Secondary Logo

Institutional members access full text with Ovid®

Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients

Trogrlić, Zoran, RN, MSc1; van der Jagt, Mathieu, MD, PhD1; Lingsma, Hester, PhD2; Gommers, Diederik, MD, PhD1; Ponssen, Huibert H., MD3; Schoonderbeek, Jeannette F. J., MD, PhD4; Schreiner, Frodo, MD5; Verbrugge, Serge J., MD, PhD6; Duran, Servet, MD7; Bakker, Jan, MD, PhD1,8,9,10; Ista, Erwin, RN, PhD11

doi: 10.1097/CCM.0000000000003596
Neurologic Critical Care
Buy
SDC

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.

1Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.

2Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.

3Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, The Netherlands.

4Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands.

5Department of Intensive Care, IJsselland Hospital, Rotterdam, The Netherlands.

6Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.

7Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands.

8Department of Pulmonology and Critical Care, New York University - Langone, New York, NY.

9Department of Pulmonology and Critical Care, Columbia University Medical Center - New York Presbyterian, New York, NY.

10Department of Intensive Care, Pontificia Universidad Catolica de Chile, Santiago, Chile.

11Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children’s Hospital University Medical Center Rotterdam, Rotterdam, The Netherlands.

Drs. van der Jagt and Ista supervised the study and contributed equally.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by grant No. 171203008 from The Netherlands Organization for Health Research and Development (ZonMw). ZonMw had no role in the statistical analyses or publication decisions.

This work was performed at Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam; Department of Intensive Care, Albert Schweitzer Hospital Dordrecht; Department of Intensive Care, Ikazia Hospital Rotterdam; Department of Intensive Care, IJsselland Hospital Rotterdam; Department of Intensive Care, Sint Franciscus Gasthuis Rotterdam; and Department of Intensive Care, Maasstad Hospital Rotterdam, all in the Netherlands.

Drs. Trogrlic’s and van der Jagt’s institutions received funding from The Netherlands Organization for Health Research and Development (ZonMw) with the grant number: 171203008 awarded to Drs. van der Jagt and Ista. Drs. Verbrugge’s and Bakker’s institutions received funding from ZonMW. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Zoran Trogrlić, RN, MSc, Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam‘s Gravendijkwal 230, P.O. Box 2040, 3000CA Rotterdam, the Netherlands, office: Ne-405. E-mail: z.trogrlic@erasmusmc.nl

Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.