Education Module to Enhance the Accuracy of Delirium Detection in Pediatric Intensive Care Units

Purposes: This dissertation aimed to (1) assess the diagnostic accuracy of existing pediatric delirium screening tools through a systematic review and meta-analysis, (2) translate and validate the Cornell Assessment of Pediatric Delirium (CAPD) for Indonesian pediatric intensive care unit (PICU) settings, and (3) evaluate the effect of an educational intervention to improve delirium recognition among PICU nurses.
Methods: This research consists of three interrelated studies. Study 1 was a systematic review and meta-analysis comparing the diagnostic accuracy of four pediatric delirium screening tools: Pediatric Confusion Assessment Method for the ICU (pCAM-ICU), Preschool Confusion Assessment Method for the ICU (psCAM-ICU), Pediatric Anesthesia Emergence Delirium (PAED) scale, and CAPD. A systematic search of four electronic databases was conducted from inception to March 1, 2023. Eligible studies were full-text observational research evaluating the sensitivity and specificity of four delirium screening tools in PICUs. Study 2 was a prospective methodological study was conducted from January to April 2024 in a 6-bed pediatric intensive care unit, involving 90 patients aged 0–18 years. The sensitivity and specificity of the I-CAPD were assessed using receiver operating characteristic (ROC) curve analysis. Study 3 employed a quasi-experimental design and was conducted between January and February 2024 among nurses in two PICUs in Indonesia. The intervention was the DELIMA (DELirium Introduction and Maintenance) programme, a 4-week, theory-driven, multimodal educational intervention based on the knowledge-to-action framework. Main outcomes—nursing knowledge, self-confidence, and attitudes—were assessed at baseline and the third and fourth weeks postintervention. Delirium screening accuracy was evaluated using the CAPD at the third and fourth weeks postintervention.
Results: Study 1 identified a total of four, five, three, and seven studies were identified for the pCAM-ICU, psCAM-ICU, PAED, and CAPD, respectively. Due to the limited number of PAED studies, pooled diagnostic accuracy could not be estimated. The pooled sensitivity for the pCAM-ICU, psCAM-ICU, and CAPD was 0.73, 0.84, and 0.95, respectively, while pooled specificity was 0.98, 0.90, and 0.81. CAPD demonstrated significantly higher sensitivity than both pCAM-ICU and psCAM-ICU tools (both p = 0.04), but lower specificity compared to the pCAM-ICU (p < 0.001). Study 2 had a mean age of 8 years, with 53% being female. Based on DSM-5 criteria, 55.6% were diagnosed with PICU delirium. The I-CAPD demonstrated excellent internal consistency and reliability, with a Cronbach’s α and intraclass correlation coefficient of 0.94. Factor analysis revealed a single-factor structure explaining 72% of the total variance. I-CAPD has excellent psychometric properties, achieving 92% sensitivity and 93% specificity in detecting delirium in Indonesian PICUs. Study 3 enrolled 44 nurses (mean age: 28 years) participated in the study. Compared to the control group, the intervention group demonstrated substantial improvements in knowledge, self-confidence, attitudes, and delirium screening accuracy by weeks 3 and 4 (all p < 0.05). I-CAPD screening accuracy in the intervention group increased from 50% (week 1) to 86% (week 3) and 100% (week 4), while the control group showed only modest gains from 17% to 33% and 37%, respectively.
Conclusion: This dissertation underscores the importance of standardized delirium assessment in PICUs. The findings support the use of the CAPD as a preferred screening tool, with I-CAPD providing a validated option for Indonesian healthcare settings. Moreover, structured educational interventions like the DELIMA program effectively enhance nurses’ ability to recognize delirium, ensuring better patient outcomes. Integrating validated assessment tools with educational strategies can significantly improve delirium management in critically ill pediatric patients.
Keywords: Delirium, Cornell Assessment of Pediatric Delirium, diagnostic accuracy, pediatric intensive care unit, education