CNA672 Evaluation of Clinical Practice Assessment Answer

Task 3) Conduct a search for up to 3 examples of high-level evidence to answer your question. Succinctly describe your search process and provide justification for the resources that you chose to search for and the evidence selected. Include the abstract/s or summary/summaries of the high-level evidence in your final assignment

While answering the clinical questions, the practitioners or clinicians must practice on the bases of highly available literature. Evidence-based practice (EBP) assists in enhancement of the clinical outcomes. EBP promotes clinicians to make decisions based on evidence with the aim of providing efficient and effective care (Li et al., 2019, p.1). By reviewing the available evidence, clinicians can identify the most reliable and relevant studies, assess their quality, and determine the applicability of the findings to their patients' situations. EBP helps clinicians recognize the limits of their expertise and acknowledges the importance of incorporating patient values and preferences into the decision-making process. By considering these three elements together, clinicians can make more informed and patient-centered decisions. The search strategy is an ideal way of retrieving accurate information. This is demarcated as an organized structure of key terms that are employed to retrieve adequate information from the database (Heath et al., 2022, p. 8). Boolean operators (AND, OR, NOT) are used to combine or exclude keywords and phrases when constructing search queries. They help narrow or broaden the search and specify the relationships between different concepts. To carry out the research, databases such as Google Scholar, PubMed, and Cochrane Library were employed to retrieve high-quality evidence. Boolean operators i.e., AND, OR was employed to search for the data. MeSH terms were employed to search for appropriate articles on PubMed (National Institute of Health, 2023). MeSH terms such as “delirium, dementia, and cognitive disorder” were typed into the search box with the field restrictor set at 'Title, Abstract, Key words'.

The research conducted by Burry et al., (2019), p. 2 aimed at assessing the efficiency of the pharmacological interventions for management of delirium in critically ill patients. To comprehend the efficiency of pharmacological interventions randomized controlled trial (RCTs) of any drug was analysed and compared with that of the non-pharmacological one. Databases such as Cochrane Library, MEDLINE, etc. were searched to retrieve the evidence. After the literature search, it was analyzed that alpha ₂ agonist dexmedetomidine was the most ideal choice of pharmacological drug that was used to control the symptoms of delirium amongst critically ill patients. The next best choice was atypical antipsychotics. It was also analyzed that alpha ₂ agonist dexmedetomidine was associated with shortened ICU stay and reduction in delirium duration.

In a similar study carried out by Boncyk et al., (2021), p. 713 the major objective was to analyze the influence of the medication choice for the treatment of delirium in ICU patients and what this has an influence on in-hospital outcomes. A retrospective approach was adopted for the scope of the study. Data concerning the mental status, pharmacological alternatives and etc. was obtained. For the purpose of statistical analysis linear regression models were used. Out of the 8591 encounters with patients suffering from delirium, half of the patients received pharmacological interventions with the major drug being antipsychotics. Haloperidol and olanzapine were the most widely used antipsychotics and were associated with declined lower hospital stays and enhanced condition, with a decline in the number of ICU days. But in some cases, it may worsen the condition, so care should be taken while assessing the efficacy of such medications.

In the systemic review presented by Lange et al., (2022), p. 760, the major objective was to evaluate the non-pharmacological nursing intervention to mitigate the incidences of delirium among patients in ICU. The systemic review methodology was adopted for this purpose and evidence was collected using databases such as PubMed, Scopus, Cochrane Library and etc. After analyzing the literature it was evident that multicomponent interventions were effective in dealing the cases of delirium. Along with multicomponent non-pharmacological interventions, family participation was also crucial in causing a decline in the incident rates of delirium or causing a reduction in the clinical presentation among the patients in ICU. It can be visualized from this systemic review that non-pharmacological intervention can assist in causing a reduction in the duration of delirium in ICU patients.

Task 4) Discuss the barriers that may exist in your specific clinical setting if there was a need to change practice based on the high-level recommendations and how these barriers may be overcome and/or strategies that exist to promote EBP within your practice setting.

Several barriers hamper the attainment of adequate delirium management by employing non-pharmacological interventions. First is the lack of awareness and knowledge. Healthcare professionals may not be familiar with or have limited expertise in non-pharmacological approaches for managing delirium. This may result in the underutilization of these interventions due to a lack of knowledge about their advantages and effective application (Arachchi & Pinto, 2021, p. 1415). Secondly, non-pharmacological treatments frequently need extra resources, including trained personnel, specialized tools, or set apart time. The implementation and sustainability of these interventions in clinical settings may be hampered by the limited availability or allocation of these resources. Lastly, multidisciplinary collaboration and open communication among members of the healthcare team is frequently necessary for the efficient implementation of non-pharmacological therapies for delirium management (Penuela et al., 2019,p. 432). The coordinated administration of these interventions may be hindered by poor communication or teamwork, which would reduce their effectiveness in improving patient outcomes. It is crucial to offer thorough education and training programs for healthcare professionals on non-pharmacological approaches for managing delirium. This entails spreading knowledge about the interventions, their advantages, and appropriate implementation methods. For implementation to be successful, multidisciplinary coordination between healthcare providers is essential. This entails fostering collaboration among medical staff members, nurses, occupational therapists, and other pertinent specialists (Reznik & Slooter, 2019,p. 60).

Task 5) Compare and contrast the answer to your question in the high-level evidence to the current practice in this area. Your discussion should highlight the level of evidence or strength of the recommendations and any differences that exist between the evidence-based recommendations and your existing practices.

The critical appraisal of the following chosen systemic review can assist in comparing and bringing out the contrast with the current practice in ICU.

Herling, S. F., Greve, I. E., Vasilevskis, E. E., Egerod, I., Mortensen, C. B., Møller, A. M., .& Thomsen, T. (2018). Interventions for preventing intensive care unit delirium in adults. Cochrane Database of Systematic Reviews , (11). 10.1002/14651858.CD009783.pub2

The literature review ideally addressed the PICO question. The information regarding the population, intervention, comparison, and outcomes was highlighted in the article. The use of antipsychotic drugs to prevent delirium in ICU patients is evaluated critically in the review. It studies the efficiency of various antipsychotics and evaluates how they affect the occurrence, intensity, and duration of delirium. The review takes into account the evidence that is currently available about the advantages and potential drawbacks of antipsychotic usage in the ICU setting. The evaluation evaluates how well physical treatments work in keeping adult ICU patients from becoming delirious. Early mobilization, physical therapy, and rehabilitation programs are a few examples of these therapies. A physical intervention's effect on delirium's occurrence, duration, and patient outcomes including functional status, mortality, and length of ICU stay are examined in the critical evaluation. In the ICU, the review assesses the contribution of environmental interventions to delirium prevention. Environmental remedies prioritize improving the immediate surroundings, reducing noise, promoting sleep, and preserving a regular day-night cycle. The effectiveness of these therapies in lowering the frequency of delirium and enhancing patient outcomes is examined in the critical appraisal. RCTs and quasi-randomized trials, which are regarded as reliable study designs for evaluating therapies, are included in the review. The review enhances replication of the review by providing explicit and transparent documentation of the search strategy, research selection procedure, and data extraction methodologies. More RCTs need to be carried out as it was evident that these above-mentioned interventions are imperative in managing the incidences of delirium in ICU patients.

Though pharmacological interventions are given weightage in the ICU setup, there is scarcity in the area of non-pharmacological interventions including both physical and environmental interventions. The nursing staff lacks knowledge and expertise regarding these interventions and hence there exists paucity in the practice. To compare and contrast the medical expertise supported by substantial evidence with the ignorance of nursing staff would be impossible and meaningless.

References

Arachchi, T. M. J., & Pinto, V. (2021). Understanding the barriers in delirium care in an intensive care unit: a survey of knowledge, attitudes, and current practices among medical professionals working in intensive care units in teaching hospitals of Central Province, Sri Lanka. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine , 25 (12), 1413. 10.5005/jp-journals-10071-24040

Boncyk, C. S., Farrin, E., Stollings, J. L., Rumbaugh, K., Wilson, J. E., Marshall, M., .& Hughes, C. G. (2021). Pharmacologic management of intensive care unit delirium: clinical prescribing practices and outcomes in more than 8500 patient encounters. Anesthesia & Analgesia , 133 (3), 713-722. 10.1213/ANE.0000000000005365

Burry, L., Hutton, B., Williamson, D. R., Mehta, S., Adhikari, N. K., Cheng, W., ...& Rose, L. (2019). Pharmacological interventions for the treatment of delirium in critically ill adults. Cochrane Database of Systematic Reviews , (9). 10.1002/14651858.CD011749.pub2

Grover, S., & Avasthi, A. (2018).Clinical practice guidelines for management of delirium in elderly. Indian Journal of Psychiatry , 60 (Suppl 3), S329. 10.4103/0019-5545.224473

Heath, A., Levay, P., & Tuvey, D. (2022). Literature searching methods or guidance and their application to public health topics: A narrative review. Health Information & Libraries Journal , 39 (1), 6-21. 10.1111/hir.12414

Lange, S., MÄ™drzycka-DÄ…browska, W., Friganovic, A., Oomen, B., & Krupa, S. (2022). Non-Pharmacological Nursing Interventions to Prevent Delirium in ICU Patients—An Umbrella Review with Implications for Evidence-Based Practice. Journal of Personalized Medicine , 12 (5), 760. 10.3390/jpm12050760

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