by Trogrlic, Zoran; van
der Jagt, Mathieu; Lingsma, Hester; Gommers, Diederik; Ponssen, Huibert H.;
Schoonderbeek, Jeannette F. J.; Schreiner, Frodo; Verbrugge, Serge J.; Duran,
Servet; Bakker, Jan; Ista, Erwin
Objectives:
Implementation of delirium guidelines at ICUs is suboptimal. The aim was to
evaluate the impact of a tailored multifaceted implementation program of ICU
delirium guidelines on processes of care and clinical outcomes and draw lessons
regarding guideline implementation. Design:
A prospective multicenter, pre-post, intervention study.
Setting: ICUs
in one university hospital and five community hospitals.
Patients:
Consecutive medical and surgical critically ill patients were enrolled between
April 1, 2012, and February 1, 2015. Interventions: Multifaceted, three-phase
(baseline, delirium screening, and guideline) implementation program of
delirium guidelines in adult ICUs. Measurements and Main Results: The primary
outcome was adherence changes to delirium guidelines recommendations, based on
the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain
dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A
total of 3,930 patients were included. Improvements after the implementation
pertained to delirium screening (from 35% to 96%; p < 0.001), use of
benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light
sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy
(from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p
< 0.001). Brain dysfunction improved: the mean delirium duration decreased
from 5.6 to 3.3 days (–2.2 d; 95% CI, –3.2 to –1.3; p < 0.001), and coma
days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4–0.6; p < 0.001).
Other clinical outcome measures, such as length of mechanical ventilation,
length of ICU stay, and hospital mortality, did not change.
Conclusions: This
large pre-post implementation study of delirium-oriented measures based on the
2013 Pain, Agitation, and Delirium guidelines showed improved health professionals’
adherence to delirium guidelines and reduced brain dysfunction. Our findings
provide empirical support for the differential efficacy of the guideline bundle
elements in a real-life setting and provide lessons for optimization of
guideline implementation programs.
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