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Introduction: Critically ill patients should routinely be evaluated for the presence and intensity of pain, assessed as to their sedation level, and screened for delirium. However, assessing both pain and delirium in intensive care unit (ICU) patients is particularly challenging, given the confounding effect of sedation. The purpose of this study was to describe the validity and reliability of real-time practice-based nursing concurrent assessments of pain, sedation and delirium, in an ICU where these three assessments occur as part of routine nursing care. Methods: Thirty randomly selected nurses were observed by one of two trained adjudicators for documentation and clinical bedside evaluation of pain, sedation level and delirium scoring. The scales were the numeric rating scale,1 the Richmond agitation and sedation scale2 and the intensive care delirium screening checklist3 score for the evaluation of delirium. Each feature was assessed as to documentation in the bedside nursing sheets; accurate use of a scale; and validity of use of the scale with a joint bedside examination of the patient. Results: The reliability between adjudicators for the bedside evaluation of pain and sedation was 100%. The Cronbach’s α score for the evaluation of delirium was 86.3% overall. Except for the agitation/slowing criteria (70.8%), reliability between adjudicators was over 80% for the other seven criteria of the delirium score. A majority of nurses (27/30) documented pain assessments and 20/30 followed recommended standards. Nurses relied on their own evaluation of the patient’s pain 25% of the time, without an objective patient-driven scale. Bedside pain evaluation comparing nurses to adjudicators showed perfect correlation. Sedation was often documented (28/30) correctly (27/30); at bedside assessment of sedation, the correlation (r2) with adjudicators was 0.85 (P < 0.0005, Cronbach’s α of 0.960). A majority of nurses documented delirium scales (28/30); 18 of the 27 available scores showed proper scale use. Bedside assessments showed a r2 of 0.854 (P < 0.0005, Cronbach’s α of 0.957). The daytime shift (mean ICU nursing experience: 11.5 years) had the best overall performance; the night shift was next (mean ICU nursing experience: 2.7 years) and the evening shift (mean ICU nursing experience: 6.3 years) the worst. The highest variability in nursing assessment performance occurred in delirium assessments of psychomotor agitation or slowing. Conclusions: In a single centre ICU with mandated routine assessments, the evaluation of pain, sedation and delirium occurs over 90% of the time. Assessment quality varies based on type of assessment (with sedation being evaluated best, delirium next best, and pain least well). Daytime, night time, and evening nurses’ performance vary significantly, particularly with regard to delirium assessment. |
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