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Swiss Med Wkly. 2020 Jan 27;150:w20185. doi: 10.4414/smw.2020.20185. eCollection 2020 Jan 13.

Implementation of a multiprofessional, multicomponent delirium management guideline in two intensive care units, and its effect on patient outcomes and nurse workload: a pre-post design retrospective cohort study.

Author information

1
School of Health Professions, ZHAW Zurich University of Applied Science, Winterthur, Switzerland / Centre of Clinical Nursing Science, University Hospital Zurich, Switzerland.
2
Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland.
3
Division of Surgical Intensive Care, University Hospital Zurich, Switzerland.
4
Department of Entomology, Virginia Tech, Blacksburg, USA / Clinical Trial Unit, Institute of Social and Preventive Medicine, University of Bern, Switzerland.
5
Centre for Intensive Care, Cantonal Hospital Winterthur, Switzerland.
6
Faculty of Medicine, Department Public Health, Institute of Nursing Science, University of Basel, Switzerland.
7
Department of Psychiatry and Psychotherapy, University Hospital Zurich, Switzerland / Centre for Gender Variance, University Hospital Basel, Switzerland.
8
Division of Neurology, University of Zurich and University Hospital Zurich, Switzerland.
9
Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Basel, Switzerland.

Abstract

AIM OF THE STUDY:

Delirium is a frequent intensive care unit (ICU) complication, affecting 26% to 80% of ICU patients, often with serious consequences. This study aimed to evaluate the effectiveness, costs and benefits of following a standardised multiprofessional, multicomponent delirium guideline on eight outcomes: delirium prevalence and duration, lengths of stay in ICU and hospital, in-hospital mortality, duration of mechanical ventilation, and cost and nursing hours per case. It also aimed to explore the associations of delirium with length of ICU stay, length of hospital stay and duration of mechanical ventilation.

METHODS:

This retrospective cohort study used a pre-post design. ICU patients in an historical control group (n = 1608) who received standard ICU care were compared with a postintervention group (n = 1684) who received standardised delirium management – delirium risk identification, preventive measures, screening and treatment – with regard to eight outcomes. The delirium management guideline was developed and implemented in 2012 by a group of experts from the study hospital. As appropriate, descriptive statistics and multivariate, multilevel models were used to compare the two groups and to explore the association between delirium occurrence and the selected outcomes.

RESULTS:

Twelve percent of the 1608 historical controls and 20% of the 1684 postintervention patients were diagnosed with delirium according to the ICD-10 delirium diagnosis codes. Patients being treated for heart disease, and those with septic shock, ARDS, renal insufficiency (acute or chronic), older age and higher numbers of comorbidities were significantly more likely to develop delirium during their stay. Multivariate models comparing the historical controls with the post intervention group indicated significant differences in delirium period prevalence (odds ratio 1.68, 95% confidence interval [CI] 1.38–2.06; p <0.001), length of stay in the ICU (time ratio [TR] 0.94, CI 0.89–1.00; p = 0.048), cost per case (median difference 3.83, CI 0.54–7.11; p = 0.023) and duration of mechanical ventilation (TR 0.84, CI 0.77–0.92; p <0.001). The observed differences in the other four outcomes – in-hospital mortality, delirium duration, length of stay in the hospital, and nursing hours per case – were not significant. Delirium was a significant predictor for prolonged duration of mechanical ventilation and for both ICU and hospital stay.

CONCLUSION:

Standardised delirium management, specifically delirium screening, supports timely detection of delirium in ICU patients. Increased awareness of delirium after the implementation of standardised multiprofessional, multicomponent management leads to increased therapeutic attention, a prolongation of ICU stay and increased costs, but with no influence on mortality.

PMID:
31986217
DOI:
10.4414/smw.2020.20185
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