HNN108 Assignment Task 1: Interventions for Delirium in Hospitals

This assignment, a comprehensive evidence synthesis, addresses the critical issue of delirium in acute hospital settings. The student critically evaluated three primary research articles to determine effective interventions for preventing and reducing delirium incidence. The search strategy involved detailed concept descriptions, similar search terms, and database searches like CINAHL, Google Scholar, MEDLINE, and PubMed. The analysis of each article included assessing the purpose, sample, design, method, findings, and level of evidence, while also noting ethical considerations. The synthesis highlighted the dangers of hospital-acquired delirium, especially among elderly patients, and the need for multifaceted interventions. The student utilized the PICO framework to formulate the research question, which guided the selection of the three articles. These articles included a prospective observational cohort study assessing a Delirium Observation Screening Scale (DOSS), a before-and-after study evaluating a delirium management program, and a randomized controlled trial examining an educational package's efficacy. The synthesis discussed the strengths and weaknesses of each study design, sample representativeness, data collection methods, and potential biases. The student concluded by synthesizing the findings to identify effective interventions and their implications for clinical practice.

Running head: HNN108 ASSIGNMENT TEMPLATE
Assessment Task 1 – Evidence Synthesis
Name of the Student
Name of the University
Author Note

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Search Strategy
Description of concepts Similar search terms, using “phrase searching”,
truncation (*), wild cards (?), alternate words and
alternate spellings etc.
Limits:
(language, peer
reviewed etc.)
Delirium
Disturbance in mental
ability that leads to
decreased awareness and
confused thinking
acute confusion or confusion or disorientation or confus(*) or disorient(*) Language-
English
Year- January
2015 to August
2019
Peer reviewed
Full TextIntervention
Actions that are adopted
or implemented for
improving a mental
or strategies or best practices or treatment or therapy or therapies
1
AND
OR
OR

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disorder
Prevention
Activities or methods
that will deter or reduce
the incidence or
prevalence of the mental
problem
intervention or treatment or program or management
Acute hospital setting
The healthcare branch
where a patient is
provided short-term
treatment for an episode
of sickness, brutal injury,
vital medical state, or
during recuperation from
surgical procedure.
hospital or acute care setting or acute care
2
AND
AND
OR
OR

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Databases searched:
CINAHL Google Scholar
MEDLINE PubMed
Article summaries
Reference Purpose/Aim of
the study
Is the purpose
relevant to my
question?
Sample – Who
was included in
the study?
Consider: Does
the sample
represent the
target population
in my question?
Design
Consider: Is
the design
relevant?
Method
How was the
research
conducted?
Was there a
potential for
bias?
Findings
What were the
key findings?
Are the
findings
relevant for my
question?
Level of
Evidence
Is the research
high level
evidence or
just opinion?
Additional
notes
- Was ethics
review
undertaken?
- Is it primary
or secondary
research?
Teale, Munyombwe,
Schuurmans, Siddiqi
To determine the
utility of a
The study was
conducted in nine
The researchers
conducted a
The researchers
subjected the
Of the 216
residents who
Level II-2 Ethical
approval was
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and Young (2017) Delirium
Observational
Screening Scale
(DOSS) for the
detection of
delirium amid
care home
residents
nursing care and
residential care
homes amid
residents aged
more than 65
years, apart from
patients who were
not capable of
completing
delirium
assessment or
approached end of
their life. This
ensured
representativeness
of the sample
prospective
observational
cohort study.
This can be
cited as a
correct
approach
owing to the
fact that it
allowed the
researchers to
follow the
population over
time, in order
to determine
the
care home staff
to a 25-item
DOSS on a
regular basis,
and compared
the findings
with those of
the Confusion
Assessment
Method
(CAM). This
CAM was
performed
twice each
week. This was
followed by
participated,
50% reported
cognitive
impairment and
39% of the
DOSS
assessments
were complete.
71 delirium
episodes were
associated with
78 positive
CAM results
over 70 weeks.
However,
DOSS reported
obtained from
the Leeds West
Research
Ethics
Committee
(14/YH/1174).
Primary study.
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since older adults
commonly report
serious
disturbance in
mental capabilities
that often lead to
decreased
awareness of the
surrounding and
confused thinking.
effectiveness of
the delirium
assessment
scale, in
relation to the
health
outcomes of
the patients.
determining the
specificity,
sensitivity,
predictive
values,
likelihood
ratios and
diagnostic
odds. However,
there might
have been
selection bias
in the research
that affected
enrolment of
the study
sensitivity and
specificity of
0.61 and 0.71,
respectively.
This helped in
elucidating that
DOSS results
cannot be used
as a measure of
delirium in
acute care
settings.
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subjects.
However, no
residents were
lost during
follow-up thus
preventing bias
in the results.
Hasemann (2016) To assess the
impacts of a
delirium
management
program
(DemDel)
conducted by
nurses for
management of
The research was
conducted upon
268 patients
having cognitive
impairment,
recruited from 4
medical wards
present in an acute
care hospital.
Before and
after study
This helped in
determining
efficacy of the
intervention on
delirium
management
138 and 130
patients were
allocated to the
intervention
and control
group,
respectively.
the intervention
comprised of
32.5% patients
out of 268
reported
delirium, with
58.6%being
mixed, 11.5%
hyperactive
and 29.9%
hypoactive.
Level II-1 The research
was sanctioned
by local ethics
board.
Primary study.
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cognitive
impairment.
Cognitive
impairment being
a core symptom of
delirium ensured
representativeness
of the research
sample
education
sessions,
planned
approaches,
and cognitive
screening.
31.9% in
intervention
group reported
less severe
episodes and
needed
medication.
Siddiqi (2016) To determine the
feasibility of an
enhanced
educational
package, ‘Stop
Delirium!’ for
management of
delirium risk
factors
The study was
conducted among
older people
recruited from 14
care homes in UK.
This sample was
representative of
the entire
population since
The research
was a
randomized
feasibility
study.
This helped to
assess whether
the educational
package was
The
educational
package was
applied for 16
months to the
care home
staff, followed
by assessing
delirium rate,
One-month rate
of delirium
prevalence was
4% in
intervention
group, which
was
significantly
less than 7.1%
Level I The NHS
Research
Ethics
Committee
(12/YH/0018)
had approved
the research.
Primary
research.
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older adults stying
in long-term
hospital facilities
report signs and
symptoms of
altered attention,
consciousness,
and cognitionmore
often.
profitable,
technically
practicable and
advantageous
for the
population.
However,
determination
of the health
outcomes
might have
been subjected
to observer
bias. However,
the random
allocation of
quality of life,
falls, hospital
admission, and
adherence
in control
group.
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the research
participants to
different
groups
prevented
allocation bias,
however, did
not create any
impact on other
biases.
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Synthesis of findings
Hospital acquired delirium is a dangerous and common condition that often remains untreated and
unnoticed and can even be fatal. Several patients when they are admitted to the hospital have to initially
gain entry to the emergency department, which acts as the portal of entry. The emergency setting in a
hospital an extremely busy location with great turnover, and patients who are admitted to such acute care
settings most often report severe but temporary form of mental impairment, which aggravates over time.
The condition is more commonly reported by elderly patients and can be triggered by several factors such
as, infection, isolation, surgery, and poor nutrition and dehydration, administration of medication like
sedative, sleeping pills, and pain killers. Without conducting a comprehensive and careful assessment,
and lack of medical history of the patient often makes the healthcare professionals confuse delirium with
other chronic organic brain syndrome or psychiatric disorders such as psychosis depression and
dementia. Therefore, effective treatment and management of delirium requires addressing the underlying
factors through the administration of multifaceted interventions that will help in identifying the potential
reasons, which lead to the onset of delirium among patients in acute hospital settings.
While in several cases symptomatic and/or temporary treatments are utilised for providing
comfort to the patient, antipsychotics are generally not provided to those who are admitted to hospital.
The treatment of delirium typically comprises of two main techniques namely, (i) identification and
treatment of underlying medical disorder, and (ii) management of the prevalent behavioural disturbances.
Time and again it has been found that common treatment strategies include hydration, nutrition,
oxygenation, mobilization, comfort, metabolites and electrolyte, therapeutic medication, and pain control.
While both non-pharmacologic and pharmacologic medications are implemented for delirium treatment
among patients, there is the need to identify the most effective interventions that can prevent or reduce
the incidence of delirium in acute hospital setting, such that their benefits must outweigh the risks
involved (if any). This led to the formulation of the research question following the PICO framework
which is given below:
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“Which interventions are effective in preventing and reducing incidence of delirium in the acute hospital
setting?”
On conducting a thorough and comprehensive search of the aforementioned electronic databases
the three primary articles discussed in the previous sections were extracted, which were found most
relevant to the research question given above.
The first article by Teale, Munyombwe, Schuurmans, Siddiqi and Young (2017) was based on our
prospective observational cohort study design. The researchers addressed a well-focused question since
their primary objective was to investigate utility of a Delirium Observation Screening Scale (DOSS) in
early detection of behavioural changes amid hospitalized patients who suffer from delirium. The biggest
advantage of selecting this research design can be credited to the fact that it enabled the researchers to
observe the prospective subjects (older patients) in their natural setting such as, residential and nursing
care home. This helped in revealing penetrating insights that would not have been easily observable if the
researchers have adopted any other method for conducting this investigation (McCusker & Gunaydin,
2015). Furthermore, the prospective cohort study provided a clear indication of the temporal sequence
between outcome and exposure. It also provided opportunity to the researchers to avert the presence of
selection bias at the time of participant recruitment, owing to the fact that the outcome was not known at
baseline at the time of establishing the exposure status (Poustchi et al., 2017). The sample recruited for
the research was appropriate since older adults who aged more than 65 years and did not suffered from
any communication difficulties were only selected for the research.
Sample size calculation ensured that the sample was representative of the wider population and
there was no bias the results. After providing training to the research staff and their home staff regarding
administration of CAM instrument and identification of behavioural disturbance for completing DOSS,
data collection was based on regular DOSS assessments. This can be cited an accurate approach since the
screening allowed easier and faster delirium identification and the 25-item scale has been validated earlier
among hospitalized patients (Gavinski, Carnahan & Weckmann, 2016). However, the researchers did not
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randomize the study participants, which might have prevented members of the target population from
getting an equal opportunity to be in the research, thus causing selection bias.
The second research by Hasemann (2016) was a before and after study that assessed the
effectiveness of a comprehensive delirium management program among older patients admitted to acute
care. This research design was appropriate since observations were made prior to and after
implementation of the DemDel, for both the intervention and the control group. This non-experimental
design was a reasonable option for determining feasibility of the intervention, though it suffered from
several threats to internal validity (Bryman, 2017). The study was conducted on 268 older in patients who
suffered from cognitive impairment and had been allocated to the treatment and control group. The
sample size can be considered accurate the number of patients in both the groups were almost
comparable. However, this allocation was not randomised Therefore an unknown proportion of the target
population was not included in the sample, thereby leading to lack of representatives of the data. It also
reduced the generalisability of the research findings, when compared to findings obtained from random
sampling studies (LoBiondo-Wood & Haber, 2017).
Following implementation of the interventions, data collection procedures were based on several
questionnaires and surveys that helped in measuring delirium and cognitive impairment. Use of these
questionnaires was a correct approach since they provided an increased level of general capacity for
representing the mental status of the larger population, and also produced precise results with good
statistical significance. Besides the associated low cost, data gathering was also convenient for the
researchers (Abildgaard, Saksvik & Nielsen, 2016). However, the patients might have provided false
information or thoughtless answers to the questionnaires, thus reducing the reliability of the findings.
The third study by Siddiqi (2016) was a randomised control trial that evaluated efficacy of an
educational package in preventing delirium and addressing its risk factors. The major advantage of
research design can be associated to the fact that it directly compared the intervention to standard care, in
order to establish superiority of one, and the study design also helped in making inferences, thus proving
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the most empirical evidence of efficacy of a treatment. The design also minimised selection bias and
allocation bias, besides making both the groups comparable according to unknown and known factors
(McCusker & Gunaydin, 2015). The research was carried amid 215 older patients, who were residence of
nursing home, thus ensuring representativeness of the sample and adequate sample size. Data collection
procedure was based on measuring the rate of delirium, the quality of life of the patients, rate of patient
fall and adherence to the intervention. Hence, it can be suggested that the researchers took efforts to
address all underlying factors which might contribute to delirium amid older adults in hospital settings.
According to Teale, Munyombwe, Schuurmans, Siddiqi and Young (2017) DOSS had a low sensitivity
that acted as a limitation for its clinical utilisation for detecting delirium as a part of routine nursing care
for residents. The findings by Hasemann (2016) established the DemDel program as an effectual strategy
for improving health outcomes among older adults who suffered from delirium and cognitive
impairment. This intervention was also found to be feasible for incorporating in medical wards. However,
Siddiqi (2016) suggested that though the educational package was able to reduce the one month
prevalence rate of delirium among the patients, further improvements and modification need to be done in
order to determine its efficacy.
Therefore, it can be stated that, the DemDel program is the most effective strategy that can be easily
implemented across all nursing homes and acute hospital settings for effective prevention and
management of delirium among older adults.
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References
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assessment of qualitative and quantitative approaches to data collection in the process evaluation
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Bryman, A. (2017). Quantitative and qualitative research: further reflections on their integration.
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https://www.taylorfrancis.com/books/e/9781315248813/chapters/10.4324/9781315248813-3
Gavinski, K., Carnahan, R., & Weckmann, M. (2016). Validation of the delirium observation screening
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Hasemann, W., Tolson, D., Godwin, J., Spirig, R., Frei, I. A., & Kressig, R. W. (2016). A before and after
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Poustchi, H., Eghtesad, S., Kamangar, F., Etemadi, A., Keshtkar, A. A., Hekmatdoost, A., ... & Sheikh,
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