Introduction
‘The problem of delirium is far from an academic one. Not only does the presence of delirium often complicate and render more difficult the treatment of a serious illness, but also it carries the serious possibility of permanent irreversible brain damage’, Engel and Romano [1].
Methods
Search strategy and selection criteria
Selection of studies
Data extraction and synthesis
Category
|
Individual strategies
|
Description
|
---|---|---|
Professional | 1. Distribution of educational materials | Distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audio-visual materials and electronic publications. The materials may have been delivered personally or through mass mailings. |
2. Educational meetings | Conferences, lectures, workshops or traineeships. | |
3. Local consensus processes | Inclusion of participating providers in discussion to ensure that they agreed that the chosen clinical problem was important and the approach to managing the problem was appropriate. | |
4. Outreach visits | Use of a trained person who met with providers in their practice settings to give information with the intent of changing the provider’s practice. The information given may have included feedback on the performance of the provider(s). | |
5. Local opinion leader | Use of providers nominated and explicitly identified by their colleagues as educationally influential. | |
6. Patient-mediated intervention | New, previously unavailable clinical information collected directly from patients and given to the provider; for example, patient depression scores from a survey instrument. | |
7. Audit and feedback | Any summary of clinical performance of health care over a specified period of time. The summary may also have included recommendations for clinical action. The information may have been obtained from medical records, computerized databases, or observations from patients. | |
8. Reminders | Patient or encounter-specific information, provided verbally, on paper or on a computer screen, which is designed or intended to prompt a health professional to recall information. This would usually be encountered through their general education; in the medical records or through interactions with peers, and so remind them to perform or avoid some action to aid individual patient care. Computer-aided decision support and drugs dosage are included. | |
9. Marketing / Tailored interventions | Use of personal interviewing, group discussion (focus groups), or a survey of targeted providers to identify barriers to change and subsequent design of an intervention that addresses identified barriers. | |
10. Mass media | (1) Varied use of communication that reached great numbers of people including television, radio, newspapers, posters, leaflets, and booklets, alone or in conjunction with other interventions; (2) targeted at the population level. | |
Organizational | 11. Provider oriented interventions | Revision of professional roles, for example, expansion of role to include new tasks; creation of clinical multidisciplinary teams who work together; formal integration of services; skill mix changes (changes in numbers, types or qualifications of staff); arrangements for follow up; satisfaction of providers with the conditions of work and the material and psychic rewards (for example, interventions to boost morale); communication and case discussion between distant health professionals |
12. Patient oriented interventions | Mail order pharmacies (for example, compared to traditional pharmacies); presence and functioning of adequate mechanisms for dealing with patients’ suggestions and complaints; consumer participation in governance of health care organization; other categories | |
13. Structural interventions | Changes to the setting/site of service delivery; changes in physical structure, facilities and equipment; changes in medical records systems (for example, changing from paper to computerized records); changes in scope and nature of benefits and services; presence and organization of quality monitoring mechanisms; ownership, accreditation, and affiliation status of hospitals and other facilities; staff organization | |
Financial | 14. Provider or patient interventions | In summary: patient or provider is financially supported to execute specific actions. For detailed definitions, see reference [10] |
Regulatory | 15. Changes in medical liability | Any intervention that aims to change health services delivery or costs by regulation or law (these interventions may overlap with organizational and financial interventions). |
16. Management of patient complaints | ||
17. Peer review or Licensure |
Methodological quality
Statistical analyses
Results
Selection of studies
Methodological quality
Implementation strategies
Implementation strategy
|
Studies reporting both clinical outcomes and process outcomes before versus after implementation
|
Studies reporting process outcomes, without clinical outcomes, before versus after implementation*
|
Percent using strategy
| |||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Author
|
Mansouri
|
Skrobik
|
Balas
|
Radtke
|
Robinson
|
Kamdar
|
Reade
|
Dale
|
Bryckz.
|
Eastwood
|
Devlin
|
Scott
|
Gesin
|
Riekerk
|
Kastrup
|
Boogaard
|
Pun
|
Hager
|
Soja
|
Page
|
Bowen
| |||
PO
| 1 | Distribution** | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 81 |
2 | Educational Meetings | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 100 | |
3 | Local consensus | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 62 | |
4 | Outreach | 0 | 0 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 1 | 67 | |
5 | Opinion leaders | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 1 | 0 | 1 | 1 | 0 | 1 | 52 | |
6 | Patient-mediated | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 86 | |
7 | Audit/feedback | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 62 | |
8 | Reminders | 0 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 38 | |
9 | Tailoring (barriers) | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 1 | 1 | 0 | 1 | 33 | |
10 | Mass media | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
O
| 11 | Provider-oriented | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 0 | 0 | 43 |
12 | Patient-oriented | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 10 | |
13 | Structural | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 48 | |
F
| 14 | Provider | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 10 |
R
| 15 | Medical liability | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
16 | Patient complaints | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
17 | peer review/licensure | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 5 | |
Total number IS used
|
7
|
9
|
12
|
7
|
5
|
6
|
4
|
5
|
3
|
4
|
6
|
4
|
7
|
10
|
7
|
12
|
6
|
10
|
10
|
4
|
8
| |||
Post-implementation***
| ||||||||||||||||||||||||
Mortality
|
⬇
| ⬇ | ⬇ | ↓ | ↓ | ↓ | ↑ | = | ↓ | ↑ | - | - | - | - | - | - | - | - | - | - | - | |||
ICU length of stay
| ⬇ | ⬇ | ↓ | ⬇ | ↓ | ↓ | = | ⬇ | ⬇ | = | - | - | - | - | - | ↓ | - | - | - | - | - | |||
Screening adherence
| ⬆ | ↑ | ⬆ | ⬆ | - | - | - | ⬆ | - | - | ⬆ | ⬆ | - | ⬆ | ⬆ | ⬆ | ⬆ | = | ⬆ | ⬆ | ⬆ | |||
Incidence
| - | ↓ | ⬇ | - | - | ⬇ | ⬇ | ⬇ | ↑ | - | - | - | - | - | ↑ | ⬆ | - | ⬆ | - | - | - | |||
Antypsychotic drug use
| ↓ | ↑ | ↑ | - | ↑ | - | - | ⬇ | ↓ | ⬇ | - | - | - | - | - | ⬇ | - | - | - | - | - | |||
Delirium knowledge
| - | - | - | - | - | - | - | - | - | - | - | ⬆ | ⬆ | ⬆ | - | ⬆ | - | - | - | - | - |
Implementation characteristics, process outcomes and clinical outcomes
Author, year (design)
|
Implementation
|
Process outcomes
|
Clinical outcomes
| ||||||
---|---|---|---|---|---|---|---|---|---|
Number of strategies used
|
Implemented care components
|
Implementation model
|
Screening adherence
|
Delirium incidence
|
Use of antipsychotic drugs
|
Delirium knowledge
|
Mortality change
|
ICU length of stay, days
| |
Balas, 2014 [16] (B/Aa study, n = 296) | 12 | ABCDEb
| CFIRc
|
+50% (0 to 50%)d
|
−13% (62 to 49%),
P =
0.02
| +12 mg (6 to 18 mg)e, P = 0.24 | - |
−8.6% (19.9 to 11.3%),
P
= 0.04
|
−1f (5 to 4), P = 0.21 |
Van den Boogaard, 2009 [17] (B/A study, n = 1742) | 12 | Delirium screening | Model of Grol and Wensing |
+14% (77 to 92%),
P
<0.0001
|
+13% (10 to 23%),
P
<0.05g
|
−12 mg (18 to 6 mg)e
,
P
= 0.01
|
+1.2 (6.2 to 7.4),
P
<0.001
|
-
|
−0.3 (1.3 to 1)f
P
<
0.05
|
Riekerk, 2009 [18] (B/A study, n = NA) | 10 | Delirium screening | Structural implementation pathway |
+57% (38 to 95%)d
|
-
|
-
|
+1d,h
(3–4)
|
-
|
-
|
Hager, 2013 [19] (B/A study, n = 202) | 10 | PADw
| 4Es frameworki
| 0 (90 to 90%) |
+18%j
(20 to 38%),
P
= 0.01
|
-
| - |
-
|
-
|
Skrobik, 2010 [20] (B/A study, n = 1133) | 9 | PAD | - | +3k (89 to 92%), P = 0.055 | −0.5% (34.7 to 34.2%), P = 0.9 | +0.3% (39.4 to 39.7%), P = 0.7 | - |
−6.5% (29.4 to 22.9%),
P
= 0.009
|
−0.97l
(6.32 to 5.35),
P
= 0.009
|
Bowen, 2012 [21] (pilot study, n = 34 nurses) | 8 | Delirium screening | Diffusion of Innovations theory |
+75% (10% to 85%)
|
-
|
-
| - |
-
|
-
|
Soja, 2008 [22] (Prospective study, n = 347) | 10 | Delirium screening | - |
+84% (0 to 84)d
| - | - | - |
-
|
-
|
Gesin, 2012 [23] (B/A study, n = 20 nurses) | 7 | Delirium screening | - | - |
-
|
-
|
+2.1 (6.1 to 8.2),
P
= 0.001
|
-
|
-
|
Mansouri, 2013 [24] (RCT, n = 201) | 7 | PAD | - |
+100%m
(0 to 100%)
| - | −2.5 mgn (3.2 to 0.7 mg), P = 0.12 | - |
−12% (24 to 13%),
P
= 0.046
|
−3.1 (7.1 to 4.0)f
,
P
<0.001
|
Pun, 2005 [25] (Prospective study, n = 711) | 6 | PAD | - |
+90% (0 to 90)d
+84% (0 to 84)d
|
-
| - | - |
-
|
-
|
Radtke, 2012 [26] (B/Ae study, n = 131) | 7 | PAD | Modified extended training |
+1.6 (0 to 1.6),
P
<0.01
| - | - | - | −4.8%o (9.9 to 5.1%), P = 0.16 | −4 (18 to 14)p, P = 0.40 |
−4 (8 to 4)p
,
P
<0.01
| |||||||||
Eastwood, 2012 [27] (B/A study, n = 288 patients/2368 shifts) | 4 | Delirium screening | - |
-
| - |
+8.5%q
(5.8 to 14.3%),
P
<0.0001r
| - | +3.2% (5 to 8.2)s,t
P = 0.31 | 0 (2 to 2), P = 0.34 |
Kamdar, 2013 [28] (B/A study, n = 285) | 6 | Multifaceted sleep promotion program | Structured QI model | - |
odds ratio 0.46a
,
P
= 0.02
|
-
| - | −6% (25 to 19%), P = 0.88s
| −1.1u (5.4 to 4.3), P = 0.60 |
Scott, 2012 [29] (B/A study, n = 119) | 4 | Delirium screening | - |
+78% (0 to 78%)d
|
-
|
-
|
+14%v
(71 to 85%),
P
<0.001
|
-
|
-
|
Dale, 2014 [30] (B/A study, n = 1483) | 5 | PAD | - |
+1.14x
(0.35 to 1.49),
P
<0.01
|
odds ratio 0.67,
p
= 0.01
|
−1.7 (2.7 to 1.0)y
,
P
<0.01
| - | 0 (14 to 14%), P = 1.0 |
−12.4%j
,
P
= 0.04
|
Kastrup, 2011 [31] (B/A study, n = 205) | 7 | Visual feedback system | - |
+37.5% (0.5 to 38%),
P
<0.01
| +4% (25 to 29%), P = 1.0za
|
-
| - |
-
|
-
|
Robinson, 2008 [32] (B/A study, n = 119) | 5 | PAD | - | - | - | +14% (31 to 45%), P = 0.25 | - | −2.9% (17.6 to 14.7), P = 0.64 | −1.8 (5.9 to 4.1), P = 0.21 |
Devlin, 2008 [33] (B/A study, n = 601) | 6 | Delirium screening | SCTzb
|
+70% (12 to 82%),
P
<0.0005
| - |
-
| - | - | - |
Page, 2009 [34] (Retrospective study, n = 60) | 4 | Delirium screening | - |
+92% (0 to 92%)d
|
-
| - | - | - | - |
Reade, 2011 [35] (B/A study, n = 288) | 4 | Delirium screening | - | - |
−16% (37 to 21%),
P
= 0.004
|
-
| - | +3.2% (5 to 8.2)zc, P = 0.31 | 0 (2 to 2), P = 0.34 |
Bryczkowski, 2014 [36] (B/A study, n = 123) | 3 | Delirium prevention program | - | - | +11% (58 to 47%), P = 0.26 | −1% (7 to 6%), P = 0.83 | - | −4% (7 to 3%), P = 0.31 |
−3 (9 to 6),
P
= 0.04
|
ICU-LOS
Mortality
Discussion
Conclusion
Key messages
-
Implementation programs can effectively improve delirium screening adherence or knowledge, but have had varying effects on delirium incidence and use of antipsychotic drugs.
-
There seems to be no easy way out implementing delirium-oriented interventions, especially when combined with related care components as described in the PAD guidelines or ABCDE bundle: to implement these inclusive, integrated management frameworks, use of multiple implementation strategies concurrently that are targeted both at the care providers and at organizational aspects seems to be necessary.
-
Successful implementation, meaning effective practice change, should be clearly delineated from the effect of such practice changes on clinical outcomes.
-
Robust data on effectiveness of specific implementation strategies with regard to the care of delirious critically ill patients are scarce and there is a lack of data on the association between specific practice changes (for example, delirium screening) and improvements in clinical outcomes.