Running Head: CLINICAL QUESTION PAPER 1

Clinical Question Paper

Shelby Birchmeier

NURS 350

CLINICAL QUESTION PAPER 2

Clinical Question Paper

Introduction

“Nurses interpret research findings and use evidence-based research to support nursing

decisions. The purpose of this assignment is to reflect how nursing knowledge is disseminated

for use in personal and professional practice” (Gabua, 2014). Working in an intensive care unit

(ICU) a patient may become confused or delirious just from the staying in ICU, usually an

extended period, along the contributing factors like lack of sleep or drug induced; this is

considered ICU delirium. “Delirium is a syndrome of several different etiologies characterized

by a disturbance of consciousness with accompanying change in cognition. Characteristic

features of the syndrome include impaired short-term memory, impaired attention, disorientation,

development over a short period of time, and a fluctuating course” (Cavallazzi, Saad, & Marik,

2012). It is important to recognize if the patient may be experiencing delirium or if another

clinical issue is causing the confusion/delirium which in turn may change the interventions that

the patient requires to receive the proper treatment. One way to identify if a patient may be

experiencing delirium is with the CAM-ICU (Confusion Assessment Method for ICUs) tool.

Throughout this paper the author will discuss what CAM-ICU is, nursing research and evidence-

based research regarding CAM-ICU using the PICOT format, critiques of the articles/research on

CAM-ICU, and how it relates to one’s professional practice, especially working in ICU.

Clinical Question

An 84 year old patient has been in the ICU for two weeks now and beginning to get

confused or delirious. The nurses have not been completing a CAM-ICU assessment for the

patient, as it is not required nor protocol. As mentioned above, the CAM-ICU is the Confusion

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Assessment Method for ICU patients. “Using a structured format, this tool evaluates four

features, namely, acute onset or fluctuating course, inattention, disorganized thinking, and altered

level of consciousness” (Cavallazzi, Saad, & Marik, 2012). Here is a link to view the CAM-ICU

tool to help one visualize what the nurse does at the bedside to assess for ICU delirium if one

may be unfamiliar or unaware of it: http://www.icudelirium.org/docs/CAM_ICU_worksheet.pdf

(Ely & Vanderbilt University, 2014, p. 7). So the doctors and nurses begin completing tests to

rule out some causes of the patient’s confusion or delirium. Could it be hypoxia (lack of oxygen

to the brain), increased carbon dioxide, or ICU delirium? If the CAM-ICU assessment was being

completed could they have caught that the patient was beginning to experience some

confusion/delirium related to the ICU/hospital stay and contributing factors like lack of sleep?

Could it have eliminated other invasive or non-invasive tests the patient may have received?

“Evidence-based nursing practice requires that nurses write clinical questions”

(Nieswiadomy, 2012, p. 282). Working at the bedside of the patients who may experience ICU

delirium. Those thoughts above brings the author to consider the PICOT question; does

performing the CAM-ICU scale on a patient once or twice a day reduce ICU delirium compared

to just trying to treat confusion in intensive care patients? First, the author will discuss what a

PICO question is and its significance to nursing practice. The PICOT acronym, established by

Fineout-Overholt and Johnston, is a layout used for writing clinical questions (Nieswiadomy,

2012). What does each letter stand for and how is it related to the author’s clinical question?

The P stands for patient or population and in this case the author is referring to ICU patients.

The I is referred to as an intervention or area of interest which is the CAM-ICU scale. C

represents the comparison intervention or current practice and for the question discussed; in the

paper C is referred to when nurses do not complete the CAM-ICU scale to assess for delirium

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and causes of confusion. The O is referred to as the outcome(s) desired and in this case is it to

see less confusion/delirium in the ICU patients. T is for time; it is optional in the PICOT clinical

question format. The author did not feel is was necessary to complete the time of the given

clinical question (Nieswiadomy, 2012).

Looking at the question does performing the CAM-ICU scale on a patient once or twice a

day reduce ICU delirium compared to just trying to treat confusion in intensive care patients can

improve patient quality and safety is a many ways. One way is if the nurse is performing the

CAM-ICU scale daily, each shift, or with a change in the patient’s condition it is possible they

will see the signs by having a positive CAM-ICU score and being able recognize the signs before

symptoms of delirium come into play. The nurse can then inform the doctor of the positive scale

and determine if a non-pharmacological or a pharmacological intervention is necessary. Another

reason is if confusion or delirium comes into play patients could potentially start trying to climb

out of bed and/or pull out invasive lines placing their safety at risk; if the nurses are performing

the CAM-ICU scale the delirium or confusion could have been prevented to the point the patient

was placing themselves at risk. Also, as mentioned above when a patient is becoming confused

or delirious it is important to rule out the causes of why or what caused the change in the

patient’s condition. If nurses are performing the CAM-ICU scale they could rule out if is it

related to the ICU stay, ICU delirium, and contributing hospital factors or if other tests are

required. This can improve patient quality and safety by eliminating any further non-invasive or

invasive test that may need to be performed on the patient because the CAM-ICU scale is

positive allowing the nurses and doctors to treat the patient appropriately. “ICU delirium is a

predictor of increased mortality, increased length of stay, increased time on vent, increased costs,

increased re-intubation, increased long-term cognitive impairment, and increased discharge to

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long-term care facility” (Ely, 2014). The earlier the health care team can identify ICU delirium

with the CAM-ICU scale it can significantly improve patient quality and safety.

Methodology

When the author was looking for sources related to the particular PICO question it was

important to look for relevant information on the CAM-ICU, along with how it relates to

professional nursing practice. Again the PICO clinical question is does performing the CAM-

ICU scale on a patient once or twice a day reduce ICU delirium compared to just trying to treat

confusion in intensive care patients? Beginning the search the author started on Ferris State

University’s library website search multiple databases for relevant sources. Some data bases the

author gathered the information on the PICO question were CINAHL and PUBMED, along with

google scholar.

What sources did the author choose to support evidence-based nursing research for the

CAM-ICU scale and what is the level of evidence for each source? “Levels of evidence

(sometimes called hierarchy of evidence) are assigned to studies based on the methodological

quality of their design, validity, and applicability to patient care” (Oregon Health & Science

University). One article is “Routine Use of the Confusion Assessment Method for Intensive

Care Unit” by van Eijk et al (2011). “This prospective multicenter study was performed in 10

ICUs…The study population consisted of mixed medical and surgical ICU patients who were

admitted to one of the participating ICUs during visits of the delirium experts” (van Eijk et al.,

2011). This study consisted of 306 different patients within a year span; the ten ICUs were

visited twice by the expert groups. Looking at the source and information within it the article, it

would be considered a “level III: evidence obtained from well-designed controlled trials without

randomization, quasi-experimental” (University of Wisconsin, 2014). The next article the author

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considers for the PICO question is “Validation of the Greek version of confusion assessment

method for the intensive care unit” (CAM-ICU) by Adamis et al (2012). “The application and

validity of CAM-ICU was tested in two Greek general ICUs. Each patient was included in the

study only once” (Adamis et al., 2012). There was exclusive criteria such as a previous history

of alcohol or severe hearing or visual impairment (Adamis et al. 2012). This article is also

considered a level 3 for the level of evidence. In both article’s studies previously mentioned, the

patients were not randomized and there is no experimental/control group. The third article

discussed related to the PICO clinical question is “The confusion assessment method for the

intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the

diagnosis of delirium: a systematic review and meta-analysis of clinical studies” by Gusmao-

Flores, Salluh, Chalhub, and Quarantini (2012). This article is considered a level 1 level of

evidence. Level I is considered “evidence from a systematic review of all relevant randomized

controlled trials (RCT's), or evidence-based clinical practice guidelines based on systematic

reviews of RCT's” (University of Wisconsin, 2014).

A systematic review was conducted to identify articles on the evaluation of the CAM-

ICU and the ICDSC in ICU patients. A MEDLINE, SciELO, CINAHL and EMBASE

databases search was performed for articles published in the English language,

involving adult populations and comparing these diagnostic tools with the gold

standard, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

criteria. Results were summarized by meta-analysis (Gusmao-Flores et al., 2012).

After looking at the articles used for the PICO clinical question and the levels of evidence

it is important to consider why the article information is pertinent to the author’s scope of

nursing practice, a bedside ICU nurse. Again the PICO question is does performing the CAM-

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ICU scale on a patient once or twice a day reduce ICU delirium compared to just trying to treat

confusion in intensive care patients? Working right at the patient’s bedside and experiencing

patients who come in with no impaired cognitive abilities and then seeing one become

confused/delirious after a period of time is significant. Being at the bedside the author can

perform the CAM-ICU scale and use the information given in the articles based on evidence-

based research to improve patient quality and safety, along with communicating to the team any

concerns of the patient’s CAM-ICU score or changes in their condition.

Discussion of Literature

As the author looks at the given information in the articles and for the research studies

there is a lot to consider regarding the CAM-ICU and ICU delirium. Beginning it is always

important to consider what one is reading and critique the article. “Critical appraisal is the

process of carefully and systematically examining research to judge its trustworthiness, its value,

and its relevance in a particular context” (Oregon Health & Science University). Now the author

will look at the articles discussed above for a critique.

Article Critique 1

The first article discussed is by van Eijk et al. “Routine Use of the Confusion Assessment

Method for Intensive Care Unit” (2011). This nursing research tries to determine if using the

CAM-ICU scale is effective for beside nurses to determine if a patient is experiencing ICU

delirium. The purpose statement was vague, “to investigate the diagnostic value of the CAM-

ICU in daily practice” (van Eijk et al, 2011). The sample size of the study is a strength of the

study. “This study is the largest study on the topic, with 181 included noncomatose patients

from 10 different ICUs” (van Eijk et al, 2011). The data collection was given in detail with how

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data was collected and defining terms. Information was provided on what the experts were

collecting or classifying. Statistical methods were verified in detail with how the experts

calculated the results and the tools used to reach the outcomes provided. “After exclusion of

patients who were nonassessable by either the expert groups or the nurses, we calculated the

sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for

the CAM-ICU, based on 2 × 2 tables, with the classification of the expert groups as reference”

(van Eijk et al, 2011).

What did the results of the article by van Eikj et all show? First of all, the results were

given in great detail with how the results were concluded and why. There are multiple charts

displaying data collected to determine the results of the study. The table’s data was described for

the reader and what it meant. “In this multicenter evaluation of daily practice, the CAM-ICU

was found to have sensitivity and specificity of 47% and 98% (van Eijk et al, 2011). Van Eijk et

al (2011) considered limitations within the results or characteristics to consider for the results

given; for example, “the discrepancy in findings may also be caused by inadequate training or by

incomplete implementation of the CAM-ICU in daily routine”. Overall according to van Eijk et

al. (2011) and the given study “the higher sensitivity of the CAM-ICU found in centers always

using the CAM-ICU results in daily care suggests that this may be a necessary condition for

achieving adequate implementation in daily practice”.

Article Critique 2

The next article discussed for an article critique, by Adamis et al., is “Validation of the

Greek version of confusion assessment method for the intensive care unit”. Ethics was approved

and considered by the authors/study. If the patient was able to sign consent that was completed;

“as most of participants did not have the capacity to consent and the study did not involve any

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risk or harm to the participants” (Adamis et al., 2012). The approach used for the study is

described in the article. Adamis et al. goes into great detail about the methods, settings,

participants, measurements, data collection, study procedures, results, and validity. Limitations

are considered. A “limitation is that this study was only carried in only two medium –to long

term units” (Adamis et al., 2012).

“The results show that the Greek translation of CAM-ICU is a reliable and valid scale to

detect delirium” (Adamis et al., 2012). Although the results show it is a reliable scale the

Adamis et al. makes realistic points for one to consider. Nurses and staff performing the test

require adequate training to complete to scale correctly. “Educational preparation of

inexperienced raters should emphasize that point and insist in proper comprehension and

implementation of CAM-ICU to patients” (Adamis et al., 2012). Also, considered in the results

is the small sample size, extended time of the study, and nurses not being accustomed to perform

the daily scale.

Article Critique 3

The last article discussed is by Gusmao-Flores et al. called “The confusion assessment

method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist

(ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical

studies”. The article gives great details and charts based on how the “systematic review was

conducted to identify articles on the evaluation of the CAM-ICU and the ICDSC in ICU

patients” using databases. (Gusmao-Flores et al, 2012). According to Gusmao et al. (2012) for

the statistical analysis, the tests were conducted “using the package STATA v 9.0 and MetaDiSC

adopting a significance level of 0.05”. Materials and methods were described for one to

understand when one is not completely familiar with the study and/or CAM-ICU.

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What did the results show according to Gusmao et al? “The present meta-analysis

demonstrates that the CAM-ICU is an excellent tool for the detection of delirium in critically ill

ICU patients regardless of the subgroup of patients evaluated. Despite having a good

performance, the ICDSC presents lower sensitivity and specificity as compared to CAM-ICU.

…Our results showed that the overall accuracy of the CAM-ICU is excellent, with pooled values

for sensitivity and specificity of 80% and 95.9%, respectively.” (Gusmao et al, 2012). The high

sensitivity indicates accuracy of the CAM-ICU is excellent. Some limitations considered by

Gusmao et al (2012) are “the information is collected from the previous 24 hours. Delirium is

characterized by its fluctuation, with the possibility of resolution over a long period of

evaluation. Additionally, the evaluation of inattention (“easily distracted by external stimuli”),

for example, may hinder an effective response by the evaluator”.

Significance to Nursing

After looking at the different articles supporting the PICO clinical question, how can the

evidence findings can be integrated into ones nursing practice? Improving quality and safety is a

big deal for health care workers, along with the patients. “The overall goal for the Quality and

Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses

who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the

quality and safety of the healthcare systems within which they work”. The topics the QSEN

focuses on are patient-centered care, teamwork and collaboration, evidence-based practice,

quality improvement, safety and informatics (QSEN, 2012). Performing the CAM-ICU

assessing for ICU delirium can help improve quality and safety for the patients and the nurse’s

patient care. As mentioned in the clinical question section, the CAM-ICU can assess if a

patient’s mental status is becoming altered or ICU delirium is setting in before the patient gets to

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a point where they are climbing out of bed nor recognizing familiar faces. Evidence from the

articles and studies performed mentioned in the paper state the CAM-ICU scale is effective for

monitoring for ICU delirium if the nurse receives the proper training to perform the scale.

“Many ongoing and already designed investigations hopefully will continue to edify our

understanding of how to handle delirium when it arises, to define subpopulations of patients who

may or may not benefit from specific pharmacological and non-pharmacological intervention”

(Ely, 2014).

As nurses it is important to identify something before it happens, if possible. Assessing

the CAM-ICU daily or each shift can significantly improve the patient’s outcomes. “While the

causes of delirium are legion, and not all delirium is “created equal”, it is safe to say that we

should do our best to detect its onset as early as possible in order to rectify any modifiable

causes” (Ely, 2014). Every hospital is different, each may have different protocols and/or

procedures. Procedures and protocols are put into place to help improve patient quality and

safety. The ICU the author works at it is required to perform the CAM-ICU with every shift and

with changes in the patient’s condition. Many times it can eliminate any further invasive test the

patient may require because of the increasing confusion/delirium is known to the cause of the

patient’s problem. Performing the CAM-ICU can help the nurses communicate with the

patients, get to know the needs one may have, and help the nursing care be more effective;

communication is key. Also, assessing for delirium can help nurses and doctors ensure the

patient is getting the right interventions needed and beyond adequate care to help improve

quality and safety. “Choosing the right sedative when indicated, delirium monitoring and

management, and early mobility are two frameworks of care built on evidence showing

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improved outcomes and should be incorporated into practice until newer data further guides our

care” (Ely, 2014).

“A large piece of the work undertaken by ANA (American Nurses Association) involves

being a source of information on nursing quality, due to the research and measurement efforts of

NCNQ® (National Database of Nursing Quality Indicators. NDNQI has over 1,900 participating

hospitals that use NDNQI data to improve patient safety and quality of patient care” (American

Nurses Association). The nursing research is so important when one considers caring for other’s

lives. It helps ensure to keep the patients safe and improve the quality of care. After looking at

the PICO clinical question, methodology, discussion or literature, and its significance to nursing

the author hopes one can take away the importance of performing the CAM-ICU to monitor for

ICU delirium in the patients, to catch it as early as possible if the patient starts to develop it, and

why it is important based on nursing research.

References

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American Nurses Association. Research and measurement. Retrieved from

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/

PatientSafetyQuality/Research-Measurement

Cavallazzi, R., Saad, M., & Marik P.E. (2012). Delirium in the ICU: an overview. Annals of

Intensive Car, 2(49). doi:10.1186/2110-5820-2-49

Ely, W.E. (2014). CAM-ICU worksheet. Retrieved from

http://icudelirium.org/docs/CAM_ICU_training.pdf

Ely, W.E. (2014). The details about delirium. Retrieved from

http://icudelirium.org/docs/CAM_ICU_training.pdf

Gabua, S. (2014). Welcome/syllabus. [Online Word document]. Retrieved from

https://fsulearn.ferris.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=

%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id

%3D_11633_1%26url%3D

Gusmao-Flores, D., Sallah, J.I.F., Chalhub, R.A., & Quarantini, L.C. (2012). The confusion

assessment method for the intensive care unit (CAM-ICU) and intensive care delirium

screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and

meta-analysis of clinical studies. Critical Care, 16(4). doi: 10.1186/cc11407

Nieswiadomy, R.M. (2012). Foundations of nursing research, (6th ed.). Upper Saddle River, NJ:

Pearson

Oregon Health & Science University. Evidence based practice toolkit for nursing. Retrieved

from http://libguides.ohsu.edu/content.php?pid=249886&sid=2080135

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QSEN Institute. (2012). Graduate KSAs. Retrieved from http://qsen.org/competencies/graduate-

ksas/

University of Wisconsin. (2014). Nursing resources. Retrieved from

http://researchguides.ebling.library.wisc.edu/content.php?pid=325126&sid=2940230

van Eijk, M.M., van den Boogaard, M., van Marum, R.J., Benner, P., Eikelenboom, P., Honing,

M.L.,…Slooter, A.J. (2011). Routine use of the confusion assessment method for the

intensive care unit. American Journal of Respiratory and Critical Care, 184 (3), 340-344.

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OAppUg9xh