Date on Paper

8-2021

Document Type

Doctoral Paper

Degree Name

D.N.P.

Department

Nursing

Committee Chair

Roser, Lynn

Committee Member

McRae, Emily

Abstract

Background: Pediatric delirium has emerged as a common complication of childhood illness in the intensive care setting, with estimated delirium prevalence ranging from 15.9% to 65.6%. Critically ill pediatric patients in the ICU are at risk for pediatric delirium due to modifiable risk factors including mechanical ventilation, sedating medications, physical restraints, and nutrition. In 2019, the pediatric intensive care unit (PICU) in a Kentucky children’s hospital reported only 18 % of chart audits revealed that physicians activated the physician-directed pediatric ICUs Delirium Prevention and Treatment Order Set (DPTOS) on pediatric patients. A quality improvement (QI) project was developed to identify and correct barriers to compliance with the facility’s revised nurse-directed pediatric ICUs Delirium Prevention Standing Order Set (DPSOS), address gaps in knowledge and practice, and target specific behaviors that may contribute to pediatric delirium in the unit.

Purpose: The purpose of this QI project was to decrease the Pediatric Intensive Care Unit and Cardiovascular Intensive Care Unit (PICU/CICU) delirium prevalence through QI activities aimed at the improvement of nursing knowledge and compliance with the pediatric ICU nurse-directed DPSOS.

Methodology: For implementing this QI project, Donabedian’s Theoretical Model for Evaluating Healthcare served as the backdrop, while The Institute for Healthcare Improvement (IHI)’s Model for Improvement and the Plan-Do-Act-Study (PDSA) approach were utilized to test changes on small scales. Baseline data was established from which rapid cycle PDSA interventions were directed at improving nursing knowledge and compliance with the pediatric

ICUs nurse-directed DPSOS. Interventions included administration of a pre-and post-test to nursing staff, educational sessions, and six weeks of audits for compliance with the DPSOS.

Measures: Structure, process, and outcome measures were used to evaluate this QI project. Structure measures were nursing knowledge of pediatric delirium using a 10 true/false question pre- and post-test. Average percentage of correctness and percent of change from pre-test to post-test was calculated for each question and average total score. Process measures were percentage of compliance for each element of the DPSOS, mean compliance, and total overall compliance with the nurse-directed pediatric ICU DPSOS. The outcome measure in this QI project was delirium prevalence rates. Delirium prevalence rates and percent of change were measured for three weeks prior to the project and six weeks following revisions to the DPSOS and completion of education.

Results: The average score for all participating nurses on the pre-test was 83% and 87% on the post-test with a subsequent improvement in mean scores of 4.8%. Compliance with all seven elements of the order set increased to 62.16% from 59.71% representing a positive percent of change of 4.1%. The percent of change in total compliance with all seven elements of each audited chart being met increased from 5.6% to 13.89%, representing a change in percent of compliance of 148%. After the revisions to the pediatric ICU DPSOS and completion of education, the delirium prevalence rate decreased from 27.8% to 16.7%, representing a change in prevalence rate of 39.9.

Conclusion: Delirium prevalence rates decreased with the improvement of nursing knowledge and compliance with the pediatric ICUs nurse-directed DPSOS. Nurse-directed nonpharmacological delirium prevention strategies are feasible and sustainable strategies that should be considered a standard of care in the pediatric ICU setting.

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