Intensive care unit (ICU) delirium is a complex psychiatric syndrome that mainly occurs with disorders of consciousness, impairment of sensorial perception, and changes of the sleep/awake cycle and circadian rhythms, with a fluctuating trend over time. Delirium is associated with prolonged ICU and hospital stays, increasing costs, and augmented morbidity and mortality rates.1 Delirium can affect many intensive care patients ranging from 30% to 80%.2 The wide range of delirium prevalence and incidence of ICU depends on the criteria for detecting this syndrome. Current evidence-based practices recommend to perform routine delirium monitoring using a valid and reliable diagnostic tool, every 12 hours, for all ICU patients.3 There are some validated screening tools to assess ICU delirium.4 The Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist (ICDSC) are the 2 widely validated and diffused scales in clinical practice4 and are strongly recommended for delirium assessment by the 2013 Pain, Agitation, and Delirium Guidelines.3

To increase and facilitate the assessment and recording of delirium in Italian ICUs, a mobile phone and tablet application (app) was designed and implemented through the online platform "MIT App Inventor" (http://appinventor.mit.edu/explore/). The app, named "Italian ICU Delirium', was carried out using the Italian-language version of ICDSC score,5 and it is currently available for smartphones and tablets with Android Operating System.

We performed a pilot diagnostic test evaluation study during March 2015. A sample of 30 staff nurses working in the general ICU of Perugia University Hospital was randomized into 2 groups to perform the delirium assessment on 3 vignettes. Fifteen nurses had to use the paper format of the Italian-version ICDSC, whereas the other group had to use the Italian ICU delirium app installed on their smartphones. The results of the 2 groups' delirium assessments were compared with the reference standard represented by the doctors' diagnosis of delirium in the 3 vignettes.

The Italian ICU delirium app showed a sensitivity of 95% and a specificity of 73%, whereas the paper format of ICDSC had a sensitivity of 73% and a specificity of 82%. We think that the differences in sensitivity and specificity between the 2 diverse formats could be due to the low sample of nurses and a consequent influence of some confounding factors such as length of ICU service, educational levels, and knowledge about ICDSC.

Moreover, we recorded the time to completion of the ICDSC with the 2 formats of the tool. The mean (SD) time to fill the app was 184.7 (25.83) versus 221.0 (23.97) seconds, with no statistically significant difference (P = .36).

Last, some qualitative aspects of the app were surveyed among the nurses who participated in this study. The app was evaluated "very good," whereas the paper format was considered only "good" in the following features: "simplicity," "graphical appeal," "comfort," and "liking." No differences between the tools were found when "clarity" and "usefulness" were surveyed.

Even if the results of this preliminary report are affected by some limitations such as the small sample size, the low number of clinical case scenarios evaluated, and the lack of interrater reliability, the Italian ICU delirium app seems not to be inferior to the paper format of ICDSC and could exert a higher appeal to the filling among nurses. Because the download of this app is free of charge, it should be a tool to increase the rate of delirium assessment in Italian ICUs.

This kind of study takes the cue to some reflections about the embedding of smartphone apps into clinical practices and the technological infrastructures in the hospital. Payne et al6 reported that more than 70% of medicine students and junior doctors own a smartphone, and the higher part of them use medical apps (from 1 to 5 different typologies). Interestingly, the time spent by the doctors for the use of these apps during the 24 hours varied from 1 to 20 minutes.6 The implementation of apps for smartphone in clinical settings can dramatically improve the assessment of patients, as in the study of Sangha et al,7 reporting an increase of cognitive assessment from 36% to 63%, after the introduction of the "Confusion" app.

The use of smartphone apps in nursing clinical settings is thought as a method to enhance self-learning, prevent medical errors, and allow faster communications.8 Because nursing knowledge is continuously growing, nurses relying only their memory are destined to deliver below-standard care.8 Moreover, nurses can benefit from smartphone apps including medical calculators because the usually use many clinical algorithms such as body mass index, Braden Scale, pediatric drug dosages, and so on.9

However, the use of these apps is not a "panacea" because there are some potential and actual practical problems to deal with, such as device compatibility, Wi-Fi accessibility, reluctance to use personal smartphone at the bedside (for infection or professional impact issues), and difficulties in navigability.10

So, the challenges to always design more ergonomic apps and find adequate strategies for their validation, dissemination, and implementation among nurses are still open and require the contribution of our professional community with innovative ideas and suggestions for improvement.

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