الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Although dysfunction of any organ systems continues to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU. It is defined as a disturbance of consciousness and accompanying change in cognition with acute onset and fluctuating course. It is considered a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to 80% of those who are mechanically ventilated.
Critically ill patients are subject to multiple risk factors for delirium. Some of these, pain, exposure to sedative and analgesic medications, prolonged immobility and social isolation may be modified to reduce the risk. As a result, all those patients must be monitored using a validated delirium assessment tools. Moreover, multi-component interventions as ABCDEF bundle that specifically target delirium risk factors should be tested and adopted in the systems of care as a part of routine care.
Critical care nurses play a unique role in delirium assessment and successful bundle implementation as they have direct close contact with the critically ill patients all the time and they are critical to all elements of the bundle. They are in a unique position to observe changes in mental status of patients at an early stage. In addition, they lead all the efforts and they are the communication link between different specialties.
The study design was a quasi-experimental research design. This study was carried out in five general ICUs namely: unit I, unit II, unit III, Unit IV and El-Mowasaat general ICU at the Alexandria Main University Hospital. The sample of the study was a convenient sample of at least 100 critically ill mechanically ventilated patients (randomly assigned in to 50 in control group and 50 in intervention group) admitted to the previously mentioned settings.
Tools of the study:
Three tools were used to collect the data of this study:-
Tool one: CAM-ICU-7 Delirium Severity Scale to diagnose and assess severity of delirium in critically ill patients. It consists of four features (acute onset or fluctuating course, inattention, altered level of consciousness, disorganized thinking) and specific points were assigned for each feature. Patient was considered delirious if he had features 1 and 2 and either 3 or 4. Then the delirium severity was determined according to the score.
Tool two: MMSE to assess the patient’s level of cognitive impairment. It consists of five items (orientation, registration, attention and calculation, recall, language, coping) with a 30 point questionnaire.
Tool three: Assessment of Clinical Outcomes to record clinical outcomes of critically ill patients in terms of delirium, mechanical ventilation, ICU length of stay, use of physical restraints and anti-delirious drugs and adverse events. In addition, patients’ demographic and clinical data was obtained.
Tool III were tested for content validity by 5 experts in the fields of Critical Care Nursing and Critical Care Medicine. Then a pilot study was conducted on 10 critically ill patients (10%) in order to test the clarity and applicability of the tools and necessary modifications were done.
At the beginning, newly admitted patients were screened considering the inclusion and exclusion criteria. Then, they were assigned randomly in intervention and control group. Participants in intervention group received the ABCDEF bundle during their stay in the ICU whereas those in control group received routine ICU care that was regularly provided in the ICU.
During their stay in the ICU, all patients were assessed for the occurrence and severity of delirium using tool one. Then, it was found that 76% of control group had delirium compared to 38% of intervention group with the most severe cases between patients under routine ICU care.
Further, mechanical ventilation duration, ICU length of stay, use of physical restraints and anti-delirious drugs and the occurrence of adverse events were assessed using part II of tool three. It was observed that patients under routine ICU care had more prolonged mechanical ventilation and ICU length of stay and higher use of physical restraints and anti-delirious drugs than those under ABCDEF bundle. Moreover, they encountered more adverse events than those in intervention group.
Lastly, patients’ level of cognitive impairment were assessed using tool two after extubation and once they were alert and ready to be interviewed. The result was that almost all the studied patients showed poor level of cognition with the worst impairment in control group.
Based on these findings, it can be concluded that the use of the ABCDEF bundle was effective in the management of delirium and its related negative outcomes in intervention group. In other words, management based on prevention rather than treatment using the ABCDEF bundle might help to achieve better results earlier with fewer complications.
Following, older age, admission with sepsis or respiratory problem and high APACHE II score, all found positively related to delirium and cognitive impairment. Likewise, delirium occurrence was found positively related to cognitive impairment, prolonged mechanical ventilation, prolonged ICU length of stay, more often use of physical restraints and more adverse events.
Finally, it can be recommended that:
• Delirium as a serious health problem must have more attention form the clinicians and researchers in the medical field.
• Delirium should be assessed in a regular basis using reliable tools once the patient is admitted to the ICU.
• ABCDEF bundle should be incorporated and adopted in the systems of care to prevent delirium in ICU as part of routine care.
• Education and training about delirium significance and presentation as well as the importance of ABCDEF bundle should be taught to critical care clinicians primarily nurses.
• Limitations of this study faced should be addressed, as well as specific data that could strengthen investigative conclusions should be collected.
• Investigations have to be done to uncover the biological mechanisms governing delirium and discover strategies and treatments that will reduce delirium burden.
• Further research on delirium and the ABCDEF bundle should continue in order to find the most optimal ways to improve patient outcomes in the ICU.
• Future studies should also generate more specific data on delirium subtypes that could strengthen future study conclusion and guide delirium management.