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Sustained adherence to a delirium guideline five years after implementation in an intensive care setting: A
Marlies van Bochove-Waardenburg1, Mathieu van der Jagt2, Janneke de Man-van Ginkel3
1Department of Intensive Care, Erasmus MC, Erasmus University Medical Center Rotterdam, The Netherlands; Department of Nursing Science, Program in Clinical Health Science, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.
Objective:
To explore the level of sustained adherence to a delirium guideline in a university intensive care unit setting five years after cessation of a multifaceted implementation program conducted between April 2012 and February 2015.
Research Methodology/Design:
A quantitative retrospective cohort study was conducted using the medical records of all eligible patients admitted to the intensive care unit from November 2019 to February 2020.
Setting:
Four adult intensive care units in a university hospital.
Main Outcome Measures:
Primary outcome is adherence to seven performance indicators indicated in the guideline being: light sedation days, mobilisation, physical therapy, analgesics use, delirium and sedation screening and avoiding benzodiazepines. Clinical patient outcomes such as Intensive care unit stay and prevalence of delirium were also collected. Data were compared with the results of the original implementation study's using descriptive statistics and Kruskal-wallis and Chi-square tests.
Results:
Data of 236 patients were included. The most notable decrease in adherence concerned 'number of light sedation days' (-28 %). Adherence to three indicators had increased: 'number of days receiving out-of-bed mobilisation' (+11 %); 'number of days receiving physical therapy' (+9%); and 'use of analgesics' (+12 %). Comparison of clinical outcomes showed an increased intensive care unit length-of-stay from 3 to 5 days (P < 0.001). Prevalence of delirium increased over five years from 41 % to 43 % of patients while delirium duration decreased from a median of 3 days to a median of 2 days.
Conclusion:
Five years after ceasing of implementation efforts regarding the delirium guideline, partial sustainability has been achieved. The decrease in adherence to 'number of light sedation days' could have contributed to the increased length-of-stay on the intensive care unit.
Implications For Clinical Practice:
After implementation, routine monitoring of performance indicators is required to evaluate the level of sustainment. Further, revisiting reasons for decrease in guideline adherence when contextual changes occur. Reassessment of the perceived barriers and facilitators can guide adaptations to sustain, or even improve, adherence.
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