Prevención y manejo del delirio postoperatorio en pacientes adultos: proyecto de implementación de mejores prácticas

Gnatta, Juliana Rizzo; Paes, Sarha de Oliveira Gonçalves; Faria, Maria Fernanda de Oliveira; Cicarelli, Domingos Dias; Laurino, Renata Veloso Silva; Hamano, Lina; Püschel, Vilanice Alves de Araújo; Poveda, Vanessa de Brito

doi:10.1590/1980-220X-REEUSP-2023-0426en

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Evidence Implementation Report • Rev. esc. enferm. USP 58 • 2024 • https://doi.org/10.1590/1980-220X-REEUSP-2023-0426en linkcopiar

Prevención y manejo del delirio postoperatorio en pacientes adultos: proyecto de implementación de mejores prácticas

Autoría SCIMAGO INSTITUTIONS RANKINGS

Objetivo: Describir el proceso de implementación de mejores prácticas basadas en evidencia para mejorar la prevención y el manejo del delirio posoperatorio en la sala de recuperación posanestésica.

Método: Informe de un proyecto de implementación de evidencia aplicando el JBI basado en el proceso de auditoría y retroalimentación, con un enfoque estructurado para identificar y gestionar barreras de acuerdo con las prácticas clínicas recomendadas. Se utilizaron registros médicos, sistemas electrónicos de registros de enfermería y entrevistas al personal para evaluar las tasas de cumplimiento.

Resultados: En la auditoría de referencia, se encontró una tasa de cumplimiento cero en la mayoría de los criterios en relación con la mejor evidencia. Luego de esta fase, se realizó capacitación interprofesional, provisión de una herramienta validada para identificar pacientes con riesgo de delirio y cambios en el sistema de registros electrónicos de enfermería. En la primera auditoría de seguimiento se produjo un aumento en la tasa de cumplimiento en cuatro de los nueve criterios auditados. Cuatro criterios lograron un cumplimiento del 100% en la segunda auditoría de seguimiento.

Conclusión: Se implementaron mejores prácticas que contribuyeron a mejorar la prevención y el manejo del Delirio Postoperatorio. Después de una nueva capacitación y una nueva auditoría tras un año, se observó un aumento en el cumplimiento de las mejores prácticas.

DESCRIPTORES
Delírio; Enfermería Posanestésica; Complicaciones Cognitivas Postoperatorias; Periodo de Recuperación de la Anestesia; Sala de Recuperación; Investigación Interdisciplinaria

Audit criteria*	Sample	Method used to measure percentage compliance with best practices
1. The depth of sedation during anesthesia is monitored subjectively or objectively.	• Baseline audit: 10 observations of anesthesiologists during the procedure with patients with risk factors for POD. • Follow-up audit: 10 observations of anesthesiologists during the procedure with patients with risk factors for POD.	• Direct observation by the anesthesiologist during the procedure in patients with risk factors for POD to verify whether the depth of sedation was monitored through subjective or objective measurement. Subjective measure: “Yes” – application of the sedation scale; “No” – no record. Objective measure: “Yes” – use of equipment to guide anesthesia (e.g.: Bispectral Index Monitoring – BIS); “No” − not used.
2. Preoperative risk assessment for POD is performed.	• Baseline audit: 10 nursing records of patients with risk factors for POD. • Baseline audit: 10 nursing records of patients with risk factors for POD.	• Review of nursing records to verify if there was a nursing diagnosis of “Risk for acute confusion”. “Yes” – presence of the nursing diagnosis “Risk for acute confusion”; “No” – absence of the nursing diagnosis “Risk for acute confusion”.
3. Screening for POD is performed as early as possible in the PACU.	• Baseline audit: number of patients with positive screening for POD in 10 records in electronic nursing systems of patients at risk of POD. • Follow-up audit: number of patients with positive screening for POD in 10 records in electronic nursing systems of patients at risk of POD.	• Review of electronic nursing record systems for patients at risk for POD. “Yes” – if there is a CAM-ICU score; “No” – if there is no CAM-ICU score.
4. The tools Nursing Delirium Screening Scale (Nu-DESC) or Confusion Assessment Method (CAM-ICU) are used for screening.	• Baseline audit: number of patients screened for POD using the CAM-ICU tool across 10 patient observations. • Follow-up audit: number of patients screened for POD using the CAM-ICU tool across 10 patient observations.	• Nursing documentation in the patient's medical record. “Yes” – presence of CAM-ICU score recorded in the electronic nursing record system; “No” – absence of CAM-ICU score recorded in the electronic nursing record system.
5. The screening tool is easily accessible in the PACU.	• Baseline audit: presence of printed CAM-ICU tool available in the PACU on 10 occasions. • Follow-up audit: presence of printed CAM-ICU tool available in the PACU on 10 occasions.	• Presence of copies of the CAM-ICU tool in the PACU. “Yes” – Copy of the CAM-ICU tool available in the PACU to assess patients with risk factors for POD; “No” – Copy of the CAM-ICU tool not available in the PACU to assess patients with risk factors for POD.
6. Clinicians receive training in the use of Nu-DESC and/or CAM-ICU.	• Baseline audit: 10 nurses. • Follow-up audit: 10 nurses.	• Interview with 10 nurses using a structured form to verify whether the professional received training for the use of CAM-ICU in the last year. “Yes” – if the professional received training; “No” – if the professional did not receive training.
7. Physicians receive training on DSM-5 and/or ICD-10 reference standards.	• Baseline audit: 10 anesthesiologists. • Follow-up audit: 10 anesthesiologists.	• Interview with 10 anesthesiologists using a structured form. “Yes” – if the professional received training on DSM-5 and/or ICD-10 in the past year. “No” – if the professional did not receive training on DSM-5 and/or ICD-10 in the past year.
8. Multimodal postoperative pain control is administered.	• Baseline audit: 10 post-operative medical prescriptions accompanied by the respective anesthetic prescription. • Follow-up audit: 10 post-operative medical prescriptions accompanied by the respective anesthetic prescription.	• Review of 10 postoperative medical prescriptions for patients at risk of POD who reported pain during their PACU stay. “Yes” – if the patient received an opioid analgesic combined with a non-opioid; “No” – if the patient did not receive an opioid analgesic combined with a non-opioid.
9. When necessary, low-dose haloperidol or low-dose atypical neuroleptics are given to treat POD.	• Baseline audit: 10 postoperative medical prescriptions of patients with POD who received haloperidol or atypical neuroleptics in the PACU. • Follow-up audit: 10 postoperative medical prescriptions of patients with POD who received haloperidol or atypical neuroleptics in the PACU.	• Review of 10 postoperative medical prescriptions of patients with POD who received haloperidol or atypical neuroleptics in the PACU. “Yes” – if the patient received haloperidol or low-dose atypical neuroleptics; “No” – if the patient did not receive haloperidol or low-dose atypical neuroleptics.

Criteria – Patient Records	Yes	No
1. Is there a record in the Perioperative Nursing Process (SAEP) of the Nursing diagnosis “Risk for acute confusion” in the field for patients at risk of postoperative delirium? (Preoperative risk assessment for delirium – criterion 2)
2. Is there a record in the electronic (PROCEnf) or physical medical record of the application of an instrument for early screening of delirium (Ex: Nu-DESC or CAM) in PACU? (criterion 3)
3. Is there a record in the electronic (PROCEnf) or physical medical record of the application of the Nu-DESC or CAM tools during the patient's stay in the PACU? (criterion 4)
4. Is there a record in the anesthesia record or in the postoperative medical prescription of the administration of a non-opioid analgesic in combination with an opioid? (criterion 8)
5. Is there a record in the medical prescription of post-operative haloperidol or low-dose atypical neuroleptics? (criterion 9)
Criteria – Direct Observation
6. Did the anesthesiologist monitor the depth of anesthesia using subjective (e.g., application of a validated scale for measuring sedation) or objective (e.g., BIS) measurements? (criterion 1)
7. Are printed copies of the Nu-DESC or CAM tools readily accessible or in the electronic patient data recording system (PROCEnf)? (criterion 5)
Criterium – Questioning the Anesthesiologist
8. In the past 24 months, have you received any training on the DSM-5 and/or ICD-10 reference standards? (criterion 7)
Criteria – Questioning the Nursing Professional
9. In the last 24 months, have you completed any training on the application of CAM or Nu-DESC tools for the detection of delirium? (criterion 6)

Barriers	Strategy	Resources	Results
1. Most healthcare professionals were unaware of the risk factors for POD and how to apply and interpret the CAM-ICU tool.	• Development of formal interprofessional training and monitoring of professionals at the point of care to emphasize the application and interpretation of the instrument. • Development of an algorithm to screen and assess the risk of POD.	• Formal one-hour education session involving a PowerPoint presentation, an educational video, showing the practical application of CAM-ICU. • Application of the CAM-ICU algorithm and tool, on site, in a patient in the PACU.	• Health professionals were aware of the risk factors for delirium. This outcome was measured by verifying whether patients who presented at least one risk factor for POD had the nursing diagnoses “Risk for acute confusion” or “Acute confusion” recorded in their medical records.
2. CAM-ICU was not available in the PACU.	• Provision of printed copies of the CAM-ICU in the PACU.	• Laminated copies of the CAM-ICU tool were made available in the PACU.	• Printed CAM-ICU was available at the unit. This result was measured by checking whether the copy was available on the drive.
3. Screening and evaluation of delirium were not recorded in the medical records.	• Changes to the electronic nursing record system to show CAM-ICU scores linked to appropriate nursing diagnoses related to delirium (“Risk of acute confusion” or “Acute confusion”).	• Support from the head nurse. • IT support.	• The number of nursing diagnoses for “Risk for acute confusion” or “Acute confusion” identified and cases of POD increased significantly among adult patients in the PACU. This outcome was measured by checking patient medical records and electronic nursing records.
4. There is no equipment available at the institution to monitor the depth of sedation (BIS*).	• Arrange for the purchase of equipment to monitor the depth of sedation (BIS*).	• Support from the head nurse. • Support from clinical lead anesthesiologists.	• Acquisition of equipment (BIS*). This outcome was measured by verifying whether patients who presented at least one risk factor for POD were monitored by BIS during the anesthetic-surgical procedure.

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Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] *Audit criteria: based on JBI evidence summary of best practice recommendations(¹⁴).

[2] Source: the authors.