SCCM Resource Library-53-PICU Staff Knowledge and Perceptions of Pediatric Delirium and Impact of an Educational Curriculum

Video Transcription

Thank you, everyone, for coming. My name is Sarah Goldberg. I am a faculty member in the Division of Cardiovascular Critical Care at Boston Children's Hospital,  and I am pleased to be presenting on behalf of my group today, our abstract entitled, Pick Your Staff Knowledge and Perceptions of Pediatric Delirium and Impact of an Educational  Curriculum. I do not have any disclosures or conflicts of interest. ICU delirium is acute end-organ dysfunction of the brain due to underlying medical problems,  iatrogenic exposures, and environmental factors. The American Psychiatric Association diagnostic criteria for delirium include inattention,  decreased awareness and disorientation, and disturbances in cognition and perception. Patients may have delusions or hallucinations, but those are not necessary for a diagnosis  of delirium. In our pediatric ICU patient population, delirium occurs in 20 to 60% of all PICU patients with  significant associated morbidity and mortality, including longer duration of mechanical ventilation,  longer ICU and hospital length of stay, higher hospital costs, and increased mortality. Several risk factors for pediatric delirium have been identified, including developmental  delay and younger age, as well as several specific risk factors in the ICU, including mechanical ventilation, severity of illness, infection, inflammation, vasopressor requirements,  and drug exposures, such as benzodiazepine, narcotic, and anticholinergic drugs. At Boston Children's Hospital, we endeavored to create a pediatric ICU delirium screening,  prevention and management program in the fall of 2018. And from that was born out a delirium multidisciplinary working group, which spans across three ICUs  in our hospital, the cardiac ICU, the medical ICU, and the medical-surgical ICU, all three with physician, nurse practitioner, and nurse representation.  Along the way, we've also recruited multiple other disciplines to join our group, including  the neurodevelopmental program, surgery and anesthesia representatives, psychiatry, psychology,  neurology, physical medicine and rehab, physical and occupational therapy, pharmacy, child life, and social work.  Our program debuted in May 2019, but prior to that, we wanted to administer an educational curriculum.  This would include in-person lectures, a mandatory online learning module for all bedside  providers, a delirium day where participants could listen to guest lecturers and participate in case-based workshops.  We also developed extensive educational materials for bedside providers and families. Prior to administration of that curriculum, we wanted to deliver a multidisciplinary survey  to assess delirium knowledge and attitudes, one, to establish a baseline, two, to identify barriers to implementation of our program potentially, and three, to help us assess  the efficacy of our educational program by administering that multidisciplinary survey before and after the curriculum.  We used a modified version of the multidisciplinary survey published by Flagle et al. in 2016. This survey has two separate sections.  The first focuses on attitudes towards delirium using a Likert scale of 1 through 5, strongly disagree to strongly agree.  The questions include asking whether delirium is a common problem, whether the respondent feels that it's important to diagnose and treat delirium, whether the respondent feels  that they can tell whether a patient is delirious, and whether they are confident in the management of delirium in their patients.  The second section is a knowledge assessment with several true-false statements. These statements range from characterization of delirium presentations, delirium risk factors,  as well as appropriate management strategies for delirium. We did add two additional questions to this assessment, which we thought were important,  asking respondents whether they understood that mechanical ventilation is a risk factor for delirium and whether they understood that antipsychotic medications are not the  first-line treatment for ICU delirium in children, with these being the appropriate responses. The survey was administered to 587 staff.  This included physician faculty members, fellows, advanced practice professionals, nurses, social  workers, physical and occupational therapists, and child life specialists across all three ICUs.  284 staff completed the initial survey, and of those, 182 completed the post-implementation survey about six months after rollout of the program, for a response rate of 64%.  Of those, 34% were physicians or advanced nurse practitioners, 59% were bedside nurses or nurse specialists, and 7% were other team members.  Looking at the results of the first section regarding delirium attitudes, we found that, in general, people agreed or strongly agreed that delirium is a common problem, both before  and after the educational curriculum, and also, in general, people believed that it was important to diagnose and treat delirium both before and after the curriculum, with  no statistical significance in the difference between the two pre and post by a Wilcoxon sign-rank test.  Two questions that did bear out statistically significant were whether providers felt confident  in their delirium management, which improved from 20% to 57%, answering agree or strongly agree, and then also, providers felt better able to identify delirium in their patients,  rising from 36% to 54%, either agreeing or strongly agreeing, with p-values of less than 0.001.  Now, turning our attention to the delirium knowledge assessment, we found that the majority answered questions correctly, most of the time greater than 80% had correct responses.  We did find a couple areas where there was significant improvement in pre and post response correct rates.  The first was in the understanding of benzodiazepines being generally contraindicated in the management  of delirium, with the correct response rate rising from 82% to 93% pre and post education, with a significant p-value.  Additionally, respondents were more likely to answer that mechanical ventilation was a risk factor for delirium, increasing from 80% to 92%, and also identify antipsychotics  not as an appropriate first-line treatment for delirium. Looking at these results, we discerned that there was little disagreement in the commonality  and importance of delirium in our PICU patients. However, providers did feel better able to identify delirium and felt more confident  in their delirium management skills after the educational program. Regarding the delirium knowledge base, in general, there was a high level of knowledge  prior to the delirium program debut. However, there were some notable knowledge gaps. Some improved after rollout of the educational curriculum, the first being understanding  of risk factors for delirium, namely mechanical ventilation as a risk factor, and also a better  understanding of the pharmacologic management of delirium regarding benzodiazepines and antipsychotics.  There were some persistent knowledge gaps regarding the use of Foley catheters as a risk factor for delirium, the understanding that children do, in fact, have memory of  delirium, and the appreciation that family history is not a risk factor for delirium. This was a single-center study, so somewhat limited in its generalizability.  Additionally, we only had a response rate of 64% for the post-survey, which could introduce  some component of selection bias for responders who are either more experienced or more confident in their ability to identify and manage delirium.  We also had a fairly low number of non-physician and nurse responders, limiting our ability to look at that subpopulation of responders in particular.  However, we will say from the study that in our institution, delirium was acknowledged to be a common and important problem in the pediatric ICU patient population.  We found that our educational program was able to improve confidence in identification and management of delirium.  We found that general knowledge of delirium was pretty strong, but there was some deficiency of knowledge in specific risk factors for delirium and appropriate interventions for  delirium. Our educational curriculum was effective in improving some deficiencies in delirium knowledge, but unfortunately, some did persist despite our efforts.  This reinforces the need for ongoing delirium education at a multidisciplinary level, both to maintain our provider knowledge base and the overall sustainability of our delirium  program. I'd like to thank all the members of the Delirium Working Group for making this effort possible.  Thank you very much for your attention, and I'm happy to answer any questions.

Video Summary

Sarah Goldberg, a faculty member in the Division of Cardiovascular Critical Care at Boston Children's Hospital, presents a study on pediatric delirium in the ICU. Delirium is a common problem in pediatric ICU patients, with associated morbidity and mortality. The study aimed to assess staff knowledge and attitudes towards delirium and the effectiveness of an educational curriculum. A survey was administered to 587 staff members, with a response rate of 64%. The results showed that the educational program improved confidence in delirium management and the ability to identify delirium. However, there were persistent knowledge gaps that highlight the need for ongoing education in this area.

Asset Subtitle

Pediatrics, Neuroscience, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Sarah W. Goldberg

Introduction/Hypothesis: The importance of timely recognition and treatment of Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) delirium has been a topic of recent clinical initiatives worldwide. We instituted a multidisciplinary delirium curriculum for staff in 2 PICUs and 1 PCICU in a tertiary children's hospital and to see if staff's knowledge and attitudes changed after implementation.

Methods: 587 Staff (including attendings, fellows, advanced practice professionals (APPs), registered nurses (RNs), social workers, physical and occupational therapists (PT and OT)) working in 3 ICUs were invited to complete a survey with 17 true/false knowledge questions and 4 delirium attitudes questions on a Likert scale. All staff completed a pediatric delirium curriculum covering use of the screening tool, causes of ICU delirium, and treatment strategies. The 284 staff who completed the initial survey were invited to complete it again after implementation.

Results: 182 of 284 initial respondents (64%) completed the post-implementation survey. 61/182 (33%) were medical providers, 108/182 (59.4%) were bedside nurses or nurse specialists, and 13 (7.1%) were other team members (PT, OT, Child Life, and social work). In general, staff scored correctly on the majority of knowledge questions before the curriculum was administered. A higher proportion (20%) of respondents thought benzodiazepines were helpful in the treatment of delirium before the curriculum, compared to 7% after (p=0.001). 20% incorrectly responded that mechanical ventilation was not associated with delirium before taking the curriculum, compared to 8% in the post-survey (p=0.001). In addition, the proportion who thought antipsychotics were first line delirium treatment decreased from 31% to 21% (p=0.03). Staff also reported increased ability to recognize delirious patients (53 vs. 36%, p<0.001) and confidence in treating delirium (57 vs. 20%, p<0.001). There was no significant increase in the perceived prevalence or importance of delirium between the two time points.

Conclusions: A multidisciplinary delirium screening and treatment curriculum significantly increased some aspects of staff knowledge, including benzodiazepine and antipsychotic use, as well as their perception of their ability to recognize and treat delirium.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Neuroscience

Knowledge Level Advanced

Membership Level Select

Tag Delirium

Year 2021

Keywords

Sarah Goldberg

pediatric delirium

ICU

staff knowledge

educational curriculum

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