NU 760 Unit 4 evidence review example

Evidence Review: Nurse-Delivered Multicomponent Delirium Prevention for Adults 65 and Older on a 32-Bed Medical Unit

[Author Name]

College of Nursing, Herzing University

NU 760 Scholarship for Nursing Practice

Unit 4 Assignment

[Instructor Name]

August 11, 2026

Original model document written by our desk. The unit and its numbers are a composite; no real hospital, patient or clinician is described.

Practice Question and Search Strategy

The setting is a 32-bed adult medical unit in a 240-bed community hospital where adults 65 and older filled 1,986 of the 3,410 admissions recorded in the last four quarters, or 58 percent of the unit's volume. Nursing documentation over those four quarters showed a positive Confusion Assessment Method screen at some point during admission in 214 of those 1,986 older admissions, an incidence of 10.8 per 100 older adults admitted. The practice question follows the PICOT form. In hospitalized adults 65 and older admitted to a medical unit (P), how does a nurse-delivered multicomponent nonpharmacologic prevention bundle (I) compared with usual care (C) affect the incidence of delirium during admission (O) over a 12-month period (T)?

Three databases were searched in June 2026: MEDLINE through PubMed, CINAHL Complete and the Cochrane Library. The PubMed string paired the MeSH heading Delirium/prevention and control with the keywords hospitalized OR inpatient AND (multicomponent OR nonpharmacologic OR nonpharmacological) AND (older adult* OR elderly OR geriatric). CINAHL used the same terms as subject headings with the truncation deliri*. Limits were English language, peer reviewed, human subjects, adults 65 and older, and publication years 2015 through 2026. The searches returned 1,284 records. Removing duplicates left 947. Title and abstract screening against the question removed 889, leaving 58 records read in full. Six met the inclusion criteria; four are appraised here and two are cited as supporting background.

Inclusion required an adult inpatient population outside intensive care, a prevention intervention delivered wholly or mainly by nursing staff, and a reported incidence of delirium measured with a validated instrument. Studies of pharmacologic prophylaxis alone, of postoperative intensive care cohorts and of long-term care residents were excluded, because their staffing and case mix do not match a medical unit. One deliberate exception was made to the date limit. The 1999 trial by Inouye and colleagues sits outside the ten-year window but is the source study for the intervention every later review evaluates, so excluding it would have hidden the origin of the effect estimate. Naming that exception is part of the search record rather than a footnote to it.

Appraisal of the Retained Evidence

The strongest single source is the Cochrane review by Siddiqi and colleagues (2016) of interventions to prevent delirium in hospitalized patients outside intensive care. It sits at Level I in the Melnyk and Fineout-Overholt hierarchy because it pools randomized and quasi-randomized trials under a registered protocol with duplicate screening and risk of bias assessment. The review found that multicomponent nonpharmacologic programs lowered the incidence of delirium against usual care, with the authors grading the certainty of that finding as moderate. The limits are stated in the review itself and belong in this appraisal: the pooled trials differ in which components were delivered and in how faithfully they were delivered, and blinding of ward staff was rarely possible, so performance bias cannot be ruled out.

The meta-analysis by Hshieh and colleagues (2015) is also Level I and reports the effect estimate most often quoted in practice: across the pooled studies of multicomponent nonpharmacologic programs, the odds of incident delirium were roughly halved, near an odds ratio of 0.47, and falls were reduced as a secondary outcome. Its weakness is the mix of designs it pools, including before and after studies, which inflates confidence if the reader treats every included study as a trial. The Inouye and colleagues (1999) controlled trial that generated the model is Level II. Its intervention is described component by component, which makes it the most usable source for a unit that has to build a protocol, and its 852-patient sample gives the estimate weight.

The National Institute for Health and Care Excellence guideline on delirium (2023) is a different kind of source and is treated as such. A guideline is a synthesis with a recommendation attached, so its value here is the list of risk factors and the daily interventions it names, not an effect size. Read together, the four sources agree on direction and disagree on magnitude, and the disagreement is explained by design rather than by population. The two Level I sources rest on overlapping trials, so their agreement is not four independent confirmations of the same result. That distinction is what keeps the recommendation in the next section proportionate to the evidence behind it.

Synthesis and Translation Judgment

The evidence supports one change on this unit and does not support two others. It supports a nurse-delivered bundle of six daily elements for every admitted patient 65 and older: orientation at each handoff, a sleep protocol that moves routine vital signs and medication times out of the 10 p.m. to 6 a.m. window where clinically safe, early mobility within 24 hours of admission unless contraindicated, hearing aids and glasses placed within reach at every shift, a fluid record with a target reviewed each morning, and a twice-daily Confusion Assessment Method screen. It does not support adding prophylactic antipsychotics, which the review found no consistent benefit for, and it does not support a one-time education campaign with no daily documentation, because the trials measured delivered care rather than attended training.

Feasibility was judged against what this unit already has. Five of the six elements use staff and equipment on hand; the sixth, the sleep protocol, requires pharmacy and provider agreement to move scheduled medication times, which is the one part of the plan that cannot be started by nursing alone. The cost line is modest: 24 large-print orientation boards at about 18 dollars each, 60 sets of disposable earplugs and eye masks per month at about 90 dollars monthly, and four hours of paid education per nurse across a staff of 46. The outcome measure is the same one used to describe the problem, which keeps the before and after comparable: incidence of a positive Confusion Assessment Method screen per 100 admitted patients 65 and older, reported by quarter.

Two limits belong in the recommendation rather than beneath it. The pooled trials were run on units with a dedicated volunteer or nurse coordinator, and this unit has neither, so the delivered dose of the bundle here will be lower than the dose that produced an odds ratio near 0.47; a halving of incidence is not the number to promise a nursing council. A realistic target for the first year is a reduction from 10.8 to 8.0 positive screens per 100 older admissions, with fidelity reported alongside outcome so a null result can be read correctly. If the bundle is documented on fewer than 80 percent of eligible patient days, the next question is delivery, not effectiveness.

References

Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html

Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: A meta-analysis. JAMA Internal Medicine, 175(4), 512-520.

Inouye, S. K., Bogardus, S. T., Jr., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney, L. M., Jr. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340(9), 669-676.

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing and healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

National Institute for Health and Care Excellence. (2023). Delirium: Prevention, diagnosis and management in hospital and long-term care (Clinical guideline CG103). https://www.nice.org.uk/guidance/cg103

Siddiqi, N., Harrison, J. K., Clegg, A., Teale, E. A., Young, J., Taylor, J., & Simpkins, S. A. (2016). Interventions for preventing delirium in hospitalized non-ICU patients. Cochrane Database of Systematic Reviews, 2016(3), Article CD005563.