在加利福尼亚州北部的一个拥有21家医院的系统中实施谵妄筛查与检测的临床实践指南：绩效改进中的实际挑战

Implementing clinical practice guidelines for screening and detection of delirium in a 21-hospital system in northern California: real challenges in performance improvement.

作者信息

Adams Carmen L, Scruth Elizabeth Ann, Andrade Christina, Maynard Susan, Snow Kathryn, Olson Terry L, Ingerson Stephen D, Duffy Barbara A, Cheng Eugene

机构信息

Author Affiliations: Clinical Practice Consultant (Dr Adams) and Quality Strategy Leader, Quality Division Northern California Kaiser Permanente, Oakland (Dr Scruth); Intensive Care Unit (ICU) Clinical Nurse Specialist (CNS), Santa Rosa Kaiser Medical Center (Mss Andrade and Maynard); Neuro ICU CNS, Redwood City Kaiser Permanente Medical Center (Ms Snow); ICU CNS, Modesto Kaiser Medical Center (Ms Olson); ICU CNS, Vacaville Kaiser Medical Center (Mr Ingerson); Trauma ICU CNS, South Sacramento Kaiser Medical Center (Ms Duffy); and Medical Director Intensive Care Unit, San Jose Kaiser Medical Center-the Permanente Medical Group (Ms Cheng), California.

出版信息

Clin Nurse Spec. 2015 Jan-Feb;29(1):29-37. doi: 10.1097/NUR.0000000000000098.

DOI:10.1097/NUR.0000000000000098

PMID:25469438

Abstract

PURPOSE

The purpose of this article was to describe a quality improvement process on a diverse adult intensive care unit (ICU) population for a large healthcare organization for early detection of delirium.

BACKGROUND

Delirium is often considered a common unpreventable problem in the ICU. A process for early detection of delirium allows the critical care team to evaluate the patient and intervene to improve or reverse the delirium.

DESCRIPTION

A business case was first developed, and then using performance improvement methodology combined with quality improvement methods and oversight from a Delirium/Sedation Workgroup, an implementation plan was developed. Intensive care clinical nurse specialists were educated; patients in the ICU were screened for delirium twice daily by bedside nurses using the Confusion Assessment Method. The clinical nurse specialist in each ICU was instrumental for driving the process of change and supporting the bedside nurse and physicians to discuss preventing, screening, and treating delirium.

OUTCOME

System-wide process implementation was completed in 1 year, 2011. In 2012, all medical centers had a program in place to decrease the use of benzodiazepines and improve communication in the multidisciplinary teams during daily rounds about the treatment and prevention of delirium. The process of performance improvement is ongoing with continual reassessment and feedback required to ensure sustainability.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Performance improvement involving 21 medical centers is a large-scale undertaking by an organization. It requires a systematic approach with key stakeholders and advanced practice nurses as subject matter experts involved throughout all phases of the implementation. Bedside clinicians assessing the patient must feel supported and valued members of the process. Challenges of all care providers need to be acknowledged and addressed.

摘要

目的

本文旨在描述一家大型医疗保健机构针对不同成年重症监护病房（ICU）患者群体开展的一项质量改进过程，以实现谵妄的早期检测。

背景

谵妄通常被认为是ICU中常见的不可预防的问题。谵妄早期检测流程使重症护理团队能够对患者进行评估并采取干预措施，以改善或扭转谵妄状态。

描述

首先制定了一份商业案例，然后运用绩效改进方法，结合质量改进方法，并在谵妄/镇静工作组的监督下，制定了一项实施计划。对重症监护临床护士专家进行了培训；ICU患者由床边护士每天使用混乱评估方法进行两次谵妄筛查。每个ICU的临床护士专家在推动变革过程以及支持床边护士和医生讨论谵妄的预防、筛查和治疗方面发挥了重要作用。