Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 150 No. 0304 (2020)

Implementation of a multiprofessional, multicomponent delirium management guideline in two intensive care units, and its effect on patient outcomes and nurse workload: a pre-post design retrospective cohort study

  • Maria Schubert
  • Dominique Bettex
  • Peter Steiger
  • Roger Schürch
  • Alois Haller
  • Jasmina Bogdanovic
  • David Garcia Nuñez
  • Urs Schwarz
  • Martin Siegemund
DOI
https://doi.org/10.4414/smw.2020.20185
Cite this as:
Swiss Med Wkly. 2020;150:w20185
Published
21.01.2020

Summary

AIM OF THE STUDY

Delirium is a frequent intensive care unit (ICU) complication, affecting 26% to 80% of ICU patients, often with serious consequences. This study aimed to evaluate the effectiveness, costs and benefits of following a standardised multiprofessional, multicomponent delirium guideline on eight outcomes: delirium prevalence and duration, lengths of stay in ICU and hospital, in-hospital mortality, duration of mechanical ventilation, and cost and nursing hours per case. It also aimed to explore the associations of delirium with length of ICU stay, length of hospital stay and duration of mechanical ventilation.

METHODS

This retrospective cohort study used a pre-post design. ICU patients in an historical control group (n = 1608) who received standard ICU care were compared with a postintervention group (n = 1684) who received standardised delirium management – delirium risk identification, preventive measures, screening and treatment – with regard to eight outcomes. The delirium management guideline was developed and implemented in 2012 by a group of experts from the study hospital. As appropriate, descriptive statistics and multivariate, multilevel models were used to compare the two groups and to explore the association between delirium occurrence and the selected outcomes.

RESULTS

Twelve percent of the 1608 historical controls and 20% of the 1684 postintervention patients were diagnosed with delirium according to the ICD-10 delirium diagnosis codes. Patients being treated for heart disease, and those with septic shock, ARDS, renal insufficiency (acute or chronic), older age and higher numbers of comorbidities were significantly more likely to develop delirium during their stay. Multivariate models comparing the historical controls with the post intervention group indicated significant differences in delirium period prevalence (odds ratio 1.68, 95% confidence interval [CI] 1.38–2.06; p <0.001), length of stay in the ICU (time ratio [TR] 0.94, CI 0.89–1.00; p = 0.048), cost per case (median difference 3.83, CI 0.54–7.11; p = 0.023) and duration of mechanical ventilation (TR 0.84, CI 0.77–0.92; p <0.001). The observed differences in the other four outcomes – in-hospital mortality, delirium duration, length of stay in the hospital, and nursing hours per case – were not significant. Delirium was a significant predictor for prolonged duration of mechanical ventilation and for both ICU and hospital stay.

CONCLUSION

Standardised delirium management, specifically delirium screening, supports timely detection of delirium in ICU patients. Increased awareness of delirium after the implementation of standardised multiprofessional, multicomponent management leads to increased therapeutic attention, a prolongation of ICU stay and increased costs, but with no influence on mortality.

References

  1. Morandi A, Jackson JC. Delirium in the intensive care unit: a review. Neurol Clin. 2011;29(4):749–63. doi:.https://doi.org/10.1016/j.ncl.2011.08.004
  2. Rudiger A, Begdeda H, Babic D, Krüger B, Seifert B, Schubert M, et al. Intra-operative events during cardiac surgery are risk factors for the development of delirium in the ICU. Crit Care. 2016;20(1):264. doi:.https://doi.org/10.1186/s13054-016-1445-8
  3. Pandharipande P, Cotton BA, Shintani A, Thompson J, Pun BT, Morris JA, Jr, et al. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65(1):34–41. doi:.https://doi.org/10.1097/TA.0b013e31814b2c4d
  4. van den Boogaard M, Schoonhoven L, van der Hoeven JG, van Achterberg T, Pickkers P. Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study. Int J Nurs Stud. 2012;49(7):775–83. doi:.https://doi.org/10.1016/j.ijnurstu.2011.11.016
  5. Zhang Z, Pan L, Ni H. Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. Gen Hosp Psychiatry. 2013;35(2):105–11. doi:.https://doi.org/10.1016/j.genhosppsych.2012.11.003
  6. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–62. doi:.https://doi.org/10.1001/jama.291.14.1753
  7. Weinrebe W, Johannsdottir E, Karaman M, Füsgen I. What does delirium cost? An economic evaluation of hyperactive delirium. Z Gerontol Geriatr. 2016;49(1):52–8. doi:.https://doi.org/10.1007/s00391-015-0871-6
  8. Pauley E, Lishmanov A, Schumann S, Gala GJ, van Diepen S, Katz JN. Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. Am Heart J. 2015;170(1):79–86, 86.e1. doi:.https://doi.org/10.1016/j.ahj.2015.04.013
  9. Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med. 2004;32(4):955–62. doi:.https://doi.org/10.1097/01.CCM.0000119429.16055.92
  10. Schubert M, Schürch R, Boettger S, Garcia Nuñez D, Schwarz U, Bettex D, et al. A hospital-wide evaluation of delirium prevalence and outcomes in acute care patients - a cohort study. BMC Health Serv Res. 2018;18(1):550. doi:.https://doi.org/10.1186/s12913-018-3345-x
  11. McPherson JA, Wagner CE, Boehm LM, Hall JD, Johnson DC, Miller LR, et al. Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med. 2013;41(2):405–13. doi:.https://doi.org/10.1097/CCM.0b013e31826ab49b
  12. Ibrahim K, McCarthy CP, McCarthy KJ, Brown CH, Needham DM, Januzzi JL, Jr, et al. Delirium in the Cardiac Intensive Care Unit. J Am Heart Assoc. 2018;7(4):e008568. doi:.https://doi.org/10.1161/JAHA.118.008568
  13. Arumugam S, El-Menyar A, Al-Hassani A, Strandvik G, Asim M, Mekkodithal A, et al. Delirium in the Intensive Care Unit. J Emerg Trauma Shock. 2017;10(1):37–46. doi:.https://doi.org/10.4103/0974-2700.199520
  14. 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(5):1024–36. doi:.https://doi.org/10.1097/CCM.0000000000000129
  15. Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, et al.; DAS-Taskforce 2015. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. Ger Med Sci. 2015;13:Doc19. doi:.https://doi.org/10.3205/000223
  16. Collinsworth AW, Priest EL, Campbell CR, Vasilevskis EE, Masica AL. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med. 2016;31(2):127–41. doi:.https://doi.org/10.1177/0885066614553925
  17. Miller RR, 3rd, Wesley Ely E. Delirium and cognitive dysfunction in the intensive care unit. Semin Respir Crit Care Med. 2006;27(3):210–20. doi:.https://doi.org/10.1055/s-2006-945532
  18. Awissi DK, Bégin C, Moisan J, Lachaine J, Skrobik Y. I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann Pharmacother. 2012;46(1):21–8. doi:.https://doi.org/10.1345/aph.1Q284
  19. Boettger S, Knöpfel S, Schubert M, Garcia Nuñez D, Plichta MM, Klaghofer R, et al. Pipamperone and delirium: a preliminary evaluation of its effectiveness in the management of delirium and its subtypes. Swiss Med Wkly. 2017;147:w14471. doi:.https://doi.org/10.4414/smw.2017.14471
  20. Boettger S, Meyer R, Richter A, Fernandez SF, Rudiger A, Schubert M, et al. Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): Symptom profile and utility of individual items in the identification of delirium dependent on the level of sedation. Palliat Support Care.. 2019;17(1):74–81. doi:.https://doi.org/10.1017/s1478951518000202
  21. Boettger S, Nuñez DG, Meyer R, Richter A, Fernandez SF, Rudiger A, et al. Delirium in the intensive care setting: A reevaluation of the validity of the CAM-ICU and ICDSC versus the DSM-IV-TR in determining a diagnosis of delirium as part of the daily clinical routine. Palliat Support Care. 2017;15(6):675–83. doi:.https://doi.org/10.1017/S1478951516001176
  22. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27(5):859–64. doi:.https://doi.org/10.1007/s001340100909
  23. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–44. doi:.https://doi.org/10.1164/rccm.2107138
  24. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270(24):2957–63. doi:.https://doi.org/10.1001/jama.1993.03510240069035
  25. Sundararajan V, Henderson T, Perry C, Muggivan A, Quan H, Ghali WA. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol. 2004;57(12):1288–94. doi:.https://doi.org/10.1016/j.jclinepi.2004.03.012
  26. Bundesamt für Statistik. Schweizerische Operationsklassifikation (CHOP) ICD-9-CM, volume 3, version 10.0, 2008. Neuchatel: Bundesamt für Statistik BFS; 2008. https://www.bfs.admin.ch/bfs/de/home/statistiken/kataloge-datenbanken/publikationen.assetdetail.344563.html
  27. SGI-SSMI. Minimaler Datensatz der SGI (MDSI), vol. 24d_2013. http://docplayer.org/12224800-Minimaler-datensatz-der-sgi-mdsi.html.
  28. Bundesamt für Statistik. Statistik der stationären Betriebe des Gesundheitswesens, Medizinische Statistik der Krankenhäuser. Neuchatel: Bundesamt für Statistik, Abteilung Bevölkerung und Beschäftigung; 1997. pp 1–43. https://www.bfs.admin.ch/bfsstatic/dam/assets/230430/master
  29. Baumberger D, Kuehne G, Hieber S. LEP Making nurses’ work visible. LEP Nursing 3.3. In: vol. 2, March 2007 edn. St. Gallen, Switzerland: LEP-AG; 2007. pp 1–10.
  30. DIMDI. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), [Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme 10. Revision], Version 2013. In., vol. CD-10-GM Version 2013, 21.09.2012 edn. Koeln, Germany: Deutschen Institut für Medizinische Dokumentation und Information (DIMDI) 2013. https://www.dimdi.de/static/de/klassifikationen/icd/icd-10-gm/kode-suche/htmlgm2013/
  31. Akaike H. A New Look at the Statistical Model Identification. IEEE Trans Automat Contr. 1974;19(6):716–23. doi:.https://doi.org/10.1109/TAC.1974.1100705
  32. Team RDC. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2008.
  33. Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, et al. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ. 2015;350:h2538. doi:.https://doi.org/10.1136/bmj.h2538
  34. Loss SH, de Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, et al. The reality of patients requiring prolonged mechanical ventilation: a multicenter study. Rev Bras Ter Intensiva. 2015;27(1):26–35. doi:.https://doi.org/10.5935/0103-507x.20150006
  35. Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L ; Quality of Life After Mechanical Ventilation in the Aged (QOL-mechanical ventilation) Investigators. Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study. Crit Care. 2007;11(1):R9. doi:.https://doi.org/10.1186/cc5667
  36. Mossello E, Tesi F, Di Santo SG, Mazzone A, Torrini M, Cherubini A, et al.; Italian Study Group on Delirium. Recognition of Delirium Features in Clinical Practice: Data from the “Delirium Day 2015” National Survey. J Am Geriatr Soc. 2018;66(2):302–8. doi:.https://doi.org/10.1111/jgs.15211
  37. Aparanji K, Kulkarni S, Metzke M, Schmudde Y, White P, Jaeger C. Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds. BMJ Open Qual. 2018;7(2):e000239. doi:.https://doi.org/10.1136/bmjoq-2017-000239
  38. 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(2):451–63. doi:.https://doi.org/10.1213/ANE.0b013e3181d7e1b8
  39. Kram SL, DiBartolo MC, Hinderer K, Jones RA. Implementation of the ABCDE Bundle to Improve Patient Outcomes in the Intensive Care Unit in a Rural Community Hospital. Dimens Crit Care Nurs. 2015;34(5):250–8. doi:.https://doi.org/10.1097/DCC.0000000000000129
  40. 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(3):367–74. doi:.https://doi.org/10.1513/AnnalsATS.201306-210OC
  41. Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, et al.; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):1985–92. doi:.https://doi.org/10.1001/jama.2012.13872
  42. 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(1):280–8. doi:.https://doi.org/10.1016/j.jss.2014.02.044
  43. 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(9607):126–34. doi:.https://doi.org/10.1016/S0140-6736(08)60105-1
  44. 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(9678):1874–82. doi:.https://doi.org/10.1016/S0140-6736(09)60658-9
  45. Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512–20. doi:.https://doi.org/10.1001/jamainternmed.2014.7779

Most read articles by the same author(s)

1 2 > >>