Effectiveness of Bundle Interventions on ICU Delirium: A
Meta-Analysis*
by Zhang, Shan; Han, Yuan; Xiao, Qian; Li, Haibin; Wu, Ying
Critical Care
Medicine: February 2021
- Volume 49 - Issue 2 - p 335-346
Objective:
To evaluate the impact of bundle interventions on ICU
delirium prevalence, duration, and other patients’ adverse outcomes.
Data Sources:
The Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and
MEDLINE from January 2000 to July 2020. The protocol of the study was
registered in International prospective register of systematic reviews
(CRD42020163147).
Study
Selection:
Randomized clinical trials or cohort studies that examined
the following outcomes were included in the current study: ICU delirium prevalence
and duration, proportion of patient-days with coma, ventilator-free days,
mechanical ventilation days, ICU or hospital length of stay, and ICU or
inhospital or 28-day mortality.
Data
Extraction:
Using a standardized data-collection form, two authors
screened the studies and extracted the data independently, and assessed the
studies’ quality using the Modified Jadad Score Scale for randomized clinical
trials and the Newcastle-Ottawa Scale for cohort studies.
Data Synthesis:
Eleven studies with a total of 26,384 adult participants
were included in the meta-analysis. Five studies (three randomized
clinical trials and two cohort studies) involving 18,638 patients demonstrated
that ICU delirium prevalence was not reduced (risk ratio = 0.92; 95% CI, 0.68–1.24). Meta-analysis showed
that the use of bundle interventions was not associated with shortening the
duration of ICU delirium (mean difference = –1.42 d; 95% CI, –3.06 to 0.22; two
randomized clinical trials and one cohort study), increasing ventilator-free
days (mean difference = 1.56 d; 95% CI, –1.56 to 4.68; three randomized
clinical trials), decreasing mechanical ventilation days (mean difference =
–0.83 d; 95% CI, –1.80 to 0.14; four randomized clinical trials and two cohort
studies), ICU length of stay (mean difference = –1.08 d; 95% CI, –2.16 to 0.00;
seven randomized clinical trials and two cohort studies), and inhospital
mortality (risk ratio = 0.86; 95% CI, 0.70–1.06; five randomized clinical
trials and four cohort studies). However, bundle interventions are effective in
reducing the proportion of patient-days experiencing coma (risk ratio = 0.47;
95% CI, 0.39–0.57; two cohort studies), hospital length of stay (mean
difference = –1.47 d; 95% CI, –2.80 to –0.15; four randomized clinical trials
and one cohort study), and 28-day mortality by 18% (risk ratio = 0.82; 95% CI,
0.69–0.99; three randomized clinical trials).
Conclusions:
This meta-analysis fails to support that bundle
interventions are effective in reducing ICU delirium prevalence and duration,
but supports that bundle interventions are effective in reducing the proportion
of patient-days with coma, hospital length of stay, and 28-day mortality.
Larger randomized clinical trials are needed to evaluate the impact of bundle
interventions on ICU delirium and other clinical outcomes.