Table 1.

Implementation Readiness Test (exposure in number of intensive care units (ICUs))

Implementation strategy	Norm/requirements	IRT 1*	IRT 2	IRT 3
Part 1: Execution of implementation strategies
Education: Learning Part 1 screening	≥75% of nurses have completed the e-learning?	6†	6	6
Education: e-learning Part 1 screening	≥75% of physicians have completed the e-learning?	4	5	6
Education: e-learning Part 2 - treatment and preventive protocol	≥75% of nurses have completed the e-learning?	2	2	6
Education: e-learning Part 2 - treatment and preventive protocol	≥75% of physicians have completed the e-learning?	2	3	6
Clinical lessons screening	New employees are trained around delirium management?	3	4	4‡
Educational outreach
Spot checks screening	There are at least four spot checks done by a nurse?	5	5	5
Quality control screening	This is scored by the experts? (interobserver variation)?	3	4	5
Local implementation teams
	Local implementation team is multidisciplinary (at least: intensivist, IC nurse and possibly: psychiatrist/neurologist/geriatrician/physical therapist)?	6	6	6
	There were at least two consultations between local implementation team members (since beginning of the study) and there are agreements on implementation?	4	5	6
	It was agreed (preferably also recorded) who is responsible for which part of the implementation.	6	6	6
Local opinion leaders	It is clear who the implementation team members are and who is a contact for delirium in general and the study in particular?	5	5	6
Audit and feedback
Indicators poster screening and incidence	1. Are the posters visible?	5	6	6
	2. Are those discussed in the management team?	2	5	6
Decision support
Laminated pocket cards screening CAM-ICU or ICDSC	Are pocket cards present for nurses and physicians?	5	6	6
	Pocket cards are used in practice?	3	4	5§
Reminders	There are reminders regarding screening and management of delirium (if available, pop-ups PDMS for screening)	6	5	6
Focus groups/barrier analysis	Bottlenecks are discussed in local multidisciplinary meetings at the ICU level and is the implementation aimed to address them?	2	3	5
TOTAL (of max 99)		69 (70%)	80 (81%)	96 (97%)
Part 2: Implementation of protocol
PDMS (patient demographic management system)	Is PDMS modified and helpful for delirium screening?	5	5	5¶
Treatment delirium	Are the 4HS 4TS used in practice regularly if delirium screening result is a positive one (new delirium)?	0	3	5
	Is it clear what the drug treatment for delirium (according to protocol) is?	4	6	5
	Is medication sometimes modified following the screening?	5	6	6
	Are the non-pharmacological measures optimised before starting medication?	2	3	5
Prevention of delirium: physical therapy and early mobilisation	Physical therapy: there are structural arrangements with physical therapist and there is agreement about how to provide early physical therapy and mobilisation?	2	3	6
	Mobilisation of patients is basically addressed by daily patient rounds and this is implemented in the daily rounds?	4	5	6
	Is department policy that seeks to mobilise ventilated patients if possible?	3	4	5
Prevention: sleep hygiene	Is there a protocol regarding sleep promotion?	3	6	6
	Used this protocol and regularly followed in practice?	0	5	5
	Sleep protocol contains at least the next recommendations: lights off or muted overnight, strive for sleep (no standard rounds running if not necessary), and use of earplugs?	5	5	6
Prevention: psycho hygiene (among other, reducing sensory deprivation)	Is there a structural focus on using eyeglasses and of hearing aid if applicable throughout the ICU admission?	4	5	6
Evaluation of pain-sedation-delirium	Daily delirium screening is implemented and ‘going well‘?	3	4	6
	The coordination of delirium, sedation and pain management is implemented in any way in the daily rounds (eg, visit form)?	4	5	6
	Daily rounds checklist is implemented and used?	3	4	5
Sedation	Sedation with midazolam (or other benzodiazepines) by continuous infusion is avoided, and alternative sedation (analgo-sedation with opiate and possibly clonidine/dexmedetomidine/propofol targeting addressable patient comfortable?) is used?	4	5	6
Family engagement	Is there a leaflet about delirium for family?	4	4	6
	Family of the ICU patient is getting the opportunity to contribute in identifying and/or treatment of delirium (eg, to help with washing, etc)?	3	5	6
	Poster about family engagement by delirium is presented in the family room?	1	2	5
TOTAL (of max 113)		59 (52%)	84 (74%)	106 (94%)

*IRT, Implementation Readiness Test, drafted to measure the actual exposure to implementation strategies as perceived by the local study team. All three IRT overviews were made in phase III during the implementation of guideline (total time=10 months). The last one IRT overview was made just before the start of third data collection period (T3).

†The numbers indicate the number of sites that have implemented the item in daily practice.

‡Not applicable for two ICUs because there were no new employees during previous period.

§Not applicable for one ICU because the information as given in pocket cards was integrated in PDMS.

¶Not applicable for one ICU because no PDMS system was available.