The future of intensive care: delirium should no longer be an issue

Abstract

In the ideal intensive care unit (ICU) of the future, all patients are free from delirium, a syndrome of brain dysfunction frequently observed in critical illness and associated with worse ICU-related outcomes and long-term cognitive impairment. Although screening for delirium requires limited time and effort, this devastating disorder remains underestimated during routine ICU care. The COVID-19 pandemic brought a catastrophic reduction in delirium monitoring, prevention, and patient care due to organizational issues, lack of personnel, increased use of benzodiazepines and restricted family visitation. These limitations led to increases in delirium incidence, a situation that should never be repeated. Good sedation practices should be complemented by novel ICU design and connectivity, which will facilitate non-pharmacological sedation, anxiolysis and comfort that can be supplemented by balanced pharmacological interventions when necessary. Improvements in the ICU sound, light control, floor planning, and room arrangement can facilitate a healing environment that minimizes stressors and aids delirium prevention and management. The fundamental prerequisite to realize the delirium-free ICU, is an awake non-sedated, pain-free comfortable patient whose management follows the A to F (A-F) bundle. Moreover, the bundle should be expanded with three additional letters, incorporating humanitarian care: gaining (G) insight into patient needs, delivering holistic care with a 'home-like' (H) environment, and redefining ICU architectural design (I). Above all, the delirium-free world relies upon people, with personal challenges for critical care teams to optimize design, environmental factors, management, time spent with the patient and family and to humanize ICU care.

Keywords: Architecture; ICU design; Intensive care unit; Neuroesthetics; Outcome; PICS; PICS-F.

Fig. 1

a Future of delirium-free ICU-design – hotel space vs medical space. b Future of delirium-free ICU-design—the importance of healing environment

Fig. 1

a Future of delirium-free ICU-design – hotel space vs medical space. b Future of delirium-free ICU-design—the importance of healing environment

Fig. 2

The ABCDEFGHI bundle—A–I bundle. A—Assessment and management of pain: subjective (NRS, VAS) behavioral tools (CPOT, BPS) should be complemented by novel pain assessment technology (ANI, NOL, PPI), multimodal approach to pain, pain-free noninvasive monitoring, pain-free blood drawing for labs. B—Both SATs and SBTs: daily, regular spontaneous awakening trials and spontaneous breathing trials to limit analgesia and sedation needs. C—Choice of analgesia and sedation: good sedation practices complemented by a rethink of design and connectivity of ICU to facilitate optimal sedation, anxiolysis and comfort using non-pharmacological means supplemented by balanced pharmacological interventions when necessary. D—Delirium detection and management: traditional validated tools (CAM-ICU or ICDSC) complemented by novel tools (wireless EEG, NIRS, noninvasive brain electrolyte monitoring, video-assisted delirium signs recognition, electrodermal activity measured by wristband devices). E—Early mobility and exercise: tailor made stepwise physical and cognitive activity programs using specially adapted equipment (virtual reality) and easy access to the outside world. F—Family engagement and empowerment: allowing visits 24/7 (including children and pets), family can sleep in the same room, large picture frames for family photographs, video panel to allow easy reach of key family members. G—Gaining insight: acknowledging patients’ personal needs, preferences, and habits (music therapy, colors, scents) for holistic and personalized care. H—Holistic and personalized care with ‘Home-like’ aspects: providing familiar, safe environment within a customized ICU including provision of circadian rhythm and adequate sleep hygiene. I—ICU design redefinition: environment where patient’s feel safe, comfortable, with recognizable things, not overwhelming (separate hi-tech environment and noisy alarm systems from patient accommodation; remote, minimally invasive monitoring, natural light, access to nature, VR aids). Abbreviations: NRS, numeric rating scale; VAS, visual analogue scale; CPOT, critical care pain observation tool; BPS, behavioral pain scale; ANI, analgesia nociception index; NOL, nociception level index; PPI, pupillary pain index; ICU, intensive care unit; EEG, electroencephalography; VR, virtual reality; NIRS, Near Infrared Spectroscopy, CAM-ICU, Cognitive Assessment Method for Intensive Care Unit; ICDSC, Intensive Care Delirium Screening Checklist