Patient Care

Simulation Training, Coaching, and Cue Cards Improve Delirium Care

A quality improvement study supports the use of multimodal education to enhance clinical practice for care of patients with delirium.

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Many clinicians continue to think that delirium or acute confusion is inevitable, untreatable, and harmless. However, nothing could be further from the truth.1 Delirium is a common and costly clinical syndrome that plagues a large percentage of older adults in a variety of settings. Numerous clinical studies conducted over the past 20 years have validated a high incidence of delirium in acute care hospitals.2-5 Reported rates of delirium among veteran and nonveteran populations vary widely, from 20% to 80%, but even these rates may reflect underrecognition and underreporting.6

Veterans with delirium pose a unique challenge to clinicians and health care systems because they often concurrently experience dementia, depression, posttraumatic stress disorder, and delirium. This complex syndrome caused by a myriad of environmental, physiologic, and psychological factors has been associated with profoundly poor clinical outcomes, including increased institutionalization, hospital length of stay, medication use, restraint use, falls, and mortality.3,7,8

Financial costs associated with delirium have been estimated at between $38 billion and $152 billion per year.9 In addition, this syndrome is costly in human resource expenditures, including increased burden on family members and the need for additional care providers, such as “sitters.” Families and clinicians report increased burden and stress in their interactions with these patients.10-12 Mounting evidence exists that some people with delirium never return to baseline cognitive function after even a single episode of delirium.1,8 Unfortunately, many clinicians do not recognize the seriousness of acute confusion.

Clinical practices related to routine screening for delirium vary widely. Although the Confusion Assessment Method (CAM) screening tool has high sensitivity and specificity, only 17% of hospitals consistently use this tool in clinical practice.2,6,13,14 According to a survey by Ely and colleagues, physicians reported being aware of delirium but inconsistently applying treatment protocols in clinical practice.2 Nurses noted similar difficulties in consistently screening patients and using delirium management protocols.15 Given the high incidence of delirium and its associated morbidity, including long-term cognitive impairment and human and financial costs, there is an urgent need to implement programs that enhance delirium prevention, timely recognition, and effective management to improve patient outcomes and address caregiver burden.

Over the past decade, educational strategies for improving delirium prevention, recognition, and management have included didactic education, consultation, and use of protocols.2,3,5,16 Bedside mentoring, implementation of protocols, and other interventions have been proposed as well.16,17 Several program models, including consultation by psychiatrists or psychiatric advanced practice nurses, have been implemented to increase detection and treatment of delirium.2,3,5,15 These pilot programs have been successful to varying degrees but in general have not shown independent effects beyond intervention or significantly increased recognition and management of adverse consequences for most patients. The cause of these outcomes seem to be multifactorial, but the complexity of the syndrome is part of the problem.18-20

Other possible barriers to change regarding delirium-related issues in clinical practice are lack of knowledge and skills and individual attitudes.20-22 Continuing evidence exists that clinicians feel ill-prepared to help delirious patients and frustrated enough to resort to using restraints and medication as first-line treatment.17 Yanamadala and colleagues reviewed 26 studies that identified strategies for delirium education.23 Most of the studies reported on didactic teaching methods that included information on resources. Only 1 study with nursing students reported using actors for simulation training. The programs most successful in improving knowledge, skills, attitudes, practice changes, and patient outcomes seemed to be those that used multiple educational methods, including information dissemination, use of guidelines and protocols, and peer and expert feedback.

This finding is consistent with the report that didactic learning alone, though improving competency, is less likely to change behavior or improve outcomes.24 A constellation of didactic education, mentoring, use of protocols to target high-risk patients, and a therapeutic environment has helped to reduce delirium incidence.4,25,26 Rudolph and colleagues found an association between multimodal education (risk assessment, sensory improvement, sleep promotion) and shorter hospital stays and less use of restraints.27 In clinical practice,however, implementation of evidence-based nonpharmacologic interventions, such as enhanced communication, mobility, nutrition, and meaningful activities, continues to lag despite education.28,29

Multimodal Education

To address these gaps in knowledge and skills, a multidisciplinary delirium resource team at the Louis Stokes Cleveland VAMC in Ohio developed a multimodal educational program incorporating simulation. The team of physicians, nurses, care coordinators, and social workers met regularly and developed interventions, educational materials, cue cards (eFigure 1), sense-enhancing aids (hearing amplifiers, puzzles, books, music CDs, prism glasses), clinical protocols, and delirium resources, such as CARES (Confusion Assessment Resource Enhancement Supplies) activity carts.

The CARES carts are small, rolling wooden carts stocked with various resources that focus on comfort and entertainment. The carts hold guided imagery CDs and Playaways (small audio players that come with ear buds for individual use and preloaded with a specific guided imagery session). The carts also hold books, books on tape, magazines, portable CD players, music CDs, games, exercise bands, healthful snacks, DVDs, and a portable DVD player.

Bedside mentoring continued throughout this quality improvement (QI) project, and a CARES teaching tool kit was developed. This kit, which continues to be used, includes videos and webinars for professionals and family caregivers; delirium pocket cue cards for physicians, nurses, aides, and sitters; a list of patient diversion supplies; and a family brochure. Delirium resource team members continue to provide the health care team with education and support. Given the emphasis on clinicians and patient outcomes in intensive care units (ICUs), the teaching tool kit is a valuable guide for assessing and treating patients with delirium during rounds and consultations.


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