experience talks
TRANSCRIPT
EXPERIENCE TALKS
Authors: Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN, AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, andCindy Lefton, PhD, RN, Keizer, OR, Philadelphia, PA, and St Louis, MO
As emergency nurses, we are responsible for a myriad ofpatient populations. Some of the most vulnerable arethose with behavioral health issues, substance misuse, andcognitive changes. This month, we chose to highlight 2successful programs that we hope provide you with someideas to enhance the care of these patients in youremergency department.—Jeff, Cindy, and AnnMarie
Give “PEACE” a Chance (Physiologic, Environmental,
Activities of Daily Living/Sleep, Communication, and
Education): A Scientific Holistic Nursing Approach to
Treat Delirium
Delirium is described as an “emerging epidemic” and con-stitutes a major health challenge because of increasing costs,incidence, and mortality and morbidity rates.
According to King et al.,1 delirium should be consid-ered a type of organ dysfunction, much as shock is consid-ered a type of cardiovascular dysfunction. There is acommon misconception that delirium is a relatively“benign” syndrome. It is thought to be something thatmost older adults experience when they are sick, that itreally does not hurt them, and that it will just go awaybefore they return home. We now know that this is abso-lutely not the case. Delirium is actually one of the mostcommon, costly, and dangerous conditions that can devel-op in a patient. For example, patients in whom deliriumdevelops during their hospital stay are now known to havea 10-fold increased risk of in-hospital death. The agitationand lethargy associated with delirium are also believed tolead to aspiration, pressure ulcers, pulmonary emboli, anddecreased oral intake. Patients with delirium are more likelyto require some form of post–acute care placement,whether it is in a nursing home, rehabilitation center, orlong-term care hospital. We now know that delirium alsodoes not always “go away” right at hospital discharge.
Delirium has been found to be an independent predictorof death, and it takes at least 3 months for full recoveryfrom it. More importantly, we now know that somepatients never recover from an episode of delirium andlong-term cognitive impairment/dementia develops. Con-ditions like delirium that are common, frequently iatro-genic, and linked to the care that patients receive in thehospital are now considered to be indicators of qualityhealth care. National quality measures and the Agencyfor Healthcare Research and Quality have determined theoccurrence of delirium to be not only a marker of the qual-ity of care patients receive but also an important patientsafety issue. Delirium is now recognized as 1 of the top 3conditions for which quality of care needs to be improved.A lack of familiarity with screening tools used to diagnosedelirium in the ICU setting and in general medical surgicalunits contributes to an inaccurate or missed diagnosis. Tominimize the incidence of this problem and to be proac-tive, researchers are now implementing evidence-based stra-tegies to treat delirium.
According to Balas et al.,2 the prevalence of delirium isabout 33% among older ED patients; with this high preva-lence rate and the increased risk of death, emergency nursesneed to be vigilant and skilled in detecting delirium earlyand instigating the proper interventions. The “PEACE”approach is an ideal strategy that, if used appropriately,can significantly decrease the incidence of delirium and con-tributes to better outcomes in patients with delirium.Patients nowadays are spending more time in the emer-gency department because of shortages of beds and staffmembers. Educating emergency nurses and providing themwith the necessary tools and evidence will ensure best prac-tice and, ultimately, safer and more competent nursing care.
The mnemonic listed in the Table is used to helpnurses understand the contributing factors to deliriumand the related nursing interventions. It was adapted fromthe work of Dr Michele Balas (2010).—Mohammed TouficEl Hussein, RN, BN, MN, Mount Royal University, Calgary,Alberta, Canada; E-mail: http://[email protected]
Successful Implementation of an Alcohol Withdrawal
Protocol Using the Clinical Institute for Withdrawal of
Alcohol (CIWA) Tool
Management of alcohol withdrawal in ED and acutely illhospitalized patients with a critical illness is challenging
The opinions expressed are those of the respondents and should not be con-strued as the official position of the institution, ENA, or the Journal.
J Emerg Nurs 2012;38:280-2.
Available online 9 April 2012.
0099-1767/$36.00
Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.
doi: 10.1016/j.jen.2012.02.003
E X P E R I E N C E T A L K S
280 JOURNAL OF EMERGENCY NURSING VOLUME 38 • ISSUE 3 May 2012
for all health care providers. Alcohol is often a diagnosis con-sidered in patients admitted with trauma; however, it can beconfused with other conditions that are not traumatic. It isestimated that 1 in 4 patients admitted to the hospital meetsthe diagnostic criteria for alcohol dependence.3
When patients are identified as having the potential forgoing through withdrawal, symptom-based therapy, such
as the Clinical Institute for Withdrawal of Alcohol (CIWA)tool, can be used to treat them. The CIWA tool is a10-item scale that consists of signs and symptoms of alco-hol withdrawal: nausea, vomiting, tremor, paroxysmalsweats, anxiety, agitation, tactile and visual disturbances,headache, and orientation. Patients must be verbal andare asked to evaluate the symptoms on 7-point and 4-point
TABLEPEACE mnemonic
Recommended nursing interventions
Physiologic Monitor and maintain normal nutrition, elimination patterns, oxygenation, blood glucose levels, and vital signsPrevent/correct electrolyte disturbances and dehydrationReview pharmacy utilization records and stop all nonessential medicationsAssess and manage pain
Environmental Discontinue all unnecessary lines and tubesKeep call bell in reach, avoid frequent room changes/transfersConsider “camouflaging” lines and tubesKeep the environment calm, quiet, and clutter-free
ADLs/sleep Provide methods of nonpharmacologic sleep promotionEncourage routine sleep hygiene practicesProvide glasses, hearing aids, and/or other assistive devicesAssist with feeding and other ADLS
Communication PatientProvide a way of communicating needsUse reality orientation; repeat information as necessary; explain the situation, environment, and equipmentListen to and observe behaviorRemember that all behavior is meaningfulAcknowledge feelings and fears
FamilyInterview caregivers and family to determine patients’ baseline behavior and methods they use to relieveanxiety and depressionInvolve and inform significant others of patients’ change in mental status (provide emotional support)Encourage scheduled visits by family/friends (may be helpful to call in family 24/7)
StaffAlways perform walking rounds and mental status examination with off-going care providerPerform formal delirium screenings at least once a shiftEncourage and participate in multidisciplinary roundsProvide for continuity in careBe able to provide a rapid response for challenging situations
Education Avoid physical restraint useNote that restraints are indicated in the emergency department in cases of self-harm or harm to others (over-dose, hyperactive agitation, and so on)Remember that restraints are an exceptional measure that is indicated only if other nonrestrictive measures havefailed and if the patient’s behavior puts the patient or others at risk for harmProvide “social restraints” (eg, 1:1 care)Ensure that “informed consent” is not obtained from a delirious patient
ADLs, Activities of daily living.
Solheim et al/EXPERIENCE TALKS
May 2012 VOLUME 38 • ISSUE 3 WWW.JENONLINE.ORG 281
Likert scales. Scores range from 0 to 67 points. A score of 8points or less indicates mild withdrawal.4
At Robert Wood Johnson University Hospital, a mul-tidisciplinary team of emergency nurses and physicians,psychiatrists, pharmacists, internal medicine physicians,medical surgical staff nurses, and information systems staffwere brought together to critically look at the treatment ofpatients going through alcohol withdrawal. The pre-imple-mentation data showed that patients were not being treatedwith any consistency and their length of stay was pro-tracted. Many complications developed, such as falls, andthey were more likely to require restraints. The committeereviewed the literature related to management of the alco-hol withdrawal patient. We also contacted other traumacenters and university hospitals around the country to helpto determine what the existing best practice is. It wasdecided by the team that the CIWA tool would be the besttool to use. With the help of the Pharmacy and Therapeu-tics Committee, it was decided that the drugs that weregoing to be administered would be diazepam and loraze-pam. These would be administered if the patient had ascore of 10 points or greater, which is indicative of mildwithdrawal. The committee decided to increase the scorefrom 8 to 10 during the pilot program to help alleviate con-cerns from staff nurses regarding overmedicating. Patientswould be monitored frequently according to their score.The monitoring included not only the CIWA tool but alsovital signs. Parameters were developed to help guide thenursing staff and to prevent overmedication. The warningparameters included a respiratory rate of less than 10breaths per minute, blood pressure of less than 90/60mm Hg, marked somnolence, seizures, acute change inmental status, and cumulative doses over a 3-hour periodof 60 mg of diazepam or 12 mg of lorazepam. A nursingflow sheet and a policy and procedure were developed bythe staff nurse champion members of the team in colla-boration with a clinical nurse specialist and the ClinicalDirector. Information systems were used to help navigatethe challenges of the hospital’s computer system to allowfor the nursing staff to enter the orders as a nursing proto-col. Once the team believed that the necessary tools wereready to be implemented, a pilot program was developed. Itwas decided that the CIWA tool would be trialed in theemergency department and a selected medical surgical floorthat had a high volume of patients with behavioral healthissues and alcohol withdrawal. Under the direction of the
clinical nurse specialist and nursing director, an educationaloffering was developed by the staff nurse champions on theteam. The educational offering was a contact hour programthat discussed the physiology of alcohol dependence andwithdrawal in addition to information specifically aboutthe CIWA tool. Staff nurse volunteers participated in avideo where they acted out the various CIWA scores,and the participants in the audience then completed thetool and reasoned through how to best treat the patientbased on the protocol. The pilot program lasted 4 months,during which over 100 patients were placed on the proto-col. No patients needed to be transferred to the ICU, nodeaths occurred, and restraint use and falls decreased inboth units. Staff satisfaction with the protocol was over-whelmingly positive.
There were multiple requests from physicians andnurses from other areas of the hospital to implement theCIWA tool. The team met monthly to review all chartsand processes, and it was decided that the protocol wouldbe implemented hospital-wide. The nurse champions onceagain helped with the hospital-wide education, and to date,the results remain overwhelmingly positive.
At Robert Wood Johnson University Hospital, symp-tom-based therapy using the CIWA tool has been provento be successful in the management of patients with alcoholwithdrawal. This success was due in part to the multidisci-plinary collaboration and planning, but it could not havehappened without the support and expertise of the staffnurse champions who were able to realize the importancein providing safe care to this patient population.—KathleenEvanovich Zavotsky, MS, RN, CCRN, CEN, ACNS-BC,and Lorraine Martino, MSN, RN, NE-BC, Robert WoodJohnson University Hospital, New Brunswick, NJ; E-mail:http://[email protected]
REFERENCES1. King M, Render M, Ely EW, Watson P. Liberation and animation:
strategies to minimize brain dysfunction in critically ill patients. SeminRespir Crit Care Med. 2010;31(1):87-96.
2. Balas MC, Gale M, Kagan SH. Delirium doulas: an Innovative ap-proach to enhance care for critically ill older adults. Crit Care Nurse.2004;24(4):36-46.
3. Bayard M, McIntyre J, Hill KR, Woodside J. Alcohol withdrawal syn-drome. Am Fam Physician. 2004;69(6):1443-550.
4. Sullivan J. Assessment of alcohol withdrawal: the revised clinical institutewithdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;(84):1353-7.
EXPERIENCE TALKS/Solheim et al
282 JOURNAL OF EMERGENCY NURSING VOLUME 38 • ISSUE 3 May 2012