A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes

Zoran Trogrlić, Mathieu van der Jagt, Jan Bakker, Michele C Balas, E Wesley Ely, Peter H J van der Voort, Erwin Ista, Zoran Trogrlić, Mathieu van der Jagt, Jan Bakker, Michele C Balas, E Wesley Ely, Peter H J van der Voort, Erwin Ista

Abstract

Introduction: Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes.

Method: We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described.

Results: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioral change, was also associated with reduced mortality.

Conclusion: Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.

Figures

Figure 1
Figure 1
Selection of included studies for the review.
Figure 2
Figure 2
Pooled analysis of determinants of changes in ICU length of stay (days) in implementation studies (n = 7) that included delirium-oriented interventions. Determinants of ICU length of stay reduction that were studied were: use of either the guideline for the management of pain, agitation and delirium (PAD) or the awakening and breathing coordination, choice of sedative, delirium monitoring and management and early mobility (ABCDE) bundle (a) or use of high or low number of implementation strategies (b). (c) Impact of high or low number of strategies within the studies reporting ICU length of stay and using PAD/ABCDE (n = 4). See text for more details. Study by Radtke reported multiple populations and these were separately assessed.
Figure 3
Figure 3
Pooled analysis of determinants of changes in mortality (risk ratio) in implementation studies (n = 9) that included delirium-oriented interventions. Determinants of mortality reduction that were studied were: use of either the guideline for the management of pain, agitation and delirium (PAD) or the awakening and breathing coordination, choice of sedative, delirium monitoring and management and early mobility (ABCDE) bundle (a) or use of high or low number of implementation strategies (b). (c) Impact of high or low number of strategies within the studies reporting mortality and using PAD/ABCDE (n = 6). See text for more details.

References

    1. Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis. 1959;9:260–77. doi: 10.1016/0021-9681(59)90165-1.
    1. Hipp DM, Ely EW. Pharmacological and nonpharmacological management of delirium in critically ill patients. Neurotherapeutics. 2012;9:158–75. doi: 10.1007/s13311-011-0102-9.
    1. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306. doi: 10.1097/CCM.0b013e3182783b72.
    1. Vasilevskis EE, Pandharipande PP, Girard TD, Ely EW. A screening, prevention, and restoration model for saving the injured brain in intensive care unit survivors. Crit Care Med. 2010;38:S683–91. doi: 10.1097/CCM.0b013e3181f245d3.
    1. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371:126–34. doi: 10.1016/S0140-6736(08)60105-1.
    1. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–82. doi: 10.1016/S0140-6736(09)60658-9.
    1. van der Jagt M, Trogrlic Z, Ista E. Untangling ICU delirium: is establishing its prevention in high-risk patients the final frontier? Intensive Care Med. 2014;40:1181–2. doi: 10.1007/s00134-014-3383-8.
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6 doi: 10.1371/journal.pmed.1000100.
    1. Slomka J, Hoffman-Hogg L, Mion LC, Bair N, Bobek MB, Arroliga AC. Influence of clinicians’ values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation. Am J Crit Care. 2000;9:412–8.
    1. EPOC:2002. .
    1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225–30. doi: 10.1016/S0140-6736(03)14546-1.
    1. Sinuff T, Muscedere J, Adhikari NK, Stelfox HT, Dodek P, Heyland DK, et al. Knowledge translation interventions for critically ill patients: a systematic review*. Crit Care Med. 2013;41:2627–40. doi: 10.1097/CCM.0b013e3182982b03.
    1. Anderson LA, Sharpe PA. Improving patient and provider communication: a synthesis and review of communication interventions. Patient Educ Couns. 1991;17:99–134. doi: 10.1016/0738-3991(91)90014-V.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88. doi: 10.1016/0197-2456(86)90046-2.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60. doi: 10.1136/bmj.327.7414.557.
    1. Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42:1024–36. doi: 10.1097/CCM.0000000000000129.
    1. van den Boogaard M, Pickkers P, van der Hoeven H, Roodbol G, van Achterberg T, Schoonhoven L. Implementation of a delirium assessment tool in the ICU can influence haloperidol use. Crit Care. 2009;13:R131. doi: 10.1186/cc7991.
    1. Riekerk B, Pen EJ, Hofhuis JG, Rommes JH, Schultz MJ, Spronk PE. Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit. Intensive Crit Care Nurs. 2009;25:242–9. doi: 10.1016/j.iccn.2009.04.001.
    1. Hager DN, Dinglas VD, Subhas S, Rowden AM, Neufeld KJ, Bienvenu OJ, et al. Reducing deep sedation and delirium in acute lung injury patients: a quality improvement project. Crit Care Med. 2013;41:1435–42. doi: 10.1097/CCM.0b013e31827ca949.
    1. Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg. 2010;111:451–63. doi: 10.1213/ANE.0b013e3181d7e1b8.
    1. Bowen CM, Stanton M, Manno M. Using Diffusion of Innovations Theory to implement the confusion assessment method for the intensive care unit. J Nurs Care Qual. 2012;27:139–45. doi: 10.1097/NCQ.0b013e3182461eaf.
    1. Soja SL, Pandharipande PP, Fleming SB, Cotton BA, Miller LR, Weaver SG, et al. Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients. Intensive Care Med. 2008;34:1263–8. doi: 10.1007/s00134-008-1031-x.
    1. Gesin G, Russell BB, Lin AP, Norton HJ, Evans SL, Devlin JW. Impact of a delirium screening tool and multifaceted education on nurses’ knowledge of delirium and ability to evaluate it correctly. Am J Crit Care. 2012;21:e1–11. doi: 10.4037/ajcc2012605.
    1. Mansouri P, Javadpour S, Zand F, Ghodsbin F, Sabetian G, Masjedi M, et al. Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: a randomized clinical trial. J Crit Care. 2013;28:918–22. doi: 10.1016/j.jcrc.2013.06.019.
    1. Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, et al. Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med. 2005;33:1199–205. doi: 10.1097/.
    1. Radtke FM, Heymann A, Franck M, Maechler F, Drews T, Luetz A, et al. How to implement monitoring tools for sedation, pain and delirium in the intensive care unit: an experimental cohort study. Intensive Care Med. 2012;38:1974–81. doi: 10.1007/s00134-012-2658-1.
    1. Eastwood GM, Peck L, Bellomo R, Baldwin I, Reade MC. A questionnaire survey of critical care nurses’ attitudes to delirium assessment before and after introduction of the CAM-ICU. Aust Crit Care. 2012;25:162–9. doi: 10.1016/j.aucc.2012.01.005.
    1. Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013;41:800–9. doi: 10.1097/CCM.0b013e3182746442.
    1. Scott P, McIlveney F, Mallice M. Implementation of a validated delirium assessment tool in critically ill adults. Intensive Crit Care Nurs. 2013;29:96–102. doi: 10.1016/j.iccn.2012.09.001.
    1. Dale CR, Kannas DA, Fan VS, Daniel SL, Deem S, Yanez ND, 3rd, et al. Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation. Ann Am Thorac Soc. 2014;11:367–74. doi: 10.1513/AnnalsATS.201306-210OC.
    1. Kastrup M, Nolting MJ, Ahlborn R, Braun JP, Grubitzsch H, Wernecke KD, et al. An electronic tool for visual feedback to monitor the adherence to quality indicators in intensive care medicine. J Int Med Res. 2011;39:2187–200. doi: 10.1177/147323001103900615.
    1. Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma. 2008;65:517–26. doi: 10.1097/TA.0b013e318181b8f6.
    1. Devlin JW, Fong JJ, Howard EP, Skrobik Y, McCoy N, Yasuda C, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care. 2008;17:555–65.
    1. Page VJ, Navarange S, Gama S, McAuley DF. Routine delirium monitoring in a UK critical care unit. Crit Care. 2009;13:R16. doi: 10.1186/cc7714.
    1. Reade MC, Eastwood GM, Peck L, Bellomo R, Baldwin I. Routine use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) by bedside nurses may underdiagnose delirium. Crit Care Resusc. 2011;13:217–24.
    1. Bryczkowski SB, Lopreiato MC, Yonclas PP, Sacca JJ, Mosenthal AC. Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults. J Surg Res. 2014;190:280–8. doi: 10.1016/j.jss.2014.02.044.
    1. Khalifezadeh A, Safazadeh S, Mehrabi T, Mansour BA. Reviewing the effect of nursing interventions on delirious patients admitted to intensive care unit of neurosurgery ward in Al-Zahra Hospital, Isfahan University of Medical Sciences. Iran J Nurs Midwifery Res. 2011;16:106–12.
    1. van Zanten AR, Brinkman S, Arbous MS, Abu-Hanna A, Levy MM, de Keizer NF, et al. Guideline bundles adherence and mortality in severe sepsis and septic shock. Crit Care Med. 2014;42:1890–8. doi: 10.1097/CCM.0000000000000297.
    1. Klein Klouwenberg PM, Zaal IJ, Spitoni C, Ong DS, van der Kooi AW, Bonten MJ, et al. The attributable mortality of delirium in critically ill patients: prospective cohort study. BMJ. 2014;349:g6652. doi: 10.1136/bmj.g6652.
    1. Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182:752–61. doi: 10.1164/rccm.200912-1918OC.
    1. Eccles M, Grimshaw J, Campbell M, Ramsay C. Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care. 2003;12:47–52. doi: 10.1136/qhc.12.1.47.
    1. Ista E, Trogrlic Z, Bakker J, Osse R, van Achterberg T, van der Jagt M. Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECePTIvE study. Implement Sci. 2014;9:143. doi: 10.1186/s13012-014-0143-7.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅