I've known astute, dedicated caregivers whose overall approach to working with observation patients has likely lessened the need for observation ("Decreasing Patient Agitation Using Individualized Therapeutic Activities," October).

Delirium is a medical emergency, however, and requires intervention as such. As a psychiatry clinical nurse specialist once required to monitor the practice of observation, I have witnessed institutions' reliance on observation as the main intervention, as well as the tendency to ignore that patients are at significant risk for a poor outcome once delirium has developed and the need for observation has been identified.

Distracting activities targeted at delirious (already highly distractible) patients only causes further agitation. I'm pleased that television is not listed as a suggested activity for several reasons, including that nighttime viewing (often by observers) prolongs delirium by disrupting patients' sleep.

Sharon Van Fleet, MS, RN, PMHCNS-BC

Jacksonville, FL