Mental Status Documentation: Information Quality and Data Processes

Abstract

Delirium is a fluctuating disturbance of cognition and/or consciousness associated with poor outcomes. Caring for patients with delirium requires integration of disparate information across clinicians, settings and time. The goal of this project was to characterize the information processes involved in nurses’ assessment, documentation, decisionmaking and communication regarding patients’ mental status in the inpatient setting.

VA nurse managers of medical wards (n=18) were systematically selected across the US. A semi-structured telephone interview focused on current assessment, documentation, and communication processes, as well as clinical and administrative decision-making was conducted, audio-recorded and transcribed. A thematic analytic approach was used.

Five themes emerged: 1) Fuzzy Concepts, 2) Grey Data, 3) Process Variability 4) Context is Critical and 5) Goal Conflict. This project describes the vague and variable information processes related to delirium and mental status that undermine effective risk, prevention, identification, communication and mitigation of harm.

Introduction

Delirium is defined as a fluctuating disturbance of cognition (memory, language, orientation) and/or consciousness with reduced ability to focus, sustain, or shift attention.¹ Delirium may impact 14–56% of all hospitalized elderly patients,^2,3 and is associated with poor outcomes, including: increased length of stay, increased likelihood of falls and accidents and discharge to a nursing home. Delirium causes diagnostic dilemmas for physicians and due to the need for increased monitoring, is often a significant burden on nursing staff.⁴

Several factors make delirium a difficult clinical problem. The first is that delirium often goes undetected: the prevalence of undiagnosed delirium was found to be as high as 32-67% on general medical units, 65% in emergency departments⁵ and 86% in nursing homes.^6,7 Across 22 studies, Steis and Fick found that nurses’ recognition of delirium symptoms ranged from only 26% to 83%.⁸ Complicating matters is that delirium may be the result of a variety of causes including: urinary tract infections, post anesthesia effects, pain, and iatrogenic effects from medications.⁹ A confounding issue in dealing with the problem of delirium is the distributed responsibility for care in inpatient settings. For example, a nurse may note that the patient is confused; this information is likely recorded either in a narrative note or in verbal handoffs or both. Physicians will likely not read the note and unless the nurse informs them verbally, then physicians will likely not be aware of the problem. Since fluctuation in alertness is the hallmark of delirium, multiple observations must be recorded to quantify the problem. Some of the communication norms may be implicit, as individuals may assume that when nothing is mentioned, there is not a problem.

Clinical decision support interventions were shown to increase delirium detection rates. However, despite increased recognition, these interventions were relatively ineffective in improving outcomes in patients with delirium.^10–14 In some settings, increased detection of delirium did not result in changes in patient care.^11,12,15 In studies showing improved outcomes, improvements appear to be associated with a multidisciplinary approach, including enhanced communication and shared awareness of goals across the healthcare team.^6,16–18 Current practices regarding nurses’ data collection and communication processes related to mental status are not well understood. This study helps to fill that gap.

In this paper we describe a qualitative analysis using semi-structure interviews with inpatient nurse managers of acute medicine floors across the Veterans Health Administration (VHA). The purpose of this study was to understand how information about patients’ mental status (with a focus on delirium) is recorded, transferred, communicated and tracked. This formative work was intended to inform the future development of a shared information space for the healthcare team to support communication, decision making, action planning and tools such as decision support technology.

Conceptual Framework

Successful detection and treatment of delirium depends on the healthcare team sharing information effectively. Effective communication requires not just sharing information, but sharing one’s beliefs regarding the meaning and implications of the information, expectations regarding the distribution of responsibilities and beliefs about the cause. Based on our belief that shared situational awareness drives effective clinical care of individuals’ with delirium, we based this work on Herbert Clark’s theories of communication. Clark proposes that communication and language are for the general purpose of creating “joint action” or activities with “rational organization around a common goal”¹⁹–²¹ (p. 69) Joint activities involve mechanisms for coordination (e.g. establishing definite reference, negotiating responsibility), for establishing common ground (understanding the intentions, roles, responsibilities and knowledge of each other), for accumulating coordination rules over time (through learning, minutes, and policy) and for the ubiquitous need for constant repair of miscommunication.

Methods

Settings and Study Participants

The Central Institutional Review Board of the VA, as well as the University of Utah and the Salt Lake City VA local IRBs approved the study. A convenience sample of nurse managers from 18 VA medical-surgical patient care units was selected from across the U.S. Four worked in the VA western area, four in the eastern, three in the southern, and one in a central area. Participants ranged in age from 38-57 years with a mean of 43.5 years. Their years of experience in the VA ranged from 6 months to 29 years with the modal experience at 10-13 years. The majority of nurses had bachelor’s degrees (n=6) or master’s degrees (n=5). Unit selection maximized variability: medicine, dialysis, rehabilitation, telemetry, transplant, and combined medical/surgical. The average census on units ranged from 6-29 (mean = 18.5) patients.

Setting

The VA is supported by VISTA, a mature electronic health record or EHR, (Stage 7 HIMSS Analytics) which includes clinical documentation, closed loop medication administration, orders management, decision support, and data warehousing. The clinician-facing component of VISTA, called CPRS, has standard templates for electronic documentation with the capability to create site-specific and unit-specific electronic forms for clinical documentation.

Interview Guide Development

The semi-structured interview guide was developed by the authors (CW, NS and BG) to address 1) current practices in managing and communicating patients’ mental status changes, 2) decision-making processes for staffing and resource use, and 3) practices for communication between and within the various clinical roles. The semi-structured interview was piloted and refined during interviews with two nurse managers before the study began.

Procedures

The team recruited potential participants through phone contact with the site’s nurse executive and email invitations sent directly to participants. After the consenting process was completed, two researchers (BG, NS) completed telephone interviews using the semi-structured interview guide. The specific interview questions are in the Appendix. The interviews lasted 15-20 minutes at the minimum and sometimes up to an hour for a few and a median of 25”. They were recorded, transcribed, verified for accuracy and de-identified by a professional transcriptionist. Transcripts were loaded into Atlas.ti™ for analysis.

Data Analysis

The team used an iterative process of qualitative content analysis.²² After group calibrations, each member of the team independently created “pre-codes” or short text that paraphrased the text. The associated quotations were discussed and aggregated by assigning more abstract codes in an iterative consensual process of group discussion and re-coding. Final thematic categories were identified by grouping quotations, comparing and contrasting content through discussion and network display analysis and final re-reading of the original text for validation. The authors (CW, BG, and TT) jointly reviewed all 18 of the interviews using Atlas ti^TM.

Results

We organized the concepts identified in our analysis into five thematic categories referring to mental status information content and processes: Fuzzy Concepts, Grey Data, Process Variability, Context is Critical, and Goal Conflict. Each is described below with representative quotations.

Theme 1. Fuzzy Concepts: References to mental status are generally “fuzzy” and imprecise

References to acute mental status changes range from informal to moderately structured. A variety of terms are used including: confusion, acute confusion, agitation, altered mental status, delirium, dementia, and, at times, more colloquial terms like “wacky” and “sundowners.” We noted significant reluctance by nurse interviewees to use the word “delirium” unless patients were formally diagnosed as having the condition: One nurse said, “Nurses don’t diagnose.” The most common term nurses mentioned was “confusion.”

Use of structured mental status data is limited to designated fields in EHR templates (e.g. nurse admission note for orientation) and is usually non-specific for delirium (e.g., patient is alert and oriented x 4). Delirium is not typically formally assessed in general medical surgical units unless orders such as the Richmond Agitation and Sedation Scale (RASS) and the CAM (Confusion Assessment Method) were rarely used. The methods for assessing mental status and the timing at which the assessments occurred were viewed as being a matter of nurses’ individual clinical judgment.

Some institutions used a structured format for handoffs, such as SBAR (Situation, Background, Assessment Recommendation), as a framework for their handoff forms. However, this framework is not specific enough to ensure consistent documentation and communication of mental status: “The oncoming nurse has their blank SBAR form and they fill it out during their verbal handoff.”

Theme 2. Grey Data: Information regarding mental status is invisible or difficult to find

Grey data refers to information that is not available in the EHR, either at the individual, ward level, or system level. As a result, this information can’t be easily accessed for decision-making. Information can be difficult to find, either because it is not integrated with other data that makes it meaningful, because it is in a non-useful format, or because it is buried deep within clinical notes. Nurses’ use of templates for documentation makes it difficult for physicians to locate relevant information because they are lengthy, not created to display information “at a glance” and do not allow indicators for critical information. In addition, key information such as the patient’s risk for developing delirium or trends in mental status signs and symptoms tend to be verbal and informal. Often mental status information is not recorded.

Theme 3 “Process Variability” in measurement, information exchange and documentation processes.

The methods for assessing mental status and the timing at which the assessments occurred were viewed as being a matter of nurses’ individual clinical judgment. Mental status information is also communicated in at least 4 ways: (1) in written form as part of the her formal clinical note templates or narrative, (2) verbally (handoffs, phone calls, rounds, hallway conversations) and (3) in electronic forms outside of the EHR (e.g. spreadsheets), and (4) on paper (e.g. Nurse’s paper “ brains” which are thrown away after the shift is over). Guidelines for when, where and how to communicate are not standardized and are largely left up to nursing judgment. Nurses sometimes call physicians and then document the phone call in a note with the title “physician notification” or in an “addendum” to another note.

Timing of nursing documentation is often disjunctive with changes in the delirious patient’s condition. Nursing documentation may occur once in 4 hours, once per shift, or mental status may not be documented regularly at all. The assumption is that if a patient’s mental status changed the information would be communicated verbally. Thus, verbal communication often serves as the mode for sharing mental status information.

Theme 4. Context is Critical: The meaning of mental status information is derived from context, clinical expectations and baseline comparisons.

The interpretation of mental status information requires fully knowing the patient’s condition. Patients at risk are rarely formally? identified. Few participants reported protocols for instituting systematic monitoring or nursing interventions for patients at risk (with the exception of ETOH withdrawal protocols). The concept of identifying patients at risk was even difficult to explain to interviewees. Red flags reported by nurses that required enhanced action included a sudden change in mental status (from a normal baseline), a fall, or a behavioral difficulty. Resistance to “diagnosing” delirium was frequent.

Theme 5: Goal Conflict-Tension exists between patient safety requirements, diagnostic dilemmas, nurse’s staffing levels, accountability and cost. These tensions impact information use.

The response to a finding of delirium is largely increased monitoring (with the resultant increased demand for nursing resources) with the goal of maintaining patient safety. Identifying the cause is often secondary and “confusion” may often be viewed as a permanent state like dementia. When physicians are called, it is often regarding a perceived safety threat or behavioral problem, so patients who are confused but less active are not brought to the physician’s attention. Staffing decisions are often based on verbal descriptions of behavior rather than perceptions of risk. The question addressed is often restricted to whether a higher acuity floor is needed or more nurses. The prevalence of the problem and the importance of keeping patients safe creates a significant burden and most units use sitters and other high-cost options.

Discussion

In this study we conducted interviews of Nurse Managers of inpatient medical units to explore how information about patients’ mental status is recorded, transferred, communicated and shared. Our focus was on policy and normative processes, as we did not observe practice patterns. We found that information processes for mental status data lack consistency, specificity, and meaning. Our most important findings suggest significant variation across settings. In addition, data collection and recording is often disjunctive with the timeframe to act (e.g. notes are written every shift but patients status may change much more rapidly than this), thus leaving critical information to be communicated verbally. This results in increased cognitive load for nurses because notifying physicians requires deliberation. Finally, much of the text about delirium is embedded in narrative note descriptions and did not support systematic processes for tracking patients with delirium at a unit or institutional level for the purposes of stewardship. These results will be discussed below in terms of communication theory, implications for development of cognitive support for nurses and nursing workload.

Problem with Vague Reference and its effects on Communication and Coordination

Managing acute mental status changes require coordination among the clinicians involved in the patient’s care. Achieving that coordination depends on effective communication. Theorists have noted that effective communication requires a clear reference to the subject or Definite Reference.²³ Failure to have definite reference results in a loss of shared focus among a team and a demand for increased effort to interpret and understand data. Because humans are “cognitive misers,” vague references to mental status may rarely get the attention required to disambiguate. In other words, if nurses and physicians refer to mental status using vague terminology (e,g, wacky) and indefinite specification (e.g. timing of onset, specific descriptors), then people fill in the information gaps with their own automatic and potentially inaccurate expectations.

The clinical context of delirium makes more precise communication particularly important. Physicians and others need to be able to correctly interpret the meaning of a nurses’ notation of abnormal mental status in the patient record. Similarly, nurses need to know about the patient’s risk for delirium, possible attributions of cause, and the degree to which managing delirium should be considered in relation to the goals of care in order to organization their assessments. Other research supports our findings that communication about mental status appears to be imprecise, relying on orientation ratings taken once per shift and using verbal and other informal modes and implicit protocols.²⁴ Finally, the evidence that physicians rarely read nurses’ notes²⁵ limits the impact of physicians’ therapeutic decision making due to the inadequate mental status information that nurses currently document.

The illusion of effective communication has been well studied. Individuals overestimate the effectiveness of their communication and have difficulty inferring the goals or the meaning of other’s discourse or writing.²⁶ This phenomenon was found in medical handoffs as well as typical human interaction.²⁷ Individuals may be especially prone to misunderstandings when they are exchanging information that is not clearly specified. Errors in communication also occur when people are under a high cognitive load, which is commonplace in clinical care settings. Although only suggestive, our findings regarding the variability and imprecision in documentation and communication processes may be contributing factors to the lack of quality of care for patients with delirium.

Cognitive Support from EHRs

Our results support a conclusion that current EHRs fail to provide the level of support for shared situation awareness of the patient’s mental status needed for healthcare teams to appropriately identify and treat delirium. Herbert Clark’s communication theory is very relevant in several areas. Establishing definite reference or precision regarding how mental status is referenced is probably the most obvious application. It is simply not easy in the distributed clinical setting to fully understand and grasp vague mental status references measured differently by many individuals and inconsistent rules for communication. Mental status terms often are without reference to context and the diversity in goals are assumed. An example is the prevalence of nurses only measuring orientation, when other metrics or descriptors might be more informative. In addition, nurses may need decision support in order to provide explicit communication to physicians, that would include baseline, additional measures and some information to support a shared understanding. about possible causes if they know them when they communicate without feeling like they are unduly responsible. Technology could really assist this process by pulling text references to mental status as in a “heat map” and include mental notation beyond delirium to better exclude dementia as a default and to express other important attributes, such as depression and anxiety, in the shared display. Time course is very important to diagnosis and so the display should have a time course.

One design feature that may improve communication is shared information displays, which offer an “at a glance” view of data from multiple sources, allowing viewers to develop shared situational awareness.²⁸ Currently in healthcare the most prevalent form of shared information display is the unit’s whiteboard. Xiao et al. found that whiteboard uses include: team attention management (e.g. drawing attention to salient patient factors), communication, problem-solving/negotiation and staff assignment. Research on electronic whiteboards in operating suites²⁹ and emergency departments³⁰ has shown that they can facilitate improvements in both administrative and workflow efficiencies as well as team performance.^{6,16–18,31,32}

Nursing Workload

The lack of specificity in language and documentation for mental status data has direct implications for the daily planning and organization of nursing staffing. Confusion, wandering, and behavioral outbreaks present significant risk for the patient and increased workload for nurses. Interviewees in this study often expressed concern over how the patient’s mental status impacted staffing and assignment decisions.³³ Nurses need precise and measurable information about mental status in order to inform decisions at the shift and institution level. The tension between costs and staffing requirements may lead to heavier workloads on nurses raising the issue of safety of patient care.^34,35

Limitations

This study has several limitations. First, although data was collected from 18 care facilities across the U.S., they were all within only one health care delivery system (the VA). The distribution of respondents mitigates some concerns, but all respondents were working in one information system and under similar nurse staffing organizational systems, In addition, our conclusions are tentative because we did not observe the flow of information directly. Our conclusions are based on results from Nurse Manager interviews; as a result, there is some degree of social desirability bias as well as simple inaccuracies.

Conclusions

Documentation and communication processes for mental status information appear to be variable, informal and imprecise. Interpretation of mental status data for nurses’ clinical decision-making requires information on context standardization and precision in references to altered mental status, and integration of information with goals of care. The ability to provide stewardship decisions may require better data capture, decision support tools, and also better communication processes.

Table 1.

Subtheme of Theme 1 “Fuzzy Concepts”

Subtheme	Quote
The term delirium is rarely used.	“Regarding like behavior, you know, as far as being agitated, calm, cooperative, all of those different kinds of things as well…” “Unfortunately a lot of people use dementia…when it’s not always the case.”
Assessments are nonspecific for delirium	Is delirium formally assessed? “Yes, sort of.” “It’s not a specific dementia or confusion assessment tool.” “We just do the mental status exam. So we look at orientation, whether they’re oriented to person, place, time; and then whether they’re awake, lethargic, unresponsive to, sedated…” “We rarely assess somnolence. Honestly, we rarely have patients that fit that criteria so they are more tuned into…alert and oriented and then relate to what the patient is not oriented to.”
	And then on your unit do you have a particular way that you ‘re defining either delirium or acute mental status changes? “Acute mental status change would be one. A lot of times what I hear just between nursing staff is a lot of times they’ll talk about sundowner’s.” “I don’t really see the actual word delirium being said, but we just would use the words, he just got confused all of a sudden.”

Table 2.

Subthemes of Theme 2 “Grey Data”

Subtheme	Quote
Dual Documentation	“..in the nursing notes, the flow sheet and possibly even in the plan of care if there’s a need identified.” About care plans: “There isn’t…it’s pretty…to be honest, it’s a little disjointed.”
Hidden data collections	“No, it’s just an Excel spreadsheet that people developed.” “ Well, we have a…we have a process for, but it’s not a formal… every delirium assessment which is one on every patient I co-sign the note, so anybody that scores a two or above I put in the folder, but I make sure my nurses are following up so I have a list going back over the last year on anybody that scored two or higher.”
Hand-offs vary and are often unstructured	“They have like a spreadsheet that they have information on all of our patients. Let me look at the headings and see if we’ve got that [mental status] as one of our headings.” “… my floor that just designed our own hand-off sheet, charge nurse to charge nurse, and it will say who the high acuity patients are; it will say who the heavy patients are.”
Persistence of paper	“That’s a paper form, but we…” “Oh, yes. Well, if there’s an ‘order’ for neuro check, then … we have a paper form to fill out …”
Lack of trended data	Q. If you wanted to know how many patients had delirium last month on your unit, how would you find that out? “ That’s a very good question. I don’t know if I could tell you that.” “If I were just to go into the CPRS, I would have to go back and look at every patient.”

Table 3.

Subthemes and quotes for Theme 3 “Process Variability”

Sub Theme	Quote
Communicating delirium to physicians may or may not be effective.	“So the patient comes in; it was documented that they were alert and oriented. So the next nurse takes over the patient and finds that the patient is not oriented to time, place and person and is actually a little agitated and doesn’t want to stay… Call the
	doctor and the doctor comes in and the patient is fine.” “They are free to call at any time they have a concern.” “We can go to the doctor any time and tell him that he’s really agitated or anxious or confused…” “I've got a physician group that are currently not receptive as much as I would like for them to be to have a collaborative relationship with the nursing group”
Documentation processes vary, are non-systematic and often unstructured.	“there’s not one unified place for multiple disciplines to document on the plan of care… they can be in multiple places, but they’re all within CPRS” “There’s no way through CPRS as far as I know at this point in terms…to extract that data.” “if they have specific things that they have to do regarding that patient, they document it in their individual disciplinary notes”
Assumption that delirium will be discussed	“We’ll talk about discharge, which would talk about their delirium if they were confused, that placement.” We wouldn’t necessarily bring up a diagnosis of delirium, but we would say maybe the patient is confused or whatever and they require a sitter. That’s about as much as would be discussed
Assessment and documentation depend on nursing judgment: no systematic way to collect data.	We don’t have any nurse-driven, you know, protocols or anything like that to identify someone that’s at risk for delirium, but it’s certainly something that the nursing staff looks out for.” “It’s up to the nurse to write about it.”
Mental status information is not monitored	“But as far as acute mental status changes, it’s not something that’s routinely reported at the facility level.” “as far as tracking that, I couldn’t even promise that. I wouldn’t know how to say in the last month how many people had it.”

Table 4.

Subthemes for Theme 4 “Context is Critical”

Subtheme	Quote
Delirium is a non-specific sign	“[Delirium] is from medications or alcohol withdrawal or it can be from a variety of things, nothing… . .it doesn’t mean that they’re infarcting their brain or anything.”
Baseline is critical	“Get reports from wherever they came from, if it was a different hospital, just to kind of get a baseline”
Nurses do look for proximal causes of delirium	“The first thing you’re going to do is you’re going to look and see, are there new medications onboard, which is the number one cause of delirium.” “We’re on a post-surgical floor, usually any mental status change could indicate a clot coming loose or an additional bleed or something like that.”
Monitoring and Intervention depends on protocols	“We have an ETOH-er who is coming in to be admitted. He’s almost at the 72-hour mark which is a warning that we should be aware of his mental status. “ We’ll initiate close monitoring so we’ll put a staff member like, okay, the sitters close to the nurse’s station, bed alarms So it depends on the level of outburst. … All of a sudden they’re on dialysis and they’re not responding, that’s a different assessment and a code will be called”

Table 5.

Subthemes for Theme 5 “Goal Conflict”

Staffing is difficult because of mental status and behavioral issues	“The physicians will write it … but a lot of times you struggle trying to make that happen because you don’t have the staffing.” “…don’t have to have a sitter, but if the patient is able to fall out of the bed or something, then I do provide a sitter.”
The first thing is patient safety, not finding a cause.	“Nurses can put a sitter in there or the physician can order a sitter, so it’s a multidisciplinary plan to address that patient for safety sake.” “Depending on whether or not he’s a safety risk to himself or not; like I said, we’ll initiate close monitoring so we’ll put a staff member like, okay, the sitters close to the nurse’s station, bed alarms.”