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

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.

Figure 1

Selection of included studies for the review.

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

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.