Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Implementation Science
Published in: Implementation Science 1/2014

Open Access 01-12-2014 | Study protocol

Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECePTIvE study

Authors: Erwin Ista, Zoran Trogrlic, Jan Bakker, Robert Jan Osse, Theo van Achterberg, Mathieu van der Jagt

Published in: Implementation Science | Issue 1/2014

Login to get access

Abstract

Background

Delirium in critically ill patients has a strong adverse impact on prognosis. In spite of its recognized importance, however, delirium screening and treatment procedures are often not in accordance with current guidelines. This implementation study is designed to assess barriers and facilitators for guideline adherence and next to develop a multifaceted tailored implementation strategy. Effects of this strategy on guideline adherence as well as important clinical outcomes will be described.

Methods

Current practices and guideline deviations will be assessed in a prospective baseline measurement. Barriers and facilitators will be identified from a survey among intensive care health care professionals (intensivists and nurses) and focus group interviews with selected health care professionals (n?=?60). Findings will serve as a foundation for a tailored guideline implementation strategy. Adherence to the guideline and effects of the implementation strategies on relevant clinical outcomes will be piloted in a before-after study in six intensive care units (ICUs) in the southwest Netherlands. The primary outcomes are adherence to screening and treatment in line with the Dutch ICU delirium guideline. Secondary outcomes are process measures (e.g. attendance to training and knowledge) and clinical outcomes (e.g. incidence of delirium, hospital-mortality changes, and length of stay). Primary and secondary outcome data will be collected at four time points including at least 924 patients. Furthermore, a process evaluation will be done, including an economical evaluation.

Discussion

Little is known on effective implementation of delirium management in the critically ill. The proposed multifaceted implementation strategy is expected to improve process measures such as screening adherence in line with the guideline and may improve clinical outcomes, such as mortality and length of stay. This ICU Delirium in Clinical Practice Implementation Evaluation study (iDECePTIvE-study) will generate important knowledge for ICU health care providers on how to improve their clinical practice to establish optimum care for delirious patients.

Trials registration

Clinical Trials NCT01952899
Appendix
Available only for authorised users
Literature
1.
American Psychiatric Association: Diagnostic and statistical manual of mental disorders, DSM-IV-TR. 4th edition. Washington, DC: American PsychiatricAssociation; 2000.
2.
Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, Truman B, Dittus R, Bernard R, Inouye SK: The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001, 27: 1892-1900. 10.1007/s00134-001-1132-2.CrossRefPubMed
3.
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J: Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?. JAMA. 2000, 284: 2762-2770. 10.1001/jama.284.21.2762.CrossRefPubMed
4.
Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW: Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc. 2006, 54: 479-484. 10.1111/j.1532-5415.2005.00621.x.CrossRefPubMed
5.
Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Inouye SK, Bernard GR, Dittus RS: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004, 291: 1753-1762. 10.1001/jama.291.14.1753.CrossRefPubMed
6.
Shehabi Y, Riker R, Bokesch P, Wisemandle W, Shintani A, Ely EW: Delirium duration strongly predicts mortality in mechanically ventilated critically ill patients. Crit Care Med. 2009, 37: A151-
7.
Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH: Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med. 2009, 180: 1092-1097. 10.1164/rccm.200904-0537OC.CrossRefPubMedPubMedCentral
8.
Balas MC, Deutschman CS, Sullivan-Marx EM, Strumpf NE, Alston RP, Richmond TS: Delirium in older patients in surgical intensive care units. J Nurs Scholarsh. 2007, 39: 147-154. 10.1111/j.1547-5069.2007.00160.x.CrossRefPubMed
9.
Desai SV, Law TJ, Needham DM: Long-term complications of critical care. Crit Care Med. 2011, 39: 371-379. 10.1097/CCM.0b013e3181fd66e5.CrossRefPubMed
10.
Ehlenbach WJ, Hough CL, Crane PK, Haneuse SJ, Carson SS, Curtis JR, Larson EB: Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA. 2010, 303: 763-770. 10.1001/jama.2010.167.CrossRefPubMedPubMedCentral
11.
Lin SM, Liu CY, Wang CH, Lin HC, Huang CD, Huang PY, Fang YF, Shieh MH, Kuo HP: The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med. 2004, 32: 2254-2259. 10.1097/01.CCM.0000110878.49476.42.CrossRefPubMed
12.
Heymann A, Radtke F, Schiemann A, Lutz A, MacGuill M, Wernecke KD, Spies C: Delayed treatment of delirium increases mortality rate in intensive care unit patients. J Int Med Res. 2010, 38: 1584-1595. 10.1177/147323001003800503.CrossRefPubMed
13.
Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, Gordon SM, Canonico AE, Dittus RS, Bernard GR, Ely EW: Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010, 38: 1513-1520. 10.1097/CCM.0b013e3181e47be1.CrossRefPubMedPubMedCentral
14.
Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW, Investigators B-IS: Long-term cognitive impairment after critical illness. N Engl J Med. 2013, 369: 1306-1316. 10.1056/NEJMoa1301372.CrossRefPubMedPubMedCentral
15.
Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, Truman B, Bernard GR, Dittus RS, Ely EW: Costs associated with delirium in mechanically ventilated patients. Crit Care Med. 2004, 32: 955-962. 10.1097/01.CCM.0000119429.16055.92.CrossRefPubMed
16.
Spronk PE, Riekerk B, Hofhuis J, Rommes JH: Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009, 35: 1276-1280. 10.1007/s00134-009-1466-8.CrossRefPubMedPubMedCentral
17.
Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA, Murray MJ, Peruzzi WT, Lumb PD: Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002, 30: 119-141. 10.1097/00003246-200201000-00020.CrossRefPubMed
18.
Pun BT, Devlin JW: Delirium monitoring in the ICU: strategies for initiating and sustaining screening efforts. Semin Respir Crit Care Med. 2013, 34: 179-188. 10.1055/s-0033-1342972.CrossRefPubMed
19.
20.
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013, 41: 263-306. 10.1097/CCM.0b013e3182783b72.CrossRefPubMed
21.
Cadogan FL, Riekerk B, Vreeswijk R, Rommes JH, Toornvliet AC, Honing ML, Spronk PE: Current awareness of delirium in the intensive care unit: a postal survey in the Netherlands. Neth J Med. 2009, 67: 296-300.PubMed
22.
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006, 355: 2725-2732. 10.1056/NEJMoa061115.CrossRefPubMed
23.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR: Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999, 282: 1458-1465. 10.1001/jama.282.15.1458.CrossRefPubMed
24.
Grol R, Wensing M, Eccles M: Improving Patient Care; The Implementation of Change in Clinical Practice. 2013, Elsevier, LondonCrossRef
25.
Sinuff T, Cook D, Giacomini M, Heyland D, Dodek P: Facilitating clinician adherence to guidelines in the intensive care unit: A multicenter, qualitative study. Crit Care Med. 2007, 35: 2083-2089. 10.1097/01.ccm.0000281446.15342.74.CrossRefPubMed
26.
Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R: Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001, 286: 2703-2710. 10.1001/jama.286.21.2703.CrossRefPubMed
27.
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: 859-864. 10.1007/s001340100909.CrossRefPubMed
28.
Rabiee F: Focus-group interview and data analysis. Proc Nutr Soc. 2004, 63: 655-660. 10.1079/PNS2004399.CrossRefPubMed
29.
Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, Dittus RS, Bernard GR: Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Crit Care Med. 2004, 32: 106-112. 10.1097/01.CCM.0000098033.94737.84.CrossRefPubMed
30.
Lugtenberg M, Zegers-van Schaick JM, Westert GP, Burgers JS: Why don’t physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci. 2009, 4: 54-10.1186/1748-5908-4-54.CrossRefPubMedPubMedCentral
31.
van den Boogaard M, Pickkers P, van der Hoeven H, Roodbol G, van Achterberg T, Schoonhoven L: Implementation of a delirium assessment tool in the ICU can influence haloperidol use. Crit Care. 2009, 13: R131-10.1186/cc7991.CrossRefPubMedPubMedCentral
32.
Forsgren LM, Eriksson M: Delirium-awareness, observation and interventions in intensive care units: a national survey of Swedish ICU head nurses. Intensive Crit Care Nurs. 2010, 26: 296-303. 10.1016/j.iccn.2010.07.003.CrossRefPubMed
33.
Gurses AP, Marsteller JA, Ozok AA, Xiao Y, Owens S, Pronovost PJ: Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Crit Care Med. 2010, 38: S282-S291. 10.1097/CCM.0b013e3181e69e02.CrossRefPubMed
34.
Cahill NE, Suurdt J, Ouellette-Kuntz H, Heyland DK: Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework. JPEN J Parenter Enteral Nutr. 2010, 34: 616-624. 10.1177/0148607110361904.CrossRefPubMed
35.
Krueger RA: Focus Groups: A practical Guide for Applied Research. 2000, Sage Publications, Thousands Oaks CACrossRef
36.
Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N: Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes.Cochrane Database Syst Rev 2010, CD005470.,
37.
Davies P, Walker AE, Grimshaw JM: A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci. 2010, 5: 14-10.1186/1748-5908-5-14.CrossRefPubMedPubMedCentral
38.
Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M: Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007, 85: 93-138. 10.1111/j.1468-0009.2007.00478.x.CrossRefPubMedPubMedCentral
39.
40.
Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, Harding SD, Bernard GR, Dittus RS, Ely EW: Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med. 2005, 33: 1199-1205. 10.1097/01.CCM.0000166867.78320.AC.CrossRefPubMed
41.
42.
de Vos Maartje LG, van der Veer SN, Graafmans WC, de Keizer NF, Jager KJ, Westert GP, van der Voort PH: Process evaluation of a tailored multifaceted feedback program to improve the quality of intensive care by using quality indicators. BMJ Qual Saf. 2013, 22: 233-241. 10.1136/bmjqs-2012-001375.CrossRefPubMed
43.
Hakkaart-van Roijen L, Tan SS, Bouwmans CAM: Manual for costing research. Methods and guideline prices for economic evaluations of health care interventions (2010 updated edition) [In Dutch]. 2010, Health Care Insurance Board, Diemen
44.
Trogrlic Z, Van der Jagt M, Bakker J, Balas M, Ely E, Van den Voort P, Ista E: Delirium screening, prevention and treatment in the ICU: a systematic review of implementation strategies. Crit Care. 2014, 18: P423-10.1186/cc13613.CrossRefPubMedCentral
45.
Riekerk B, Pen EJ, Hofhuis JG, Rommes JH, Schultz MJ, Spronk PE: Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit. Intensive Crit Care Nurs. 2009, 25: 242-249. 10.1016/j.iccn.2009.04.001.CrossRefPubMed
46.
Roberts B, Rickard CM, Rajbhandari D, Turner G, Clarke J, Hill D, Tauschke C, Chaboyer W, Parsons R: Multicentre study of delirium in ICU patients using a simple screening tool. Aust Crit Care. 2005, 18: 6-10.1016/S1036-7314(05)80019-0. 8-9, 11-14 passimCrossRefPubMed
47.
Soja SL, Pandharipande PP, Fleming SB, Cotton BA, Miller LR, Weaver SG, Lee BT, Ely EW: Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients. Intensive Care Med. 2008, 34: 1263-1268. 10.1007/s00134-008-1031-x.CrossRefPubMedPubMedCentral
48.
49.
Stein-Parbury J, Liaschenko J: Understanding collaboration between nurses and physicians as knowledge at work. Am J Crit Care. 2007, 16: 470-477. quiz 478PubMed
50.
Eccles M, Grimshaw J, Campbell M, Ramsay C: Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care. 2003, 12: 47-52. 10.1136/qhc.12.1.47.CrossRefPubMedPubMedCentral
51.
Metadata
Title
Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECePTIvE study
Authors
Erwin Ista
Zoran Trogrlic
Jan Bakker
Robert Jan Osse
Theo van Achterberg
Mathieu van der Jagt
Publication date
01-12-2014
Publisher
BioMed Central
Published in
Implementation Science / Issue 1/2014
Electronic ISSN: 1748-5908
DOI
https://doi.org/10.1186/s13012-014-0143-7

Other articles of this Issue 1/2014

Implementation Science 1/2014 Go to the issue

Study protocol

Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program

Research

Enhancing outreach for persons with serious mental illness: 12-month results from a cluster randomized trial of an adaptive implementation strategy

Research

Implementation of multidimensional knowledge translation strategies to improve procedural pain in hospitalized children

Systematic review

Using the Knowledge to Action Framework in practice: a citation analysis and systematic review

Research

Evaluation of two implementation strategies in 51 child county public service systems in two states: results of a cluster randomized head-to-head implementation trial

Study protocol

Study protocol of an economic evaluation of an extended implementation strategy for the treatment of low back pain in general practice: a cluster randomised controlled trial