Abstract
Objective: To explore the application effect of cluster nursing in post-surgery elderly patients in intensive care units (ICU). Methods: From March 2019 to August 2020, a total of 167 elderly patients admitted to the ICU in Changzhou No. 2 People’s Hospital, the Affiliated Hospital of Nanjing Medical University were recruited as the study cohort. They were divided into a test group (n=85) and a control group (n=82). The patients in the control group underwent routine nursing, and the patients in the test group underwent cluster nursing in addition to the nursing the control group underwent. The two groups’ incidences of delirium, their quality of life, and their mental health were compared. Results: The total incidences of delirium in the test group were significantly lower than they were in the control group, and the delirium outcome rate was significantly higher than it was in the control group. A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE ll) and Symptom Checklist-90 (SCL-90) scores before and after the nursing showed that the test group had notably lower scores than the control group. In addition, the nursing satisfaction rate in the test group was 88.24%, which was significantly higher than the rate in the control group (73.17%). The hospitalization expenses of the test group were lower, with a notably improved quality of life. Conclusion: Cluster nursing can reduce the incidence of delirium and improve the quality of life and mental health of post-surgery elderly ICU patients.
Keywords: Cluster nursing, intensive care unit, elderly, delirium, quality of life
Introduction
Delirium is an acute, transient, and usually reversible neuropsychiatric syndrome that occurs at all ages, and the elderly are at a high risk of developing delirium [1]. Elderly patients in intensive care units (ICU) are often in critical condition and are prone to negative emotions and delirium after their operations [2]. The consequences of delirium are long-term, including increased mortality and morbidity, long-term cognitive dysfunction and memory loss, an increased risk of falls, and a decreased functional status [3]. According to previous studies, delirium is associated with various negative consequences, such as long hospital stays, the need for institutional care, poor function, and high treatment costs, and it has also been proved to be related to higher short-term and long-term mortality [4]. Delirium has also been shown to be related to the severe pain of patients and their families, which seriously affects their quality of life [5]. Therefore, it is of great importance to prevent the occurrence of delirium in ICU patients. It is also important to find this phenomenon as early as possible and carry out nursing management to reduce the related morbidity, mortality and pain of the patients and their caregivers [6].
Cluster nursing intervention is a centralized and targeted management model that can be adopted for the same kind of patients by combining a series of evidence-based treatment and nursing measures, and it can help medical personnel provide patients with optimal medical care services and nursing outcomes as much as possible [7]. According to Leslie et al., long-term care effectively prevented delirium and reduced the medical costs of 801 inpatients aged 70 and above [8]. It is particularly important to determine the risk of delirium in terms of prevention. In the needs-based nursing model, nursing assessment is a useful component of the risk assessment of mental disorders, so it is necessary to develop a personalized nursing system [9]. Given the high risk of delirium, it would be beneficial to improve the nursing level of postoperative delirium in elderly ICU patients [10]. There have been no previous studies on the prevention of delirium in elderly ICU patients using the cluster nursing model or on the improvement of patients’ negative emotions and quality of life. It is not yet known whether cluster nursing can promote patient rehabilitation.
In this study, a cluster nursing intervention was administered to elderly ICU inpatients to analyze the impacts of this model of care on the occurrence of postoperative delirium, negative emotions, and quality of life.
Materials and methods
General data
From March 2019 to August 2020, a total of 167 elderly patients admitted to the intensive care unit (ICU) of Changzhou No. 2 People’s Hospital, the Affiliated Hospital of Nanjing Medical University were recruited as the study cohort. Inclusion criteria: patients aged 60 years old or above, patients with complete clinical data, patients with no delirium before their admission, and patients with an ICU stay time equal to or longer than 24 hours. Diagnostic criteria of delirium: clinically, patient was experiencing a cloudy state of consciousness or showed abnormal mental excitement, symptoms of restlessness, resistance, shouting, and rich delusions and hallucinations [11]. Exclusion criteria: patients with a previous history of cerebrovascular epilepsy, mental illness, acute cerebrovascular disease, neurosurgery, or malignant tumors. This study did not violate ethics. The plan was submitted to the Ethics Committee of Changzhou No. 2 People’s Hospital, the Affiliated Hospital of Nanjing Medical University for review, and it was implemented after the approval was obtained. All the subjects and their guardians signed a fully informed consent form.
Methods
The enrolled 167 patients were divided into a test group (n=85) and a control group (n=82). The patients in the control group underwent routine nursing. According to the ICU nursing procedures, the patients were provided with oxygen support and electrocardiograph (ECG) monitoring, and their vital signs were monitored throughout the whole process. Any seepage or bleeding in the patients was properly handled during the observation. In addition, the patients underwent medication nursing and complication prevention nursing based on the doctor’s advice. The patients in the test group underwent clustered nursing in addition to the nursing the control group underwent. The specific measures were as follows: according to the cultural background, the clinical data, and the medical history of each patient before admission, his/her psychological state was comprehensively evaluated. The nurses carried out the nursing work seriously and implemented the nursing tasks practically. The charge nurses took the initiative to care about the patients with delirium after their operations, patiently asked them whether they had discomfort or needs, actively encouraged them and helped them exercise as soon as possible, so as to make the patients have trust in the nurses. In the nursing process, the charge nurses were required to reduce the movement range, keep the proper humidity and temperature in the ward, keep the light in the ward soft, reduce the overall noise in the room, and ensure that the patient had enough sleep from 10 pm to 7 am the next day. The patients were encouraged to take deep breaths, cough effectively, and blow up balloons. They were instructed to maintain a reasonable diet. When the patient was able to eat, the intake of food and water was controlled to maintain a balanced diet. The charge nurses strictly checked the indexes related to delirium, such as blood oxygen saturation, consciousness, and blood pressure, so as to enable an early determination of delirium. If the patient was manic, extremely quiet, or had difficulty speaking, it was necessary to guard against the occurrence of delirium and to identify postoperative delirium early. When cleaning the patient’s body and urethral orifice, a curtain was needed, and the time and range of the patient’s body exposure were reduced, so as to make the patient feel respected.
Outcome measures
The incidence of delirium in the patients was observed at the time periods of below 24 h, 24 h-72 h, and 72 h to discharge. The delirium outcomes were observed and divided into three grades: Cured: the patients had no coma and had a clear consciousness, their attention could be concentrated effectively, and their unstable mental state disappeared completely. Improved: the patients had a clear consciousness, they could concentrate, and their mental state was stable, with no logical confusion. No response: the patients’ delirium symptoms did not change or even worsened. Outcome rate = (cured + improved)/n × 100%. The acute physiology and chronic health evaluation (APACHE ll) score system [12] was used to evaluate the patients’ health statuses before and after the nursing. The APACHE ll scoring standard is composed of acute physiology, age, and chronic health scores, and each patient’s final score is expressed as the sum of the 3 items, with a maximum possible score of 71. The higher the score, the worse the patient’s physical condition. Symptom Checklist-90 (SCL-90) [13] was used to evaluate the patients before they were admitted to the ICU and after the nursing. It mainly assessed the patients’ obsessive-compulsive sy-mptoms, including their sensitive interpersonal relationships, their emotions, somatization, psychosis, and other items. Each item used a five-level scoring system, and the higher the score, the worse the mental state of the patient. Before discharge, the nursing satisfaction of patients and their families was measured and recorded. A self-made nursing satisfaction questionnaire was used [14], which covers service attitude, operation standards, and other items. A score of over 90 points indicates greatly satisfied, a score of 80-90 points indicates satisfied, a score of 70-79 points indicates generally satisfied, and a score of less than 70 points indicates dissatisfied. Nursing satisfaction = (great satisfied + satisfied)/n × 100%. The patients’ lengths of stay of patients were recorded. The short form 36-item health survey (SF-36) [15] was used to evaluate the patients’ quality of life, including role physical (RP), general health (GH), social function (SF), physiological function (PF) and role emotional (RE). The range of each item is 20-100 points, and a higher score indicated a better quality of life.
Statistical methods
All the statistical analyses were performed using SPSS 20.0 (IBM Corp., Armonk, New York, USA). Mean ± standard deviation (Mean ± SD) was used to standardize the data, and Student’s t tests were used to compare the significance of the data. The count data were expressed as [n (%)], and chi-square tests were applied for the comparisons between groups. Paired t tests were used for the intra-group comparisons. P<0.05 was considered statistically significant.
Results
General data
Through observation and the study of the general clinical data of the test group and the control group, we found no significant differences in terms of age, gender, disease type or ASA operation grade between them (P>0.05), as shown in Table 1.
Table 1.
General clinical data of the test and control groups (means ± SD); [n (%)]
| Type | Control group n=82 | Test group (n=85) | t/χ2 value | P value |
|---|---|---|---|---|
| Age (years) | 70.3±3.5 | 71.1±2.6 | ||
| Gender | 0.047 | 0.828 | ||
| Male | 43 (52.44) | 46 (54.12) | ||
| Female | 39 (47.56) | 39 (45.88) | ||
| Disease type | 2.855 | 0.582 | ||
| Fracture | 16 (19.51) | 21 (24.71) | ||
| Intestinal obstruction | 10 (12.20) | 8 (9.41) | ||
| Gallstone | 11 (13.41) | 7 (8.24) | ||
| Tumor | 21 (25.61) | 18 (21.18) | ||
| Other | 24 (29.27) | 31 (36.47) | ||
| ASA grade | 0.458 | 0.795 | ||
| Grade I | 21 (25.60) | 18 (21.18) | ||
| Grade II | 51 (62.20) | 56 (65.88) | ||
| Grade III-IV | 10 (12.20) | 11 (12.94) | ||
| Operation time (h) | 1.76±0.62 | 1.81±0.79 | ||
| Smoking history | 0.251 | 0.616 | ||
| Present | 33 (40.24) | 31 (36.47) | ||
| Absent | 49 (59.76) | 54 (63.53) | ||
| Drinking history | 0.069 | 0.792 | ||
| Present | 35 (42.68) | 38 (44.71) | ||
| Absent | 47 (57.32) | 47 (55.29) | ||
| Diabetes history | 0.049 | 0.825 | ||
| Present | 6 (7.32) | 7 (8.24) | ||
| Absent | 76 (92.68) | 78 (91.76) | ||
| Hypertension | 0.003 | 0.953 | ||
| Present | 5 (6.10) | 5 (5.88) | ||
| Absent | 77 (93.90) | 80 (94.12) |
Comparison of the delirium in different time periods between the test group and control group
After the mechanical ventilation, the incidences of delirium in the different time periods were observed in the two groups, and we found no differences in the incidences of delirium at the time periods of below 24 h and 24 h-72 h (P>0.05). At the period of 72 h to discharge, however, the incidences of delirium in the test group were remarkably lower than they were in the control group (P<0.05). Additionally, the total number of incidences of delirium was also significantly lower in the test group than it was in the control group (P<0.05). More details are shown in Table 2.
Table 2.
Comparison of the delirium incidences between the test and control groups in the different time periods [n (%)]
| Group | n | Less than 24 h | 24 h-72 h | 72 h to discharge | Total incidence |
|---|---|---|---|---|---|
| Control group | 82 | 5 (6.10) | 10 (12.20) | 21 (25.61) | 36 (43.90) |
| Test group | 85 | 1 (1.18) | 4 (4.71) | 10 (11.76) | 15 (17.65) |
| χ2 value | - | 2.918 | 3.048 | 5.292 | 1.560 |
| P value | - | 0.088 | 0.081 | 0.021 | <0.001 |
The delirium outcomes in the test and control groups
The two groups’ delirium outcomes were observed, and they were 55.56% in the control group and 86.67% in the test group. The latter group had a significantly higher delirium outcome rate (P<0.05). More details are shown in Table 3.
Table 3.
Comparison of the delirium outcome rates between the test and control groups [n (%)]
| Group | n | Cured | Improved | No response | Outcome rate |
|---|---|---|---|---|---|
| Control group | 36 | 14 (38.89) | 6 (16.67) | 16 (44.44) | 55.56 |
| Test group | 15 | 7 (46.67) | 6 (40.00) | 2 (13.33) | 86.67 |
| χ2 value | - | - | - | - | 4.488 |
| P value | - | - | - | - | 0.034 |
The APACHE ll scores before and after the nursing in the test and control groups
Before the nursing, the APACHE ll scores of the two groups showed no significant change. After the nursing, the scores decreased remarkably in both groups (P<0.05) and were significantly lower in the test group than in the control group (P<0.05). More details are shown in Figure 1.
Figure 1.
The APACHE ll scores before and after the nursing in the test and control groups. After the nursing, the APACHE ll scores decreased remarkably in both groups (P<0.05) and were significantly lower in the test group than the control group (P<0.05). Note: *P<0.05.
Changes in the SCL-90 scores before and after the nursing in the test and control groups
There was no considerable change in the SCL-90 scores between the test group and the control group before the nursing (P>0.05). After the nursing, SCL-90 scores decreased notably in both groups (P<0.05), and they were lower in the test group than they were in the control group (P<0.05). More details are shown in Figure 2.
Figure 2.
Changes in the SCL-90 scores before and after the nursing in the test and control groups. After the nursing, the SCL-90 scores decreased notably in both groups (P<0.05), and they were lower in the test group than they were in the control group (P<0.05). Note: *P<0.05.
Nursing satisfaction in the test and control groups
The nursing satisfaction was investigated in both groups. It was 88.24% in the test group, which was significantly higher than it was in the control group (73.17%) (P<0.05). More details are shown in Table 4.
Table 4.
Comparison of the nursing satisfaction in the test and control groups [n (%)]
| Group | n | Greatly satisfied | Satisfied | Generally satisfied | Dissatisfied | Satisfaction degree |
|---|---|---|---|---|---|---|
| Control group | 82 | 35 (42.68) | 32 (39.02) | 12 (14.63) | 3 (3.66) | 81.71 |
| Test group | 85 | 51 (60.00) | 29 (34.12) | 4 (4.71) | 1 (1.18) | 94.12 |
| χ2 value | - | - | - | - | - | 6.098 |
| P value | - | - | - | - | - | 0.014 |
Length of stay in the test and control groups
The length of stay in the test group was (6.53±1.02) d, which was notably less than it was in the control group (9.51±2.13) d (P<0.05). More details are shown in Figure 3.
Figure 3.
Comparison of the lengths of stay in the test and control groups. The lengths of stay in the test group were notably shorter than they were in the control group. Note: *P<0.05.
Quality of life in the test and control groups
Before the nursing, there was no remarkable difference in the quality of life scores between the two groups (P<0.05). After the nursing, the quality of life scores improved notably in both groups (P<0.05), and they were higher in the test group than they were in the control group (P<0.05). More details are shown in Figure 4.
Figure 4.
Comparison of the quality of life scores in the test and control groups. A. Comparison of the RP scores between the test group and the control group. B. Comparison of the GH scores between the test group and the control group. C. Comparison of the SF scores between the test group and the control group. D. Comparison of the PF scores between the test group and the control group. E. Comparison of the RE scores between the test group and the control group. Note: *P<0.05.
Discussion
Delirium, depression, anxiety and other problems often occur in post-surgery elderly ICU patients, problems which seriously affect the effect of the surgical treatment and increase the risk of death after operation [16]. Therefore, for elderly ICU patients who develop postoperative delirium and negative emotions, the medical staff should provide an appropriate model of care.
Delirium can occur for a variety of reasons, making it difficult to achieve good clinical outcomes with a single model of care [17]. For example, Spronk et al. mentioned in their study that the ICU nurses seriously neglected delirium in their daily nursing, and proposed that more attention should be paid to the implementation of validated delirium screening tools in routine ICU care [18]. According to Forsgren et al., people have a poor understanding of delirium in the ICU, and they suggested that medical staff should be educated to improve the nursing quality for ICU patients [19]. Cluster nursing aims to implement targeted nursing intervention for patients on the basis of evidence-based treatment, and it can improve patient outcomes. After an operation, with the extension of the mechanical ventilation time, the incidence of delirium will increase in ICU patients [20]. Our research shows that delirium usually occurs at 72 hours post-operation, and the incidences of delirium in the patients undergoing cluster nursing were significantly reduced, and their outcomes were also notably better when compared with the control group. These findings indicate that cluster nursing can reduce the incidences of delirium in elderly ICU patients and improve the outcomes of delirium patients. Our study further revealed that the APACHE ll scores in the test group were lower than the corresponding scores in the control group, and the SCL-90 scores were significantly higher. The APACHE ll score is a commonly used scale for the assessment of patients’ disease severity, and the SCL-90 score can evaluate patients’ mental health [21,22]. In the study by van den Boogaard et al. [23], educating the nursing staff about delirium in the ICU can improve the quality of care. The application of a delirium assessment tool in the ICU allows for the early detection of delirium and the patients’ ability to undergo haloperidol treatment at lower doses, and with a shorter duration. Our study, however, focuses more on the effective reduction of the incidence of delirium and its effects on the subsequent patient recovery. It is believed that increased communication between nurses and the patients during the nursing process facilitated this improvement, as it can help the nurses promptly understand each patient’s condition. In addition, targeted nursing intervention in the patient’s environment, psychology, and diet can improve the patient’s condition significantly. Therefore, the implementation of the cluster nursing model can promote patient rehabilitation. According to the research of Boot et al., delirium is related to prolonged ventilation, related risks, and increased lengths of stay, which increase the medical costs of the patients and of national health services [24]. After cluster nursing, we found that the patients’ lengths of stay were significantly shortened and their nursing satisfaction was higher in comparison with the control group, and their quality of life was significantly improved, indicating the significant intervention effect of cluster nursing.
This study confirms that cluster nursing has a good effect on post-surgery elderly ICU patients. However, there are still some deficiencies. First of all, we did not analyze the risk factors for postoperative delirium. Second, it is not known whether cluster nursing is suitable for other diseases. More in-depth research will be conducted in future studies.
In conclusion, cluster nursing can reduce the incidence of delirium and improve the quality of life and mental health of post-surgery elderly ICU patients.
Disclosure of conflict of interest
None.
References
- 1.Reznik ME, Slooter AJC. Delirium management in the ICU. Curr Treat Options Neurol. 2019;21:59. doi: 10.1007/s11940-019-0599-5. [DOI] [PubMed] [Google Scholar]
- 2.Rosa RG, Falavigna M, da Silva DB, Sganzerla D, Santos MMS, Kochhann R, de Moura RM, Eugênio CS, Haack TDSR, Barbosa MG, Robinson CC, Schneider D, de Oliveira DM, Jeffman RW, Cavalcanti AB, Machado FR, Azevedo LCP, Salluh JIF, Pellegrini JAS, Moraes RB, Foernges RB, Torelly AP, Ayres LO, Duarte PAD, Lovato WJ, Sampaio PHS, de Oliveira Júnior LC, Paranhos JLDR, Dantas ADS, de Brito PIPGG, Paulo EAP, Gallindo MAC, Pilau J, Valentim HM, Meira Teles JM, Nobre V, Birriel DC, Corrêa E Castro L, Specht AM, Medeiros GS, Tonietto TF, Mesquita EC, da Silva NB, Korte JE, Hammes LS, Giannini A, Bozza FA, Teixeira C ICU Visits Study Group Investigators and the Brazilian Research in Intensive Care Network (BRICNet) Effect of flexible family visitation on delirium among patients in the intensive care unit: the ICU visits randomized clinical trial. JAMA. 2019;322:216–228. doi: 10.1001/jama.2019.8766. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kotfis K, Szylinska A, Listewnik M, Strzelbicka M, Brykczynski M, Rotter I, Zukowski M. Early delirium after cardiac surgery: an analysis of incidence and risk factors in elderly (≥65 years) and very elderly (≥80 years) patients. Clin Interv Aging. 2018;13:1061–1070. doi: 10.2147/CIA.S166909. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Grover S, Avasthi A. Clinical practice guidelines for management of delirium in elderly. Indian J Psychiatry. 2018;60(Suppl 3):S329–S340. doi: 10.4103/0019-5545.224473. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Luz LFDS, Santos MCD, Ramos TA, Almeida CB, Rover MC, Dal’Pizzol CP, Pohren CLDS, Martins AVDS, Boniatti MM. Delirium and quality of life in critically ill patients: a prospective cohort study. Rev Bras Ter Intensiva. 2020;32:426–432. doi: 10.5935/0103-507X.20200072. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Perez-Ros P, Martinez-Arnau FM, Baixauli-Alacreu S, Caballero-Perez M, Garcia-Gollarte JF, Tarazona-Santabalbina F. Delirium predisposing and triggering factors in nursing home residents: a cohort trial-nested case-control study. J Alzheimers Dis. 2019;70:1113–1122. doi: 10.3233/JAD-190391. [DOI] [PubMed] [Google Scholar]
- 7.Saukkoriipi M, Tuomikoski AM, Sivonen P, Karsamanoja T, Laitinen A, Tahtinen T, Kaariainen M, Kuivila HM, Juntunen J, Tomietto M, Mikkonen K. Clustering clinical learning environment and mentoring perceptions of nursing and midwifery students: a cross-sectional study. J Adv Nurs. 2020;76:2336–2347. doi: 10.1111/jan.14452. [DOI] [PubMed] [Google Scholar]
- 8.Leslie DL, Zhang Y, Bogardus ST, Holford TR, Leo-Summers LS, Inouye SK. Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc. 2005;53:405–409. doi: 10.1111/j.1532-5415.2005.53156.x. [DOI] [PubMed] [Google Scholar]
- 9.Sola-Miravete E, Lopez C, Martinez-Segura E, Adell-Lleixa M, Juve-Udina ME, Lleixa-Fortuno M. Nursing assessment as an effective tool for the identification of delirium risk in older in-patients: a case-control study. J Clin Nurs. 2018;27:345–354. doi: 10.1111/jocn.13921. [DOI] [PubMed] [Google Scholar]
- 10.Andrews PS, Wang S, Perkins AJ, Gao S, Khan S, Lindroth H, Boustani M, Khan B. Relationship between intensive care unit delirium severity and 2-year mortality and health care utilization. Am J Crit Care. 2020;29:311–317. doi: 10.4037/ajcc2020498. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Adamis D, Rooney S, Meagher D, Mulligan O, McCarthy G. A comparison of delirium diagnosis in elderly medical inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 criteria. Int Psychogeriatr. 2015;27:883–889. doi: 10.1017/S1041610214002853. [DOI] [PubMed] [Google Scholar]
- 12.Li Y, Yuan D, Li X, Wang S. Risk factors for delirium in intensive care unit and its duration. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2020;32:62–66. doi: 10.3760/cma.j.cn121430-20190909-00011. [DOI] [PubMed] [Google Scholar]
- 13.Turan N, Ancel G. Examination of the psychological changes in nurses due to workload in an intensive care unit: a mixed method study. Contemp Nurse. 2020;56:171–184. doi: 10.1080/10376178.2020.1782762. [DOI] [PubMed] [Google Scholar]
- 14.Zhang YY, Zhang C, Han XR, Li W, Wang YL. Determinants of compassion satisfaction, compassion fatigue and burn out in nursing: a correlative meta-analysis. Medicine (Baltimore) 2018;97:e11086. doi: 10.1097/MD.0000000000011086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Fan D, Han L, Qu W, Tian S, Li Z, Zhang W, Xu L, Gao H, Zhang N. Comprehensive nursing based on feedforward control and postoperative FMA and SF-36 levels in femoral intertrochanteric fracture. J Musculoskelet Neuronal Interact. 2019;19:516–520. [PMC free article] [PubMed] [Google Scholar]
- 16.Daiello LA, Racine AM, Yun Gou R, Marcantonio ER, Xie Z, Kunze LJ, Vlassakov KV, Inouye SK, Jones RN, Alsop D, Travison T, Arnold S, Cooper Z, Dickerson B, Fong T, Metzger E, Pascual-Leone A, Schmitt EM, Shafi M, Cavallari M, Dai W, Dillon ST, McElhaney J, Guttmann C, Hshieh T, Kuchel G, Libermann T, Ngo L, Press D, Saczynski J, Vasunilashorn S, O’Connor M, Kimchi E, Strauss J, Wong B, Belkin M, Ayres D, Callery M, Pomposelli F, Wright J, Schermerhorn M, Abrantes T, Albuquerque A, Bertrand S, Brown A, Callahan A, D’Aquila M, Dowal S, Fox M, Gallagher J, Anna Gersten R, Hodara A, Helfand B, Inloes J, Kettell J, Kuczmarska A, Nee J, Nemeth E, Ochsner L, Palihnich K, Parisi K, Puelle M, Rastegar S, Vella M, Xu G, Bryan M, Guess J, Enghorn D, Gross A, Gou Y, Habtemariam D, Isaza I, Kosar C, Rockett C, Tommet D, Gruen T, Ross M, Tasker K, Gee J, Kolanowski A, Pisani M, de Rooij S, Rogers S, Studenski S, Stern Y, Whittemore A, Gottlieb G, Orav J, Sperling R SAGES Study Group*. Postoperative delirium and postoperative cognitive dysfunction: overlap and divergence. Anesthesiology. 2019;131:477–491. doi: 10.1097/ALN.0000000000002729. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Cai S, Latour JM, Lin Y, Pan W, Zheng J, Xue Y, Gao J, Lv M, Zhang X, Luo Z, Wang C, Zhang Y. Preoperative cardiac function parameters as valuable predictors for nurses to recognise delirium after cardiac surgery: a prospective cohort study. Eur J Cardiovasc Nurs. 2020;19:310–319. doi: 10.1177/1474515119886155. [DOI] [PubMed] [Google Scholar]
- 18.Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35:1276–1280. doi: 10.1007/s00134-009-1466-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Forsgren LM, Eriksson M. Delirium--awareness, observation and interventions in intensive care units: a national survey of Swedish ICU head nurses. Intensive Crit Care Nurs. 2010;26:296–303. doi: 10.1016/j.iccn.2010.07.003. [DOI] [PubMed] [Google Scholar]
- 20.Pandharipande P, Cotton BA, Shintani A, Thompson J, Pun BT, Morris JA Jr, Dittus R, Ely EW. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65:34–41. doi: 10.1097/TA.0b013e31814b2c4d. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Varghese YE, Kalaiselvan MS, Renuka MK, Arunkumar AS. Comparison of acute physiology and chronic health evaluation II (APACHE II) and acute physiology and chronic health evaluation IV (APACHE IV) severity of illness scoring systems, in a multidisciplinary ICU. J Anaesthesiol Clin Pharmacol. 2017;33:248–253. doi: 10.4103/0970-9185.209741. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Huang HY, Zhang LZ, Zhang QX, Peng L, Xu B, Jiang GF, Zhong J, Fu L, Jiang LY, Song YQ, He HS, Wu XJ, Tan YS. Analysis of mental state of allergic rhinitis patients in Chengdu city by symptom check list 90 (SCL-90) scale. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2019;54:576–583. doi: 10.3760/cma.j.issn.1673-0860.2019.08.004. [DOI] [PubMed] [Google Scholar]
- 23.van den Boogaard M, Pickkers P, van der Hoeven H, Roodbol G, van Achterberg T, Schoonhoven L. Implementation of a delirium assessment tool in the ICU can influence haloperidol use. Crit Care. 2009;13:R131. doi: 10.1186/cc7991. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Boot R. Delirium: a review of the nurses role in the intensive care unit. Intensive Crit Care Nurs. 2012;28:185–189. doi: 10.1016/j.iccn.2011.11.004. [DOI] [PubMed] [Google Scholar]