Table 5. Summary of Studies Evaluating the Implementation of Multifaceted Care Processes Targeting Delirium in ICU Patients.
| Authors (year) | Study Type | N | Intervention & Implementation Strategies | Outcomes |
|---|---|---|---|---|
| Balas et al. (2013)8 | CCT | 328 RNs, NPs, RTs, PharmDs, PTs |
Intervention: ABCDE Bundle consisting of daily performance of: -spontaneous awakening trials (SATs) -spontaneous breathing trials (SBTs) -coordination of SATs and SBTs -routine delirium and sedation/agitation screening and management -early progressive mobilization Implementation strategies: -Interdisciplinary ABCDE implementation leaders including unit and staff champions -Educational resources including posters/flyers, resource manuals, in-services, CAM-ICU and RASS pocket cards -Online computer-based ABCDE training module with videos focused on
-Leading ICU delirium expert presentation at grand rounds -Nurse-led 8 hour ABCDE bundle education day -In-services over a 9-month period on how to perform CAM-ICU followed by direct observation until competence achieved -Institutional ABCDE bundle policy -Electronic ABCDE documentation forms embedded in HER -ABCDE performance and outcome data presented to leaders and staff -3 focus group sessions of ICU team members (2 during development of ABCDE policy, 1 six months after policy became standard of care -Online ABCDE bundle knowledge and impediments survey administered before ABCDE became standard of care and 4 and 9 months following implementation -Comprehensive outcomes-based evaluation of online training program |
% of patients that received a continuously infused sedative or opioid medication anytime during ICU stay I: 77.4% C: 70.2%; p=0.26 % of patients that had a continuously infused sedative or opioid medication held at least once for a SAT I: 63.6% C: 50.7%; p =0.04 SATs performed on eligible days (median % (IQR)) I: 50.0% (33.3-50.0%) C: 33.3% (24.4-52.8%); p =0.18 Underwent a SBT anytime during ICU stay I: 84.0% C: 70.7%; p=0.03 Percentage of time RASS score documented every 8 hr by bedside nurse I: 68% C: 66.3%; p=0.84 % of patients that received physical therapy consults anytime during ICU stay I: 75.3% C: 71.9%; p=0.50 % of patients mobilized out of bed at least once during ICU stay I: 66.0% C: 48.0%; p=0.002 |
| Carrothers et al. (2013)19 |
Intervention: ABCDE Bundle consisting of daily performance of: -spontaneous awakening trials (SATs) -spontaneous breathing trials (SBTs) -coordination of SATs and SBTs -choice of sedation-delirium screening and treatment -early progressive mobility Implementation strategies: -Multidisciplinary team -Physician champions -Completion of pre-implementation and post implementation gap analysis -Educational sessions, on-the-job training, train-the-trainer model, super champions, coaching -Onsite support from an improvement advisor with ABCDE content expertise -Collection of quarterly outcome and monthly process data |
% of patients receiving SATs I: 81% C: 25% % of patients receiving SBTs I: 67% C: 30% % of patients assessed for delirium I: 0% C: 65% % of patients receiving progressive mobility I: 0% C: 82% |
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| Hager et al. (2013)19 | CCT | 202 patients |
Intervention: -Sedation protocol utilizing RASS-Delirium assessment with CAM-ICU (2× daily) Implementation Strategies: -Structured QI process: “4Es” framework (engage, educate, execute, evaluate) -Multidisciplinary QI team (ICU nurse educator, pharmacist, physicians, non-ICU delirium experts) -Education on sedation protocol, tools, & delirium prevention provided to nursing staff, house staff, and attending physicians) -Nurses trained by protocol “super-user” -Nurses not passing quality assurance evaluations were retrained one-on-one until proficient -House staff trained by 2 physicians from QI team and given card with protocol and delirium prevention strategies -ICU attending physicians educated during ground rounds and faculty meetings -RASS and CAM-ICU embedded in EHR -Monthly QI team meetings to identify and resolve barriers -Formal auditing & feedback including surveys of nursing staff -Pharmacists reminded clinicians about protocols daily during rounds |
Completion of delirium screening (CAM-ICU) I: 90% C: 90% Completion of sedation evaluation (RASS) I: 94% C: 90% |
| Kastrup et al. (2011)26 | CCT | 205 patients |
Intervention:Technical feedback system to monitor and report the compliance with key performance indicators for sedation, delirium, and pain monitoring and completion of ventilator weaning program. KPIs: Sedation evaluation (3 × day) (RASS) Analgesia evaluation (3 × day) (NRS or BPS) Delirium assessment (3 × day) (CAM-ICU) SBT (1 × day); Implementation Strategies: -KPIs integrated into SOPs accessible on intranet and at bedside -EHR used to capture medical and care information, lab data, and input from ventilation and monitoring systems -Technical feedback system produced a 24-hr summary report of KPI data divided into three 8-hour nursing shifts -Color-coded report to indicate if KPIs were met accessible via the EHR -Summary of all KPIs reported to physicians and nurses monthly -ICU team instructed on evaluation of sedation and analgesia scores, completion of weaning protocol, accessing the KPI summary, and interpreting results. |
Completion of delirium screening (CAM-ICU) I: 38.4% ± 25.8% C: 0.5% ± 2.1%; p<0.01 Completion of sedation evaluation (RASS) I: 65.7% ± 16.9% C: 64.7% ± 15.6%; NS Completion of analgesia evaluation (NRS/BPS) I: 65.6% ± 16.0% C: 61.6% ± 18.5%; p<0.01 Completion of weaning protocol I: 41.9% (mean) ± 38.7% (SD) C: 0.27% ±1.74%; p<0.01 |
| Needham et al. (2010)20 | CCT | 57 patients |
Intervention: -Standardized ICU orders w/default activity level = “as tolerated” -Sedation practice changed from continuous infusion to “as needed” bolus doses -Guidelines for PT, OT, & physical medicine and rehabilitation consultation -PT, OT & rehabilitation assistant on staff -Consultations to neurologists for patients with severe/prolonged muscle weakness Implementation Strategy: Structured QI model including: -understanding the problem -multidisciplinary improvement team -all stakeholders identify barriers to change and solutions -using “4Es” framework (engage, educate, execute, evaluate) -Weekly planning meeting with multidisciplinary QI team (ICU, Rehab) -Dissemination of project information through posters, newsletters, conferences, presentations, and patient testimonials. -2 day site visit by field expert -Interdisciplinary training of nurses, PTs, OTs, and respiratory therapists -16 educational sessions for ICU nurses -Ongoing evaluation of project through weekly QI team meetings |
Number of PT and OT Is I: 810 treatments C: 210 treatments; p<0.001 |
| Pun et al. (2005)28 | CCT | 711 patients 64 nurses |
Intervention: Sedation scale (RASS) and delirium assessment (CAM-ICU) added to nursing documentation Implementation strategies: Systematic implementation strategy including: -baseline assessment -20 min introductory in-service for all ICU nurses followed by graded, staged educational interventions at regular intervals -Compliance data collected daily with spot checks on random 40% of nurses -Implementation of survey questionnaire |
Compliance with delirium monitoring (CAM-ICU) ICU 1: 94.7% ICU 2: 99.7% Compliance with sedation monitoring (RASS) ICU 1: 90.0% ICU 2: 84.0% Barriers to Implementation (n=71 total barriers reported by 55 nurses in a survey) -Time (31%) -Attendings, fellows, or residents (27%) -Confidence in performing delirium assessments (20%) |
| Radtke (2012)27 | CCT | 1,063 patients |
Intervention: -Sedation monitoring with RASS -Pain monitoring (NRS or BPS) -Delirium monitoring with delirium detection score (DDS) -Scores documented in data management system -ICU staff trained via Modified Extended Training (2 ICUs) or Local Standard Training (1 ICU) Implementation Strategy:Local Standard Training or Modified Extended Training Local Standard Training:Lectures instructional video handouts bedside teaching Modified Extended Training: -Local support team (2 nurses/1 physician) with monitoring expertise -3 consecutive training cycles of Local Standard Training with enhanced lectures |
Frequency of delirium monitoring per patient per day (DDS) ICU 1: Modified Training I: median 1.6 (IQR 0.8,2.0) C: median 0.0 (IQR 0.0,0.1); p<0.01 ICU 2: Modified Training I: median 1.3 (IQR 0.9,1.7); C: median 0.0 (IQR 0.0,0.0); p<0.01 ICU 3: Local standard training I: median 0.0 (IQR 0.0,0.0); C: median 0.0 (IQR 0.0-0.0); p=0.045 (outliers) Frequency of sedation monitoring per patient per day (RASS) ICU 1: Modified Training I: median 3.0 (IQR 2.0,3.5) C: median 0.0 (IQR 0.0-0.0); p<0.01ICU 2: Modified Training I: median 2.0 (IQR 1.6,2.4) C: median 0.0 (IQR 0.0-0.0); p<0.01 ICU 3: Local standard training I: median 0.0 (IQR 0.0-0.0); C: median 0.0 (IQR 0.0-0.0); p<0.01 (outliers) Impact of frequency of delirium monitoring on mortality OR 0.451; 95% CI 0.22-0.924 Impact of delirium monitoring on ICU LOS Not Significant Impact of delirium monitoring on ventilation time Not Significant |