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Delirium—Awareness, observation and interventions in intensive care units: A national survey of Swedish ICU head nurses
Intensive and Critical Care Nursing (2010) 26, 296—303
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
Delirium—–Awareness, observation and interventions in intensive care units: A national survey of Swedish ICU head nurses Lena M. Forsgren a,b,∗, Mats Eriksson c a
Department of Anaesthesiology and Intensive Care, Lindesberg Hospital, Lindesberg, Sweden Department of Quality and Patient Safety, Lindesberg Hospital, Lindesberg, Sweden c Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden b
Accepted 10 July 2010
KEYWORDS Delirium; Assessment; Intensive care unit; Survey
Summary Objectives: To survey the awareness and observation of delirium, and interventions used for delirium in Swedish intensive care units (ICUs) and to examine the influence of hospital categories and staff education on the afore-mentioned. Design: A questionnaire was sent to all Swedish adult patient ICUs (n = 82) and completed by 55 units. Results: The reported prevalence of delirium was 9.4%. Assessment of delirium was performed by 62% of the ICUs, commonly by observing symptoms. Most of the suggested non-pharmacologic interventions were reported to be used by at least 85% of the units. Drugs were used by 96%, most commonly haloperidol, propofol and benzodiazepines. Written pharmacological guidelines existed in 26% of the units, while 9% had non-pharmacological guidelines. Regular observation of delirium was more common in larger hospitals than in smaller ones and education was associated with reporting a higher prevalence of delirium. Conclusion: As in other countries, this study demonstrated that the awareness of delirium in ICUs is low with a lack of implementation of validated screening tools for its diagnosis. Emphasis should be placed on education and implementation of these tools to improve the quality of care for ICU patients. © 2010 Elsevier Ltd. All rights reserved.
Delirium is a disturbance of consciousness, a change in cognition or perception that develops over a short time period and is caused by medical circumstances (American Psychiatric
∗ Corresponding author at: Lindesberg Hospital, S-711 82 Lindesberg, Sweden. Tel.: +46 581 85116. E-mail address: [email protected] (L.M. Forsgren).
Association, 1999). Delirium symptoms include agitation, restlessness, irrelevant speech, fear and overreaction to stimuli or decrease in psychomotor behaviour (Marshall and Soucy, 2003). Delirium is associated with increased mortality (Lin et al., 2004; Van Rompaey et al., 2009), long-term reduced quality of life (Van Rompaey et al., 2009), prolonged intensive care (Lat et al., 2009; Truman and Ely, 2003) and hospital stay (Ely et al., 2001a; Lat et al., 2009). Inci-
0964-3397/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2010.07.003
Delirium in intensive care units dence/prevalence of delirium has been reported from 11% to 87% in intensive care units (ICUs) (Aldemir et al., 2001; Ely et al., 2001b,c; Immers et al., 2005; Roberts, 2004; Van Rompaey et al., 2009). There are special considerations in delirium assessment of intensive-care patients as they are often unable to speak (Truman and Ely, 2003). The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (Ely et al., 2001b,c; McNicoll et al., 2005) and the Intensive Care Delirium Screening Checklist (ICDSC) (Bergeron et al., 2001) are non-verbal tools validated to assess delirium in ICU patients. Further, the Cognitive Test for Delirium (CTD) (Hart et al., 1996) and the Abbreviated CTD (Hart et al., 1997) were developed for delirium in the ICU setting, but lately do not appear to be used. All of these tools derive from criteria according to Diagnostic and Statistical Model for Mental Disorders, fourth edition (DSM-IV) (American Psychiatric Association, 1999) and demonstrate good reliability and validity as well as high sensitivity and specificity. In later years, the Neelon and Champagne Confusion Scale (NEECHAM) (Neelon et al., 1996) has been adopted into ICU settings (Immers et al., 2005; Van Rompaey et al., 2008), but are not used in intubated patients. Interventions to reduce delirium in acute hospital care mainly describe multi-component non-pharmacological interventions (Table 1). Pharmacological interventions seem to principally be on the subject of antipsychotics, especially ‘atypical antipsychotics’ (Han et al., 2004; Kalisvaart et al., 2005; Lee et al., 2005; Sipahimalani et al., 1998; Skrobik et al., 2004). Few studies (Devlin et al., 2008a; Ely et al., 2004; Mehta et al., 2006; Patel et al., 2009; Van Eijk et al., 2008) report on the use of delirium evaluation, pharmacological interventions or staff education regarding delirium, in intensive care settings. The use of non-pharmacological interventions does not seem to be surveyed. The primary aim of this study was therefore to investigate the awareness and observation of delirium and interventions used to prevent and treat delirium in Swedish ICUs, related to category of hospital and recent educational efforts.
Methods Design, setting and sample This survey, with a descriptive design, was distributed to Swedish ICUs that were identified from the national healthcare address register and was completed in November 2006 (Hsiinfo, 2006). The inclusion criteria were units providing adult care and having ‘intensive care’ in the name or described as providing advanced supervision, diagnostics or treatment of patients with threatening or manifest vital organ failure. ICUs with exclusively cardiac care were excluded, as the length of stay can be short and staff experience of delirium is limited. Finally, 82 ICUs were identified.
Questionnaire development and data collection A data-collection plan was formulated and carried out (Fig. 1). The questionnaire, developed for this study, consisted of 18 questions. With the exception of three questions
297
Figure 1
Data collection procedure.
concerning demographics, all were close-ended and some were dichotomous. Most of the questions also had an open-response alternative. The questionnaire was divided into three main sections related to the objective areas observation/assessment and non-pharmacological and pharmacological interventions for delirium. The three question areas were operationalised by a systematic literature review in November 2005—February 2006 using Medline, Cinahl and PsychInfo, including studies published from 2000 to 2006. The main search words (‘delirium’/‘acute confusion’) were selected to find relevant literature in the three areas. Due to a lack of studies concerning delirium in the ICU, other groups of acute care inpatients were also included in the literature review. Based on the literature at the time, four non-verbal assessment tools were listed as response alternatives: the ICDSC (Bergeron et al., 2001), the CTD (Hart et al., 1996), the abbreviated CTD (Hart et al., 1997) and the CAM-ICU (Ely et al., 2001b,c; McNicoll et al., 2005), with the possibility of adding free text. The suggested interventions in the literature (Table 1) were used as response alternatives in the non-pharmacological interventions section. Response alternatives for pharmacological interventions identified in the literature were amilsurpride (Lee et al., 2005), haloperidol (Han et al., 2004; Kalisvaart et al., 2005; Sipahimalani et al., 1998; Skrobik et al., 2004), olanzapine (Sipahimalani et al., 1998; Skrobik et al., 2004), quetiapine (Lee et al., 2005) and risperidone (Han et al., 2004). The literature suggested a number of risk factors and risk groups, including hypertension (Dubois et al., 2001), respiratory disease (Aldemir et al., 2001) and older age (Pandharipande et al., 2006), which also were used to develop response alternatives for the questions. Finally, the responders were also asked to provide the point prevalence of delirium patients at the unit,
298
Table 1
Non-pharmacological interventions resulting in decreased delirium.
Author, sample size
Interventions Contact with relatives encouraged
Gustafson (1991), Pre/post-surgery n = 214 Inouye (1999), General medicine n = 852 Lundström (1999), Pre/post-surgery n = 35—170 X Marcantanio (2001), Post-surgery n = 126 Milisen (2001), Post-surgery n = 120 Aizawa (2002), Post-surgical n = 42 Lundström (2005), Medicine n = 400 Naughton (2005), Medicine n = 374 X Tabet (2005), Medicine n = 205 Author, sample size
Calm/familiar environment
Orientation Person present when anxious/agitated
Stimulance Sufficient hearing
Sufficient sight
Adequate hydration
X
X
X
X
X
X X
X
X
X
X
X
Adequate nutritional intake
X X
Bowel/bladder function normalised
Reduce physical restraints
Mobilisation
X
X X X
X
X
X
X
Interventions Maintain sleep and diurnal rhythm
Gustafson (1991), Pre/post-surgery n = 214 Inouye (1999), General medicine n = 852 X Lundström (1999), Pre/post-surgery n = 35—170 Marcantanio (2001), Post-surgery n = 126 Milisen (2001), Post-surgery n = 120 Aizawa (2002), Post-surgical n = 42 X Lundström (2005), Medicine n = 400 Naughton (2005), Medicine n = 374 Tabet (2005), Medicine n = 205
Adequate CNS oxygenation
Pain treatment
X X X
X X X
Anesthetic technique
Early operation
Thrombosis prophylaxis
X
X
X
X
X
Treat baseline disease X X X
Removal of unnecessary medications
X
Special physician consultation X
Individual care
Continuity in care
Staff education
X X X
X
X
X X
X X
X
X
X X X
L.M. Forsgren, M. Eriksson
Delirium in intensive care units Table 2
Demographics.
Category of hospital County hospital Regional hospital University hospital Unit type General Thoracic Neuro Burns Other Number of beds Median (inter quartile range, IQR) a
299
Included ICUs n = 55 % (n)
Non-responders/excluded ICUs n = 26 % (n)
40.0 (22) 32.7 (18) 27.3 (15)
38.5 (10) 19.2 (5) 42.3 (11)
76.4 7.3 3.5 5.5 7.3
69.3 7.7 11.5 0.0 11.5
(42) (4) (2) (3) (4)
8.0 (4,0)
(18) (2) (3) (0) (3)
8.0 (3.8)a
n = 22; ICUs where number of beds could be estimated (Hsiinfo, 2006).
at the time of answering the questionnaire, according to the observation method normally used at the unit. The questionnaire was tested in three steps and the questions were modified between each step. Initially, an expert on delirium evaluated ‘content validity’ and approved the questions. In the next step, the questions’ clarity, face validity and time to respond to the questionnaire were tested. The inter-rater reliability was calculated to 68—85%. In the last step, test—retest reliability was assessed. For each question except those regarding demographics, the kappa coefficient (Ä) was calculated and found to vary between 0.05 and 1. Most of the questions had excellent agreement. Six questions, however, showed poor or moderate agreement and were improved using the responders’ comments. The questions with the lowest Ä were removed or revised. The four ICUs that participated in the development of the questionnaire were not included in the study. The questionnaire was sent by post to head nurses in 82 ICUs with a cover letter and a prepaid envelope. The head nurses were encouraged in the cover letter to consult an intensive care nurse in the unit if there were any difficulties in answering any question. Confidentiality was also guaranteed in the cover letter. A reminder was sent after two weeks to non-responders.
Ethical considerations The respondents were informed about the study objectives and procedures, and that participation was voluntary and could be discontinued at any time. Data have been treated confidentially throughout the study. Because no patients were involved ethical approval was not necessary.
Data analysis Data were analysed with descriptive statistics and comparisons were made with non-parametric statistics using Microsoft Excel 2000 (Redmond, WA, USA) and the statistical program Vassar Stats (Lowry, 2008). Median and interquartile range (IQR) were used to illustrate data on
the interval level as there were extreme values. Nominal level data are reported with absolute and relative frequencies. For open-ended questions, categories were created using content analysis (Jackson and Furnham, 2003) and subsequently analysed with descriptive statistics. For comparisons, the chi-square or Fischer’s exact test was used on nominal level data and the Mann—Whitney U-test on interval level data. The significance level was set to 0.05. Comparative analysis was performed to examine differences between hospital categories in delirium prevalence, assessment, interventions and guidelines. In addition, the influence of staff education on the reported prevalence and management of delirium was analysed.
Results Demographics Of the 82 ICUs contacted, 58 (71%) responded to the questionnaire. One was excluded, as the unit reported not caring for intensive care patients. Two were excluded because only demographics were reported. Finally, 55 ICUs were included in the analysis. The number of beds ranged from 3 to 18 (median 8; IQR 4.0). The median number of patients that were admitted to the ICUs at the time of responding was five (IQR 2.6). The category of hospital of non-responders did not differ significantly from those of the included ICUs (p = 0.30). The type of unit did not differ between the groups of responders and non-responders (p = 0.44) (Table 2).
Observation of delirium The prevalence of delirium, as evaluated by respondents at the time of replying to the questionnaires, was 9.4% (n = 26) in altogether 276 ICU patients admitted to the responding units. Thirty-four ICUs (62%) reported using a method for observation of delirium. Only one unit used a standardised delirium instrument (the CAM-ICU) while the remaining
300
Figure 2
L.M. Forsgren, M. Eriksson
Proportion of units reporting the use of non-pharmacological interventions aiming to reduce risk factors (n = 55).
units reported other methods, mostly observation of clinical symptoms (n = 24; 44%). Assessment intervals varied, the most commonly reported being 2—4 times per day (n = 14; 45%) and observation more often than once per hour (n = 9; 29%). Three of the 34 units using a method for observation of delirium did not answer this question. In the 34 ICUs that reported using a method for delirium observation, 16 (47%) paid special attention to at least one category of patients presented in the questionnaire. Patients with alcohol addiction were specially noticed by 15 (94%) of those ICUs and patients with dementia and with cerebrovascular disease by half (50%) of the 16 units. Seven (44%) ICUs paid attention to older patients and six (37%) to those with mental-health problems. The smallest categories that were specially noticed were patients with vision problems, functional disability, men and smokers, all reported from one each of the 16 units.
Figure 3
Non-pharmacological interventions Non-pharmacological interventions aiming at reducing risk factors were practised to a great extent. Most of the interventions suggested in the survey were used by ≥47 (≥85%) ICUs, except continuity in care (n = 42; 76%) and restriction of particular medications (n = 37; 67%) (Fig. 2). Concerning non-pharmacological interventions not directly associated with risk factors, relatives were informed about the syndrome by all of the ICUs (100%). Patients themselves were informed by 44 of the 54 answering units (81%) and followup with access to psychological support were practised by 17 (31%) ICUs. Consultation of a geriatrician or a psychiatrist was performed in 28 of 54 ICUs (52%) and staff education on delirium in the preceding year was reported by seven (13%) of the ICUs. Five units had existing written delirium guidelines regarding non-pharmacological interventions.
Proportion of units reporting the use of the drugs suggested in the survey (n = 53).
Delirium in intensive care units Special attention, when performing non-pharmacological interventions, was paid to one or more categories of patients by 11 (23%) of 48 responders to this question. A large proportion of these 11 units concerned patients with alcohol addiction (n = 9; 82%), dementia (n = 8; 73%) or psychological health problems (n = 8; 73%). Less attention was paid to male gender (n = 1; 9%).
Pharmacological interventions Two ICUs did not use any medication at all to reduce delirium (two units did not answer this question). The most common drugs used by the 51 ICUs reporting medication were haloperidol (n = 49; 96%), propofol (n = 46; 90%) and benzodiazepines (n = 39; 76%). Antipsychotics other than haloperidol were used by only a few units (Fig. 3). The existence of written pharmacological guidelines was reported by 14 (26%) of the 54 ICUs answering this question.
Comparison of groups No significant difference was found in the observed prevalence of delirium between larger regional/university hospitals and smaller county hospitals. However, a method for observation of delirium was more often used in larger hospitals (73%) than in smaller ones (41%) (p = 0.018). No differences between hospital categories were recognised concerning the use of non-pharmacological interventions (adequate hydration, orientation, access to news media, mobilisation outside the unit, sufficient hearing and sight, reduced physical restraints and sleep facilitating) or in availability of non-pharmacological guidelines. No differences were reported between hospital categories concerning staff education about delirium in the preceding year, expert consultation or follow-up with psychological support to patients after an episode of delirium. When comparing the use of pharmacological interventions (haloperidol, benzodiazepines and ‘atypical’ antipsychotics) and the existence of pharmacological guidelines, there were no significant differences between hospital categories. Whether staff education with respect to delirium had been carried out or not in the preceding year had no influence on the occurrence of delirium observation or on the use of non-pharmacological interventions (adequate hydration, orientation, access to news media, mobilisation outside the unit, sufficient hearing and sight, reduced physical restraints and sleep facilitating). Neither did staff education influence the use of haloperidol, benzodiazepines and ‘atypical’ antipsychotics. The reported prevalence of delirium was, however, significantly lower in units that had not provided staff education on delirium (7%) than in units that performed delirium education in the preceding year (26%) (p = 0.001).
Discussion In this study, the reported observed prevalence of delirium was 9%, while 11—87% ICU delirium incidence/prevalence was reported in earlier international research (Aldemir et al., 2001; Ely et al., 2001b,c; Immers et al., 2005; Roberts, 2004; Van Rompaey et al., 2009). Because only one unit reported using a standardised instrument (the CAM-ICU) in
301 the present study, there is reason to regard this figure as uncertain. Furthermore, in a previous study, ICU delirium has been reported to be under-recognised (Spronk et al., 2009), which could indicate the prevalence also in this study to be underestimated. In agreement with a Canadian (Mehta et al., 2006) and an American survey (Ely et al., 2004) and also in agreement with a recently published study from Australia (Shehabi et al., 2008), assessment tools were rarely used in the present study. Figures were, respectively, Canada 3.7%, Australia 9%, the United States 16% and Sweden 1.8%. A plausible explanation of this result is the fact that delirium scales in the Swedish language have been absent until recently, when the CAM-ICU was translated (Larsson et al., 2007). All ICUs, as expected, practised the majority of the suggested non-pharmacological interventions, though nearly all of these actions are included in usual care. There seems to be a lack of studies regarding non-pharmacological interventions. One reason could be the difficulty to delimitate these as interventions directed to treat delirium, making it difficult to create and answer specific questions — a limitation also of this study. The fact that 62% of the responding ICUs reported that they observed delirium while even more reported practising interventions (86% non-pharmacological and 96% pharmacological) could indicate that there is confusion about ICU delirium. Concerning guidelines, this study showed that only a few units had written non-pharmacological strategies while one-quarter had pharmacological guidelines. The lack of guidelines has also been found in a European survey, also including Sweden (Leentjens and Diefenbacher, 2006), where no Swedish national delirium guidelines were reported, not even local ones. Some other European countries reported nationwide or institutional guidelines, but not concerning ICUs. The lack of ICU delirium guidelines could be due to limited research concerning delirium in ICU patients, and could indicate that delirium is not experienced as a problem — but also that the syndrome is under-observed. Among specially noticed patient categories, alcohol addiction dominated, being foremost in assessment (94%) but also regarding non-pharmacological interventions (82%). This finding could be due to the fact that delirium is considered to be the same as alcohol delirium — a fact also indicated by the guidelines collected with the questionnaire. This condition might indicate a need for education on the subject. However, only seven (13%) ICUs had accomplished delirium education in the preceding year. Nevertheless, staff education is of importance to reduce delirium and education has been shown to improve delirium recognition (Devlin et al., 2008b; Tabet et al., 2005). In the present study, units that had performed recent staff education indicated a higher prevalence of delirium, suggesting an increased awareness as a result of the education, rather than an increase in prevalence.
Methodological considerations The results of the present study are based on generalisations and individual opinions of representatives of the ICUs, rather than on objective data. The questionnaire and the
302 information letter were sent to the head nurses of the ICUs, who were asked to report about actual policies at the unit, and to check with co-workers if anything was unclear. There is, however, no information on how representative the answers are of the actual situation at the unit, or whose opinion they reflect. Moreover, the questionnaire was based on studies concerning risk factors and interventions not only for ICU patients but also for other emergency inpatients, mostly post-surgery. Post-surgery patients are, however, often observed in ICUs, as are risk factors and interventions identified in other environments in emergency hospitals. Therefore, results from these studies could be useful even in intensive care. Furthermore, the questionnaire was tested with respect to clarity, validity, inter-rater reliability and test—retest reliability, and the response rate could be considered satisfactory. In spite of the study limitations, this national survey presumably indicates a valid picture of delirium management in Swedish ICUs.
Conclusion As in other countries, this study demonstrates that the awareness of delirium in Swedish ICUs is low with a lack of implementation of validated screening tools for its diagnosis. Emphasis should be put on education and implementation of these tools, to improve the quality of care for ICU patients. Because there seems to be a lack of research on the subject of ICU delirium, especially intervention studies and because the syndrome is combined with severe consequences, additional research is needed. Existing recommendations should, however, be followed until further notice, combined with staff education.
Conflict of interest This study was supported by Lindesbergs Hospital, who is also the employer of Lena M Forsgren. This, however, causes no conflict of interest.
Acknowledgements We would like to express our gratitude to those taking part in the tests of the questionnaire and to the study participants.
References Aizawa K, Kanai T, Saikawa Y, Takabayashi T, Kawano Y, Miyazawa N, et al. A novel approach to the prevention of postoperative delirium in the elderly after gastrointestinal surgery. Surg Today 2002;32(4):310—4. Aldemir M, Özen S, Kara IH, Sir A, Bac ¸ B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5:265—70. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999;156:1—20. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y, Bergeron N, et al. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med 2001;27:859—64. Devlin JW, Marquis F, Riker RR, Robbins T, Garpestad E, Fong JJ, et al. Combined didactic and scenario-based education improves
L.M. Forsgren, M. Eriksson the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 2008b;12(1):R19. Devlin JW, Fong JJ, Howard EP, Skrobik Y, Yasuda C, Marshall J. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care 2008a;17(6):555—65. Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 2001;27(8):1297—304. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001a;27:1892—900. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (cam-icu). JAMA 2001b;286:2703—10. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (camicu). Crit Care Med 2001c;29:1370—9. Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, et al. 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—12. Gustafson Y, Brännström B, Berggren D, Ragnarsson JI, Sigaard J, Bucht G, et al. A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc 1991;39(7):655—62. Han CS, Kim YK, Han C-S, Kim Y-K. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004;45:297—301. Hart RP, Best AM, Sessler CN, Levenson JL. Abbreviated cognitive test for delirium. J Psychosom Res 1997;43:417—23. Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE. Validation of a cognitive test for delirium in medical icu patients. Psychosomatics 1996;37:533—46. Hsiinfo. 2006 [cited 2006 August 01]. Available from: http://www.hsiinfo.se/index.html. Immers H, Schuurmans MJ, van der Bijl JJ. Recognition of delirium in ICU patients: a diagnostic study of the NNCHAM confusion scale in ICU patients. BMC Nursing 2005;4:7. Inouye SK, Bogardus Jr ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New Engl J Med 1999;340(9):669—76. Jackson C, Furnham A. Designing and analysing questionnaires and surveys: a manual for health professionals and administrators. London: Whurr; 2003. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC, Burger BJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005;53:1658—66. Larsson C, Axell AG, Ersson A. Confusion assessment method for the intensive care unit (CAM-ICU): translation, retranslation and validation into Swedish intensive care settings. Acta Anesthesiol Scand 2007;51(7):888—92. Lat I, McMillian W, Taylor S, Janzen JM, Papadopoulus S, Korth L, et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med 2009;37:1898—905. Lee KU, Won WY, Lee HK, Kweon YS, Lee CT, Pae CU, et al. Amisulpride versus quetiapine for the treatment of delirium: a randomized, open prospective study. Int Clin Psychopharmacol 2005;20:311—4. Leentjens AFG, Diefenbacher A. A survey of delirium guidelines in Europe. J Psychosom Res 2006;61:123—8. Lin S-M, Liu C-Y, Wang C-H, Lin H-C, Huang C-D, Huang P-Y, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004;32:2254—9.
Delirium in intensive care units Lowry R. Vassarstats — web site for statistical computation. Poughkeepsie, NY, USA: Vassar College; 2008. Available from: http://faculty.vassar.edu/lowry/VassarStats.html. Lundström M, Edlund A, Lundström G, Gustafson Y. Reorganization of nursing and medical care to reduce incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 1999;13(3):193—200. Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustavsson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 2005;53(4):622—8. Marcantanio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49(5):516—22. Marshall MC, Soucy MD. Delirium in the intensive care unit. Crit Care Nurs Q 2003;26:172—8. McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK, McNicoll L, et al. Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. J Am Geriatr Soc 2005;53:495—500. Mehta S, Burry L, Fischer S, Martinez-Motta JC, Hallett D, Bowman D, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med 2006;34:374—80. Milisen K, Foreman MD, Abraham IL, Godderis J, Vandermeulen E, Fischler B, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001;49(5):523—32. Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R, Mylotte JM. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc 2005;53(1):18—23. Neelon VJ, Champagne MT, Carlson JR, Funk SG. The NEECHAM Confusion Scale: construction, validation and clinical testing. Nurs Res 1996;45:324—30. Pandharipande P, Shintani A, Peterson J, Truman B, Wilkinson GR, Dittus RS, et al. Lorazepam is an independent risk factor for
303 transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104:21—6. Patel RP, Gambrell M, Speroff T, Scott TA, Pun BT, Okahashi J, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med 2009;37(3):825—32. Roberts B. Screening for delirium in an adult intensive care unit. Intensive Crit Care Nurs 2004;20:206—13. Shehabi Y, Botha JA, Boyle MS, Ernest D, Freebairn RC, Jenkins IR, et al. Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesth Intensive Care 2008;36:570—8. Sipahimalani A, Masand PS, Sipahimalani A, Masand PS. Olanzapine in the treatment of delirium. Psychosomatics 1998;39:422— 30. Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med 2004;30:444—9. 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—80. Tabet N, Hudson S, Sweeney V, Sauer J, Bryant C, Macdonald A, et al. An educational intervention can prevent delirium on acute medical wards. Age Ageing 2005;34:152—6. Truman B, Ely EW. Monitoring delirium in critically ill patients. Using the confusion assessment method for the intensive care unit. Crit Care Nurse 2003;23:25—36. Van Eijk MM, Kesecioglu J, Slooter AJ. Intensive care delirium monitoring and standardised treatment: a complete survey of Dutch Intensive Care Units. Intesive Crit Care Nurs 2008;24(4):218— 21. Van Rompaey B, Shortridge-Baggett LM, Truijen S, Elseviers M, Bossaert L. A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients. Crit Care 2008;12(1):R16. Van Rompaey B, Shuurmans MJ, Shortridge-Baggett LM, Truijen S, Elseviers M, Bossaert L. Long term outcome after delirium in the intensive care unit. J Clin Nurs 2009;18:3349—57.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
Delirium—–Awareness, observation and interventions in intensive care units: A national survey of Swedish ICU head nurses Lena M. Forsgren a,b,∗, Mats Eriksson c a
Department of Anaesthesiology and Intensive Care, Lindesberg Hospital, Lindesberg, Sweden Department of Quality and Patient Safety, Lindesberg Hospital, Lindesberg, Sweden c Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden b
Accepted 10 July 2010
KEYWORDS Delirium; Assessment; Intensive care unit; Survey
Summary Objectives: To survey the awareness and observation of delirium, and interventions used for delirium in Swedish intensive care units (ICUs) and to examine the influence of hospital categories and staff education on the afore-mentioned. Design: A questionnaire was sent to all Swedish adult patient ICUs (n = 82) and completed by 55 units. Results: The reported prevalence of delirium was 9.4%. Assessment of delirium was performed by 62% of the ICUs, commonly by observing symptoms. Most of the suggested non-pharmacologic interventions were reported to be used by at least 85% of the units. Drugs were used by 96%, most commonly haloperidol, propofol and benzodiazepines. Written pharmacological guidelines existed in 26% of the units, while 9% had non-pharmacological guidelines. Regular observation of delirium was more common in larger hospitals than in smaller ones and education was associated with reporting a higher prevalence of delirium. Conclusion: As in other countries, this study demonstrated that the awareness of delirium in ICUs is low with a lack of implementation of validated screening tools for its diagnosis. Emphasis should be placed on education and implementation of these tools to improve the quality of care for ICU patients. © 2010 Elsevier Ltd. All rights reserved.
Delirium is a disturbance of consciousness, a change in cognition or perception that develops over a short time period and is caused by medical circumstances (American Psychiatric
∗ Corresponding author at: Lindesberg Hospital, S-711 82 Lindesberg, Sweden. Tel.: +46 581 85116. E-mail address: [email protected] (L.M. Forsgren).
Association, 1999). Delirium symptoms include agitation, restlessness, irrelevant speech, fear and overreaction to stimuli or decrease in psychomotor behaviour (Marshall and Soucy, 2003). Delirium is associated with increased mortality (Lin et al., 2004; Van Rompaey et al., 2009), long-term reduced quality of life (Van Rompaey et al., 2009), prolonged intensive care (Lat et al., 2009; Truman and Ely, 2003) and hospital stay (Ely et al., 2001a; Lat et al., 2009). Inci-
0964-3397/$ — see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2010.07.003
Delirium in intensive care units dence/prevalence of delirium has been reported from 11% to 87% in intensive care units (ICUs) (Aldemir et al., 2001; Ely et al., 2001b,c; Immers et al., 2005; Roberts, 2004; Van Rompaey et al., 2009). There are special considerations in delirium assessment of intensive-care patients as they are often unable to speak (Truman and Ely, 2003). The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (Ely et al., 2001b,c; McNicoll et al., 2005) and the Intensive Care Delirium Screening Checklist (ICDSC) (Bergeron et al., 2001) are non-verbal tools validated to assess delirium in ICU patients. Further, the Cognitive Test for Delirium (CTD) (Hart et al., 1996) and the Abbreviated CTD (Hart et al., 1997) were developed for delirium in the ICU setting, but lately do not appear to be used. All of these tools derive from criteria according to Diagnostic and Statistical Model for Mental Disorders, fourth edition (DSM-IV) (American Psychiatric Association, 1999) and demonstrate good reliability and validity as well as high sensitivity and specificity. In later years, the Neelon and Champagne Confusion Scale (NEECHAM) (Neelon et al., 1996) has been adopted into ICU settings (Immers et al., 2005; Van Rompaey et al., 2008), but are not used in intubated patients. Interventions to reduce delirium in acute hospital care mainly describe multi-component non-pharmacological interventions (Table 1). Pharmacological interventions seem to principally be on the subject of antipsychotics, especially ‘atypical antipsychotics’ (Han et al., 2004; Kalisvaart et al., 2005; Lee et al., 2005; Sipahimalani et al., 1998; Skrobik et al., 2004). Few studies (Devlin et al., 2008a; Ely et al., 2004; Mehta et al., 2006; Patel et al., 2009; Van Eijk et al., 2008) report on the use of delirium evaluation, pharmacological interventions or staff education regarding delirium, in intensive care settings. The use of non-pharmacological interventions does not seem to be surveyed. The primary aim of this study was therefore to investigate the awareness and observation of delirium and interventions used to prevent and treat delirium in Swedish ICUs, related to category of hospital and recent educational efforts.
Methods Design, setting and sample This survey, with a descriptive design, was distributed to Swedish ICUs that were identified from the national healthcare address register and was completed in November 2006 (Hsiinfo, 2006). The inclusion criteria were units providing adult care and having ‘intensive care’ in the name or described as providing advanced supervision, diagnostics or treatment of patients with threatening or manifest vital organ failure. ICUs with exclusively cardiac care were excluded, as the length of stay can be short and staff experience of delirium is limited. Finally, 82 ICUs were identified.
Questionnaire development and data collection A data-collection plan was formulated and carried out (Fig. 1). The questionnaire, developed for this study, consisted of 18 questions. With the exception of three questions
297
Figure 1
Data collection procedure.
concerning demographics, all were close-ended and some were dichotomous. Most of the questions also had an open-response alternative. The questionnaire was divided into three main sections related to the objective areas observation/assessment and non-pharmacological and pharmacological interventions for delirium. The three question areas were operationalised by a systematic literature review in November 2005—February 2006 using Medline, Cinahl and PsychInfo, including studies published from 2000 to 2006. The main search words (‘delirium’/‘acute confusion’) were selected to find relevant literature in the three areas. Due to a lack of studies concerning delirium in the ICU, other groups of acute care inpatients were also included in the literature review. Based on the literature at the time, four non-verbal assessment tools were listed as response alternatives: the ICDSC (Bergeron et al., 2001), the CTD (Hart et al., 1996), the abbreviated CTD (Hart et al., 1997) and the CAM-ICU (Ely et al., 2001b,c; McNicoll et al., 2005), with the possibility of adding free text. The suggested interventions in the literature (Table 1) were used as response alternatives in the non-pharmacological interventions section. Response alternatives for pharmacological interventions identified in the literature were amilsurpride (Lee et al., 2005), haloperidol (Han et al., 2004; Kalisvaart et al., 2005; Sipahimalani et al., 1998; Skrobik et al., 2004), olanzapine (Sipahimalani et al., 1998; Skrobik et al., 2004), quetiapine (Lee et al., 2005) and risperidone (Han et al., 2004). The literature suggested a number of risk factors and risk groups, including hypertension (Dubois et al., 2001), respiratory disease (Aldemir et al., 2001) and older age (Pandharipande et al., 2006), which also were used to develop response alternatives for the questions. Finally, the responders were also asked to provide the point prevalence of delirium patients at the unit,
298
Table 1
Non-pharmacological interventions resulting in decreased delirium.
Author, sample size
Interventions Contact with relatives encouraged
Gustafson (1991), Pre/post-surgery n = 214 Inouye (1999), General medicine n = 852 Lundström (1999), Pre/post-surgery n = 35—170 X Marcantanio (2001), Post-surgery n = 126 Milisen (2001), Post-surgery n = 120 Aizawa (2002), Post-surgical n = 42 Lundström (2005), Medicine n = 400 Naughton (2005), Medicine n = 374 X Tabet (2005), Medicine n = 205 Author, sample size
Calm/familiar environment
Orientation Person present when anxious/agitated
Stimulance Sufficient hearing
Sufficient sight
Adequate hydration
X
X
X
X
X
X X
X
X
X
X
X
Adequate nutritional intake
X X
Bowel/bladder function normalised
Reduce physical restraints
Mobilisation
X
X X X
X
X
X
X
Interventions Maintain sleep and diurnal rhythm
Gustafson (1991), Pre/post-surgery n = 214 Inouye (1999), General medicine n = 852 X Lundström (1999), Pre/post-surgery n = 35—170 Marcantanio (2001), Post-surgery n = 126 Milisen (2001), Post-surgery n = 120 Aizawa (2002), Post-surgical n = 42 X Lundström (2005), Medicine n = 400 Naughton (2005), Medicine n = 374 Tabet (2005), Medicine n = 205
Adequate CNS oxygenation
Pain treatment
X X X
X X X
Anesthetic technique
Early operation
Thrombosis prophylaxis
X
X
X
X
X
Treat baseline disease X X X
Removal of unnecessary medications
X
Special physician consultation X
Individual care
Continuity in care
Staff education
X X X
X
X
X X
X X
X
X
X X X
L.M. Forsgren, M. Eriksson
Delirium in intensive care units Table 2
Demographics.
Category of hospital County hospital Regional hospital University hospital Unit type General Thoracic Neuro Burns Other Number of beds Median (inter quartile range, IQR) a
299
Included ICUs n = 55 % (n)
Non-responders/excluded ICUs n = 26 % (n)
40.0 (22) 32.7 (18) 27.3 (15)
38.5 (10) 19.2 (5) 42.3 (11)
76.4 7.3 3.5 5.5 7.3
69.3 7.7 11.5 0.0 11.5
(42) (4) (2) (3) (4)
8.0 (4,0)
(18) (2) (3) (0) (3)
8.0 (3.8)a
n = 22; ICUs where number of beds could be estimated (Hsiinfo, 2006).
at the time of answering the questionnaire, according to the observation method normally used at the unit. The questionnaire was tested in three steps and the questions were modified between each step. Initially, an expert on delirium evaluated ‘content validity’ and approved the questions. In the next step, the questions’ clarity, face validity and time to respond to the questionnaire were tested. The inter-rater reliability was calculated to 68—85%. In the last step, test—retest reliability was assessed. For each question except those regarding demographics, the kappa coefficient (Ä) was calculated and found to vary between 0.05 and 1. Most of the questions had excellent agreement. Six questions, however, showed poor or moderate agreement and were improved using the responders’ comments. The questions with the lowest Ä were removed or revised. The four ICUs that participated in the development of the questionnaire were not included in the study. The questionnaire was sent by post to head nurses in 82 ICUs with a cover letter and a prepaid envelope. The head nurses were encouraged in the cover letter to consult an intensive care nurse in the unit if there were any difficulties in answering any question. Confidentiality was also guaranteed in the cover letter. A reminder was sent after two weeks to non-responders.
Ethical considerations The respondents were informed about the study objectives and procedures, and that participation was voluntary and could be discontinued at any time. Data have been treated confidentially throughout the study. Because no patients were involved ethical approval was not necessary.
Data analysis Data were analysed with descriptive statistics and comparisons were made with non-parametric statistics using Microsoft Excel 2000 (Redmond, WA, USA) and the statistical program Vassar Stats (Lowry, 2008). Median and interquartile range (IQR) were used to illustrate data on
the interval level as there were extreme values. Nominal level data are reported with absolute and relative frequencies. For open-ended questions, categories were created using content analysis (Jackson and Furnham, 2003) and subsequently analysed with descriptive statistics. For comparisons, the chi-square or Fischer’s exact test was used on nominal level data and the Mann—Whitney U-test on interval level data. The significance level was set to 0.05. Comparative analysis was performed to examine differences between hospital categories in delirium prevalence, assessment, interventions and guidelines. In addition, the influence of staff education on the reported prevalence and management of delirium was analysed.
Results Demographics Of the 82 ICUs contacted, 58 (71%) responded to the questionnaire. One was excluded, as the unit reported not caring for intensive care patients. Two were excluded because only demographics were reported. Finally, 55 ICUs were included in the analysis. The number of beds ranged from 3 to 18 (median 8; IQR 4.0). The median number of patients that were admitted to the ICUs at the time of responding was five (IQR 2.6). The category of hospital of non-responders did not differ significantly from those of the included ICUs (p = 0.30). The type of unit did not differ between the groups of responders and non-responders (p = 0.44) (Table 2).
Observation of delirium The prevalence of delirium, as evaluated by respondents at the time of replying to the questionnaires, was 9.4% (n = 26) in altogether 276 ICU patients admitted to the responding units. Thirty-four ICUs (62%) reported using a method for observation of delirium. Only one unit used a standardised delirium instrument (the CAM-ICU) while the remaining
300
Figure 2
L.M. Forsgren, M. Eriksson
Proportion of units reporting the use of non-pharmacological interventions aiming to reduce risk factors (n = 55).
units reported other methods, mostly observation of clinical symptoms (n = 24; 44%). Assessment intervals varied, the most commonly reported being 2—4 times per day (n = 14; 45%) and observation more often than once per hour (n = 9; 29%). Three of the 34 units using a method for observation of delirium did not answer this question. In the 34 ICUs that reported using a method for delirium observation, 16 (47%) paid special attention to at least one category of patients presented in the questionnaire. Patients with alcohol addiction were specially noticed by 15 (94%) of those ICUs and patients with dementia and with cerebrovascular disease by half (50%) of the 16 units. Seven (44%) ICUs paid attention to older patients and six (37%) to those with mental-health problems. The smallest categories that were specially noticed were patients with vision problems, functional disability, men and smokers, all reported from one each of the 16 units.
Figure 3
Non-pharmacological interventions Non-pharmacological interventions aiming at reducing risk factors were practised to a great extent. Most of the interventions suggested in the survey were used by ≥47 (≥85%) ICUs, except continuity in care (n = 42; 76%) and restriction of particular medications (n = 37; 67%) (Fig. 2). Concerning non-pharmacological interventions not directly associated with risk factors, relatives were informed about the syndrome by all of the ICUs (100%). Patients themselves were informed by 44 of the 54 answering units (81%) and followup with access to psychological support were practised by 17 (31%) ICUs. Consultation of a geriatrician or a psychiatrist was performed in 28 of 54 ICUs (52%) and staff education on delirium in the preceding year was reported by seven (13%) of the ICUs. Five units had existing written delirium guidelines regarding non-pharmacological interventions.
Proportion of units reporting the use of the drugs suggested in the survey (n = 53).
Delirium in intensive care units Special attention, when performing non-pharmacological interventions, was paid to one or more categories of patients by 11 (23%) of 48 responders to this question. A large proportion of these 11 units concerned patients with alcohol addiction (n = 9; 82%), dementia (n = 8; 73%) or psychological health problems (n = 8; 73%). Less attention was paid to male gender (n = 1; 9%).
Pharmacological interventions Two ICUs did not use any medication at all to reduce delirium (two units did not answer this question). The most common drugs used by the 51 ICUs reporting medication were haloperidol (n = 49; 96%), propofol (n = 46; 90%) and benzodiazepines (n = 39; 76%). Antipsychotics other than haloperidol were used by only a few units (Fig. 3). The existence of written pharmacological guidelines was reported by 14 (26%) of the 54 ICUs answering this question.
Comparison of groups No significant difference was found in the observed prevalence of delirium between larger regional/university hospitals and smaller county hospitals. However, a method for observation of delirium was more often used in larger hospitals (73%) than in smaller ones (41%) (p = 0.018). No differences between hospital categories were recognised concerning the use of non-pharmacological interventions (adequate hydration, orientation, access to news media, mobilisation outside the unit, sufficient hearing and sight, reduced physical restraints and sleep facilitating) or in availability of non-pharmacological guidelines. No differences were reported between hospital categories concerning staff education about delirium in the preceding year, expert consultation or follow-up with psychological support to patients after an episode of delirium. When comparing the use of pharmacological interventions (haloperidol, benzodiazepines and ‘atypical’ antipsychotics) and the existence of pharmacological guidelines, there were no significant differences between hospital categories. Whether staff education with respect to delirium had been carried out or not in the preceding year had no influence on the occurrence of delirium observation or on the use of non-pharmacological interventions (adequate hydration, orientation, access to news media, mobilisation outside the unit, sufficient hearing and sight, reduced physical restraints and sleep facilitating). Neither did staff education influence the use of haloperidol, benzodiazepines and ‘atypical’ antipsychotics. The reported prevalence of delirium was, however, significantly lower in units that had not provided staff education on delirium (7%) than in units that performed delirium education in the preceding year (26%) (p = 0.001).
Discussion In this study, the reported observed prevalence of delirium was 9%, while 11—87% ICU delirium incidence/prevalence was reported in earlier international research (Aldemir et al., 2001; Ely et al., 2001b,c; Immers et al., 2005; Roberts, 2004; Van Rompaey et al., 2009). Because only one unit reported using a standardised instrument (the CAM-ICU) in
301 the present study, there is reason to regard this figure as uncertain. Furthermore, in a previous study, ICU delirium has been reported to be under-recognised (Spronk et al., 2009), which could indicate the prevalence also in this study to be underestimated. In agreement with a Canadian (Mehta et al., 2006) and an American survey (Ely et al., 2004) and also in agreement with a recently published study from Australia (Shehabi et al., 2008), assessment tools were rarely used in the present study. Figures were, respectively, Canada 3.7%, Australia 9%, the United States 16% and Sweden 1.8%. A plausible explanation of this result is the fact that delirium scales in the Swedish language have been absent until recently, when the CAM-ICU was translated (Larsson et al., 2007). All ICUs, as expected, practised the majority of the suggested non-pharmacological interventions, though nearly all of these actions are included in usual care. There seems to be a lack of studies regarding non-pharmacological interventions. One reason could be the difficulty to delimitate these as interventions directed to treat delirium, making it difficult to create and answer specific questions — a limitation also of this study. The fact that 62% of the responding ICUs reported that they observed delirium while even more reported practising interventions (86% non-pharmacological and 96% pharmacological) could indicate that there is confusion about ICU delirium. Concerning guidelines, this study showed that only a few units had written non-pharmacological strategies while one-quarter had pharmacological guidelines. The lack of guidelines has also been found in a European survey, also including Sweden (Leentjens and Diefenbacher, 2006), where no Swedish national delirium guidelines were reported, not even local ones. Some other European countries reported nationwide or institutional guidelines, but not concerning ICUs. The lack of ICU delirium guidelines could be due to limited research concerning delirium in ICU patients, and could indicate that delirium is not experienced as a problem — but also that the syndrome is under-observed. Among specially noticed patient categories, alcohol addiction dominated, being foremost in assessment (94%) but also regarding non-pharmacological interventions (82%). This finding could be due to the fact that delirium is considered to be the same as alcohol delirium — a fact also indicated by the guidelines collected with the questionnaire. This condition might indicate a need for education on the subject. However, only seven (13%) ICUs had accomplished delirium education in the preceding year. Nevertheless, staff education is of importance to reduce delirium and education has been shown to improve delirium recognition (Devlin et al., 2008b; Tabet et al., 2005). In the present study, units that had performed recent staff education indicated a higher prevalence of delirium, suggesting an increased awareness as a result of the education, rather than an increase in prevalence.
Methodological considerations The results of the present study are based on generalisations and individual opinions of representatives of the ICUs, rather than on objective data. The questionnaire and the
302 information letter were sent to the head nurses of the ICUs, who were asked to report about actual policies at the unit, and to check with co-workers if anything was unclear. There is, however, no information on how representative the answers are of the actual situation at the unit, or whose opinion they reflect. Moreover, the questionnaire was based on studies concerning risk factors and interventions not only for ICU patients but also for other emergency inpatients, mostly post-surgery. Post-surgery patients are, however, often observed in ICUs, as are risk factors and interventions identified in other environments in emergency hospitals. Therefore, results from these studies could be useful even in intensive care. Furthermore, the questionnaire was tested with respect to clarity, validity, inter-rater reliability and test—retest reliability, and the response rate could be considered satisfactory. In spite of the study limitations, this national survey presumably indicates a valid picture of delirium management in Swedish ICUs.
Conclusion As in other countries, this study demonstrates that the awareness of delirium in Swedish ICUs is low with a lack of implementation of validated screening tools for its diagnosis. Emphasis should be put on education and implementation of these tools, to improve the quality of care for ICU patients. Because there seems to be a lack of research on the subject of ICU delirium, especially intervention studies and because the syndrome is combined with severe consequences, additional research is needed. Existing recommendations should, however, be followed until further notice, combined with staff education.
Conflict of interest This study was supported by Lindesbergs Hospital, who is also the employer of Lena M Forsgren. This, however, causes no conflict of interest.
Acknowledgements We would like to express our gratitude to those taking part in the tests of the questionnaire and to the study participants.
References Aizawa K, Kanai T, Saikawa Y, Takabayashi T, Kawano Y, Miyazawa N, et al. A novel approach to the prevention of postoperative delirium in the elderly after gastrointestinal surgery. Surg Today 2002;32(4):310—4. Aldemir M, Özen S, Kara IH, Sir A, Bac ¸ B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5:265—70. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999;156:1—20. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y, Bergeron N, et al. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med 2001;27:859—64. Devlin JW, Marquis F, Riker RR, Robbins T, Garpestad E, Fong JJ, et al. Combined didactic and scenario-based education improves
L.M. Forsgren, M. Eriksson the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care 2008b;12(1):R19. Devlin JW, Fong JJ, Howard EP, Skrobik Y, Yasuda C, Marshall J. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care 2008a;17(6):555—65. Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 2001;27(8):1297—304. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001a;27:1892—900. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (cam-icu). JAMA 2001b;286:2703—10. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (camicu). Crit Care Med 2001c;29:1370—9. Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, et al. 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—12. Gustafson Y, Brännström B, Berggren D, Ragnarsson JI, Sigaard J, Bucht G, et al. A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc 1991;39(7):655—62. Han CS, Kim YK, Han C-S, Kim Y-K. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004;45:297—301. Hart RP, Best AM, Sessler CN, Levenson JL. Abbreviated cognitive test for delirium. J Psychosom Res 1997;43:417—23. Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE. Validation of a cognitive test for delirium in medical icu patients. Psychosomatics 1996;37:533—46. Hsiinfo. 2006 [cited 2006 August 01]. Available from: http://www.hsiinfo.se/index.html. Immers H, Schuurmans MJ, van der Bijl JJ. Recognition of delirium in ICU patients: a diagnostic study of the NNCHAM confusion scale in ICU patients. BMC Nursing 2005;4:7. Inouye SK, Bogardus Jr ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New Engl J Med 1999;340(9):669—76. Jackson C, Furnham A. Designing and analysing questionnaires and surveys: a manual for health professionals and administrators. London: Whurr; 2003. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC, Burger BJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005;53:1658—66. Larsson C, Axell AG, Ersson A. Confusion assessment method for the intensive care unit (CAM-ICU): translation, retranslation and validation into Swedish intensive care settings. Acta Anesthesiol Scand 2007;51(7):888—92. Lat I, McMillian W, Taylor S, Janzen JM, Papadopoulus S, Korth L, et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med 2009;37:1898—905. Lee KU, Won WY, Lee HK, Kweon YS, Lee CT, Pae CU, et al. Amisulpride versus quetiapine for the treatment of delirium: a randomized, open prospective study. Int Clin Psychopharmacol 2005;20:311—4. Leentjens AFG, Diefenbacher A. A survey of delirium guidelines in Europe. J Psychosom Res 2006;61:123—8. Lin S-M, Liu C-Y, Wang C-H, Lin H-C, Huang C-D, Huang P-Y, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004;32:2254—9.
Delirium in intensive care units Lowry R. Vassarstats — web site for statistical computation. Poughkeepsie, NY, USA: Vassar College; 2008. Available from: http://faculty.vassar.edu/lowry/VassarStats.html. Lundström M, Edlund A, Lundström G, Gustafson Y. Reorganization of nursing and medical care to reduce incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 1999;13(3):193—200. Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustavsson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 2005;53(4):622—8. Marcantanio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49(5):516—22. Marshall MC, Soucy MD. Delirium in the intensive care unit. Crit Care Nurs Q 2003;26:172—8. McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK, McNicoll L, et al. Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. J Am Geriatr Soc 2005;53:495—500. Mehta S, Burry L, Fischer S, Martinez-Motta JC, Hallett D, Bowman D, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med 2006;34:374—80. Milisen K, Foreman MD, Abraham IL, Godderis J, Vandermeulen E, Fischler B, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001;49(5):523—32. Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R, Mylotte JM. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc 2005;53(1):18—23. Neelon VJ, Champagne MT, Carlson JR, Funk SG. The NEECHAM Confusion Scale: construction, validation and clinical testing. Nurs Res 1996;45:324—30. Pandharipande P, Shintani A, Peterson J, Truman B, Wilkinson GR, Dittus RS, et al. Lorazepam is an independent risk factor for
303 transitioning to delirium in intensive care unit patients. Anesthesiology 2006;104:21—6. Patel RP, Gambrell M, Speroff T, Scott TA, Pun BT, Okahashi J, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med 2009;37(3):825—32. Roberts B. Screening for delirium in an adult intensive care unit. Intensive Crit Care Nurs 2004;20:206—13. Shehabi Y, Botha JA, Boyle MS, Ernest D, Freebairn RC, Jenkins IR, et al. Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesth Intensive Care 2008;36:570—8. Sipahimalani A, Masand PS, Sipahimalani A, Masand PS. Olanzapine in the treatment of delirium. Psychosomatics 1998;39:422— 30. Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med 2004;30:444—9. 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—80. Tabet N, Hudson S, Sweeney V, Sauer J, Bryant C, Macdonald A, et al. An educational intervention can prevent delirium on acute medical wards. Age Ageing 2005;34:152—6. Truman B, Ely EW. Monitoring delirium in critically ill patients. Using the confusion assessment method for the intensive care unit. Crit Care Nurse 2003;23:25—36. Van Eijk MM, Kesecioglu J, Slooter AJ. Intensive care delirium monitoring and standardised treatment: a complete survey of Dutch Intensive Care Units. Intesive Crit Care Nurs 2008;24(4):218— 21. Van Rompaey B, Shortridge-Baggett LM, Truijen S, Elseviers M, Bossaert L. A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients. Crit Care 2008;12(1):R16. Van Rompaey B, Shuurmans MJ, Shortridge-Baggett LM, Truijen S, Elseviers M, Bossaert L. Long term outcome after delirium in the intensive care unit. J Clin Nurs 2009;18:3349—57.