work. Of the 84 par cipants who were presently working at a ICU or cri cal care se ng 2 did not answer the ques on, about 54% said it was screened for, 33% said it wasn't screened for and 11% said they did not know whether or not pa ents were screened for delirium. Amongst these 84 par cipants only 22.6% said they had any training or educa on regarding delirium. Regarding opinion about delirium, more than 51% believed it was under diagnosed, 40% thought it was adequately diagnosed and about 9% did not respond. Similarly, results for other ques ons are stated in Table 1.  Of the 11 ques ons that were posed to the par cipants 3 were mul ple choice ques ons where they were allowed to choose more than one op on. More than 70% reported chronic alcohol use was a risk factor for delirium, only 13% reported baseline hypertension to be a risk factor. At the same me 54% thought pre-exis ng demen a as a risk factor for delirium. Thirty-nine percent thought benzodiazepine use and only 24% said pain could be a risk factor. As shown in Table 3 Most par cipants agreed that impaired consciousness and a en on (65%) and cogni ve disturbances (72%) were symptoms of delirium. Though not a criteria listed in the ICD-10 as a symptom of delirium, almost 38% of nurses selected violence as symptom.
Knowledge level of nurses regarding delirium: To quan fy the level of knowledge of the par cipants we allocated one point for each correct answer for all single choice ques ons and for mul ple choice ques ons we allocated one point for all correct op ons. Those who secured more than 50% correct answers were considered to have good knowledge. When considering only the single op on ques ons 38% revealed good knowledge about delirium. Regarding risk factors for delirium almost 71% of par cipants scored less than 50%, which reflected that the remaining 29% had good knowledge. For the ques on about symptoms of delirium more than 72% had less than 50% score. Approximately, 76% had poor knowledge about delirium.
A chi-square test was performed to examine the rela on between working experience in ICU and level of knowledge about delirium. The rela on between these variables was 2 not significant, χ (1, N=124) = 1.44, p=.23. We also examined the sta s cal rela onship between educa onal level and knowledge regarding delirium. The rela on between these 2 variables was also not significant, χ (1, N=124) = 1.403, p=.24.

DISCUSSION
In our study 124 nurses' par cipated, most of whom were about 24 years of age, mostly were educated up to cer ficate level nursing with an average working experience of 2.6 years. Of the 124 par cipants 68% were currently working in at a ICU or cri cal care unit, and of those who were not presently working at such a unit,about 32% had previously worked at such a se ng. More than 74% did not receive any training in delirium, and there was no mechanism for screening of delirium at work places of 32% of the par cipants and 25% said they were not aware whether it was screened for. Even though the society of cri cal care medicine seda on and analgesia guidelines considers assessment of delirium in the ICU an integral part Rajbhandari N et al of adult pa ent monitoringour findings are in agreement with a web-based American survey among 331 nurses, where only 40% stated that even though their units had a seda on protocol it did not specify that delirium should be 7 assessed or they were not sure if the protocol did specify it. In this study the mean age of the respondents was 40.2 years with and average working experience of 13.6 5 years. Even with a very low mean age of par cipants and a much less dura on of experience among par cipants in our study this finding was comparable. Another American 3,8 survey, and an Australian study also had similar findings. Reports from a Swedish survey stated that 62% of the 82 2 ICUs used a method for observa on of delirium. The Swedish study ques onnaire was completed by ICU head nurses, among them 54% said delirium was screened for in their workplace. One meta-analysis showed in an intensive care unit nearly a third of pa ents developed delirium and these pa ents had longer stays in hospital and were at increased risk of death during admission and cogni ve 4 impairment following discharge. Even with these risks delirium is severely under-diagnosed, especially in the ICU. 1,2,4 Without the help of validated, reliable and easy-to-use diagnos c instrument both ICU nurses as well as intensivists 1 have difficulty in diagnosing presence of delirium. Almost two-thirds of par cipants in this study said they did not have any training in screening for delirium. A short composite and simple educa onal interven on in nurses, was seen to 5 improve the capacity of ICU nurses to detect delirium. Delirium is under diagnosed but only 51% of the par cipants agreed to this and 40% believed it was adequately diagnosed, this is in contrast to a study done in Ireland where more than 93% acknowledged that delirium was an 9 under diagnosed syndrome. This discrepancy could be because the Irish study was among intensive care nurses' and 84% said they had seda on protocol but the protocols did not assess for delirium. This indicates that exposure to more cases of delirium can increase knowledge regarding it. The top three risk factors for delirium was chronic alcohol use, pre-exis ng demen a and benzodiazepine use. Demen a and alcohol use was thought to be major contribu ng factors for risk of delirium by par cipants of 2,3,9 other studies as well. Even though almost two-third of par cipants correctly iden fied cogni ve disturbances and impaired consciousness and a en on as symptoms of delirium less than one-third iden fied the two symptoms. At the same me more than 75% had poor knowledge about delirium. This indicates there is a dire lack of educa on regarding delirium despite a growing recogni on that it is a major problem in hospitals and especially in ICU. Less than half of the par cipants said that delirium was screened at their workplace even though this is more than the 16% stated in another study, there was a severe lack of knowledge among our par cipants about 9 delirium. Although delirium was believed to cause many nega ve outcomes in pa ents such as increased mortality, cogni ve impairment, delayed weaning from ven lator and increased me spent in ICU, only 4% had thought it was 2,4,8 important to monitor for delirium. The no on that delirium is difficult to monitor in the ICU because pa ents remain sedated most of the me, seems to be 6 oversimplified. Using delirium specific assessment tools ICU health-workers, who encounter most cases of delirium can diagnose presence of delirium and hence monitor for progress with great ease.

CONCLUSION
Delirium is an underdiagnosed condi on, even though it is a major cause for mortality and increased morbidity especially among ICU pa ents. Knowledge about delirium was found to be low in our study. From various studies, including ours we see that there is a need for increasing educa on and training about delirium.

RECOMMENDATIONS
We have seen from our study, there is no protocol for screening of delirium at the centre where our par cipants work. This causes, as also believed by the par cipants, under-diagnosis. A common specula on of the past that pa ents in ICU remain sedated mostly appears to be a major 6 hindrance for adequate assessment of delirium. These problems could be overcome by providing training to assess for delirium by usage of standardized screening tools. Se ng up evidence based protocols to assess for delirium with the help of standardised screening tools could be beneficial for health-workers as well as for pa ents.

LIMITATIONS OF THE STUDY
As with majority of studies this study is also subject to limita ons. This study was carried out in a single centre, and opinion was gathered via a subjec ve ques onnaire that was not validated prior to conduc ng the study, among nurses selected through purposive sampling. Incorpora ng, opinions from nurses working in different hospitals at different ci es of Nepal and randomly selec ng the loca ons would have been be er. Also using a validated ques onnaire and conduc ng the study amongst not just nurses but other health-care workers would give us a be er picture of the status of knowledge of delirium among health professionals around the country. This would in turn help us design be er studies to help us create evidence based protocols for assessment of delirium in our pa ents.

ACKNOWLEDGEMENT
We would like to thank the management of Birat Medical College & Teaching Hospital for allowing us to conduct this study.