title: Implementing clinical practice guidelines for screening and detection of delirium in a 21-hospital system in northern California: real challenges in performance improvement.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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
  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.
authors.affiliation: 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.
authors.forename: Carmen L
authors.initials: CL
authors.lastname: Adams
authors.forename: Elizabeth Ann
authors.initials: EA
authors.lastname: Scruth
authors.forename: Christina
authors.initials: C
authors.lastname: Andrade
authors.forename: Susan
authors.initials: S
authors.lastname: Maynard
authors.forename: Kathryn
authors.initials: K
authors.lastname: Snow
authors.forename: Terry L
authors.initials: TL
authors.lastname: Olson
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Ingerson
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Duffy
authors.forename: Eugene
authors.initials: E
authors.lastname: Cheng
mesh_terms: D000328:Adult; D002140:California; D003693:Delirium / Q000175:diagnosis* / Q000451:nursing; D042241:Early Diagnosis; D006761:Hospitals; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008403:Mass Screening / Q000451:nursing / Q000592:standards*; D009720:Nurse Clinicians; D015403:Nursing Evaluation Research; D017410:Practice Guidelines as Topic; D058996:Quality Improvement / Q000458:organization & administration*