Abstract

The geriatric population with delirium experience prolonged hospitalizations and approximately two times higher mortality rates when compared to the same patient population without delirium. The study further observed in a long-term study that duration of ICU delirium in the geriatric population was independently related to a more pronounced cognitive impairment during a follow up exam. The research paper sought to conduct effective, streamlined searches with multiple bodies of literature (1) to perform a review of the evidence-based studies related to delirium interventions and (2) evaluate the effects of the interventions on length of stay outcomes. A literature search was conducted through databases to assemble evidence to answer the following PICO (P = Patient Population, I = Intervention, C= Comparison Intervention, O= Outcome) question:  Among ICU patients 65 years and older (P) experiencing delirium, how does the use of a medication regimen(I) in comparison to no-pharmacological interventions (C) affect their length of stay in the ICU (O)? The current exercise finds that that delirium is common among patients in intensive care and that it is a crucial determinant of the length of their stay there.

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Keywords: Intensive Care Unit (ICU), delirium, delirium treatment, length of stay and critical care.

Background and Significance

An acute confused state characterized by a decreased ability to focus, maintain attention, or shift attention with an altered state of consciousness defines delirium (Hshieh, Yue, Oh, Puelle, & Dowal, 2015). Delirium is typically triggered by a medical condition, medication side effect, or substance intoxication that develops over a few hours to days (Hshieh et al., 2015). The symptoms of delirium such as agitation, and hallucinations can fluctuate throughout the course of the day. Delirium is assessed through routine screening with the Confusion Assessment Method for the ICU (CAM-ICU) standardized tool. The Confusion Assessment Method for the ICU has the highest quality of psychometric supporting evidence and is one of two recommended screening tools that are considered valid and reliable for the assessment of delirium (Swan, 2014).

 The management of delirium is based upon the consensus of experts as most evidence is based on prevention of delirium using non-pharmacologic measures, and the identification of patients who are at high risk for developing delirium. According to Clegg, Siddiqi, and Heaven (2014), the incidence of delirium appears to be reduced when non-pharmacological interventions are used to assist in the management of modifiable risk factors. Thus far, there are currently no reliable interventions or collaboration of interventions that prevents delirium (Clegg et al., 2014). A study focused on early detection of delirium in geriatric inpatients found there was little impact of patient’s length of stay even when delirium was established and treated (Cole, McCusker, & Bellavance, 2002). On the contrary, in a double blind, placebo-controlled pilot study that used medication interventions to treat Intensive Care Unit patients with delirium found the use of the medications were associated with shorter episodes of delirium, and higher rates of discharge (Devlin, Roberts, & Fong, 2010).

Delirium has been identified as an independent marker for mortality (Robinson, Raebburn, & Tran, 2009). Further investigation into delirium treatment courses and its impacts on the geriatric population’s ICU length of stay is significant because delirium’s effects on the geriatric patient population is associated with increased short term and long-term mortality (Robinson et al., 2009). The geriatric population with delirium experience prolonged hospitalizations and approximately two times higher mortality rates when compared to the same patient population without delirium. In addition, it was observed in a long-term study that duration of ICU delirium in the geriatric population was independently related to a more pronounced cognitive impairment during a follow up exam.

Purpose

The purpose of this paper was to conduct effective, streamlined searches with multiple bodies of literature (1) to perform a review of the evidence-based studies related to delirium interventions and (2) evaluate the effects of the interventions on length of stay outcomes to answer the presented PICOT question provide below:

PICOT

A literature search was conducted through databases to assemble evidence for the following PICO (P = Patient Population, I = Intervention, C= Comparison Intervention, O= Outcome) question:  Among ICU patients 65 years and older (P) experiencing delirium, how does the use of a medication regimen(I) in comparison to nonpharmacological interventions (C) affect their length of stay in the ICU(O)? 

Methods

A series of searches were conducted in the following databases CINAHL, PubMed, Cochrane, and DyneMed. Keyword terms such as: delirium treatment, length of stay, and ICU patients were used as well as phrases such as: delirium treatment and length of stay, and ICU patient’s delirium treatment length of stay. The following steps were conducted in the CINAHL database search. The first key term search was delirium treatment, followed by a separate search for length of stay, then and additional search for ICU patients. ICU patients did not return any results therefore, ICU was removed from the search and patients replaced the key term which provided ample results. To further narrow the results delirium treatment and length of stay was searched, and finally, ICU patient delirium treatment length of stay was separately searched.

The same steps were followed in the PubMed, Cochrane, and DyneMed’s data base searches. The first key term search was delirium treatment, followed in a separate search by length of stay, and an additional separate search for ICU patients. Again, to further specify the results delirium treatment and length of stay were searched, and ICU patient’s delirium treatment length of stay was separately searched. The results of the search presented three articles from CINAHL, 319 from PubMed, four from Cochrane, and 46 from DyneMed that included all key word terms related to the PICO question. Further search result details can be viewed in Tables 1-4. It is of note that there were no year limits placed on the searches in any of the databases due to the minimal results it produced. Articles that were not published within the past 10 years were included to be reviewed for relevance and secondary references.

Evidence Table

Author, Location, Title, Design, and InterventionPurpose, Sample, and SettingResearch DesignFindings/ResultsData AnalysisLevel of Evidence and Comments
Authors: Deiner, Luo, Lin, Sessler, and Leif et al. (2017) Location: Intensive Care Unit at Mount Sinai Hospital, New York. Intervention: Dexmedetomidine infusion(0.5μg/kg/h) during surgery and up to two hours in the recovery room.Purpose: To evaluate examine “whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium” Sample: 390 patients completed in-hospital delirium assessments. The median age was 74.0 years old. 193 patients received dexmedetomidine, and 202 patients received placebo. Setting: multicenter Intensive Care Units:Design: double-blind, randomized, placebo-controlled trial Intervention Period: During the patient’s surgery and up to two hours in the recovery room. Outcome Measures: postoperative delirium Follow up: 3 and 6 monthsIntraoperative dexmedetomidine does not prevent postoperative delirium. Forty-six (11.8%) of the patients developed postoperative delirium, including twenty-three in the dexmedetomidine group (12.2%) and twenty-three (11.4%) in the placebo group. There was no difference in severity of delirium by treatment groupResearchers used z scores as a continuous variable double-blind, randomized, parallel-group, placebo controlled trial conducted at 10 sites Limitations: restricted the administration of dexmedetomidine to two hours post op.      This study is relevant to the study because it confirms the effects of the interventions on length of stay outcomes due to delirium treatment. No unique or else inconsistent findings were found in this article. Strengths: researchers used z scores as a continuous variable double-blind, randomized, parallel-group, placebo controlled trial conducted at 10 sites Limitations: restricted the administration of dexmedetomidine to two hours post op.      
Authors: Martinez, F., Donoso, A., Marquez, C., & Labarca, E. (2017) Location: mixed Medical/Surgical Intensive Care Unit Design: Before and after multicomponent intervention Intervention:  physiotherapy and early mobilization, daily reorientation, prevention of sensory deprivation, avoidance of drugs with the potential to trigger delirium, pain control, sleep hygiene, environmental stimulation, monitoring of urinary and rectal function, minimization of physical restraints, and family participation in carePurpose: To assess the efficacy and describe the implementation strategy of a multicomponent intervention to prevent delirium in an intensive care unit. Sample: 287 patients, 60 in the diagnostic phase and 227 in the interventional phase. Mean age of 63.3 years old. Setting: mixed Medical/Surgical Intensive Care UnitDesgn  “Before-and-after study conducted within an ICU setting encompassing: Intervention Period: Diagnostic stage May 2014 until August 2014. Intervention stage began September 2014- August 2015. Outcome Measures:   Incidence of ICU delirium ICU length of stay. Follow up: The researchers gave statistical reports every six months or the health care providers for key indicators of delirium.Intraoperative dexmedetomidine does not prevent postoperative delirium. Forty-six (11.8%) of the patients developed postoperative delirium, including twenty-three in the dexmedetomidine group (12.2%) and twenty-three (11.4%) in the placebo group. There was no difference in severity of delirium by treatment group. Multicomponent non-pharmacological interventions are effective in preventing delirium. In the observational phase, the mean delirium duration was 5.6 days, in contrast with the mean duration of 3.5 days in the interventional stage. The analysis revealed no change in the ICU length of stay.The researchers employed descriptive statistics (medians, means, interquartile ranges) to analyze the collated data. Moreover, they used FISHER exact tests to explore the bivariate relationships between categorical variables. A Mann-Whitney test was also used to compare quantitative variables.The study concurred that it is poosible to reduce derilium significantly if the right strategy is applied. The implication of this is that reducing the condition, then it is possible to reduce the lenth of stay in ICU after treatment. The study was based on a “before-and-after study conducted within an ICU setting. This article conatined unique findngs in that ), it is poosible to reduce hospital stay by reducing derilium significantly through the right strategy.  
Authors: Gorski, S., Piotrowicz, K., Krzysztof Rewiuk, et al. (2017). Location: The Department of Internal Medicine and geriatrics of the University Hospital in Krakow, Poland. Intervention: Every day trained volunteers delivered a multi-component standardized intervention targeted at risk factors of in-hospital complications to the intervention group. The control group, selected using a retrospective individual matching strategy received standard care.Purpose: Determine the effectiveness of non-pharmacological multi-component prevention delivered by trained volunteers. Sample: 130 patients participated in the study, with 65 in the intervention group. Inclusion criteria: age ≥ 75, acute medical condition, basic orientation, and logical contact on admission; exclusion criteria: life expectancy < 24 hours, surgical hospitalization, isolation due to infectious disease, and discharge to other medical wards Setting: 47 bedAcute Care  Internal Medicine and Geriatrics Ward; tertiary teaching hospitalDesign: Pilot Study based on: Intervention Period: Daily for the intervention group’s 5 initial days of the hospitalization, beginning within the first 48 hours from admission, by trained volunteers. The patients included in the control group received the usual medical care that consisted of standard Evidence-Based Medicine (EBM) guided treatment of acute conditions. Outcome Measures: The lengths of hospital stay in the intervention group and the control group. The frequency of initiation of antipsychotic medication in the intervention group and the control group. Follow up: There was no mention of follow up.Nonphramacoligical multi-componenr interventions geared towards risk factors associated with reducw hospitalization lengths significantly coupled with the initiation of antipsychotopic treatments. There was no difference with respect to baseline characteristics between the intervention and the control group. Antipsychotic medications were initiated less frequently in those in the intervention group. There was no difference between the intervention and the control group in the number of delirium episodes. There was a difference in the length of hospitalization between the intervention and the control group, mean time: 13.4 ± 7.5 versus 17.9 ± 14.4 days, respectively (???? = 0.05).The researchers analyzed the data retrospectively with regard to patients’ medical charts as well as nurses’ and doctor’s daily reports.Strengths: Non-pharmacological, multi-component intervention targeted at delirium risk factors, delivered by volunteers, could be effective in reducing the length of hospital stay and the need for antipsychotic treatment. These results are consistent with previously published data. The errors of 5% and 95% confidence interval were established. Limitations: A formal diagnosis of delirium had not been carried out.
Authors: van den Boogaard, M., Slooter, A.J.C., Brüggemann, R.J.M., et al. (2018) Location: multicenter 21 ICUs, at which non-pharmacological interventions for delirium prevention are routinely used in the Netherlands Design: Randomized, double-blind, placebo-controlled investigator-driven study Intervention: Patients received prophylactic treatment 3 times daily intravenously either 1 mg or 2 mg of haloperidol or placebo, consisting of 0.9% sodium chloride.Purpose: To determine whether prophylactic use of haloperidol improves survival among critically ill adults at high risk of delirium, which was defined as an anticipated intensive care unit (ICU) stay of at least 2 days. Sample: 1789 critically ill adults with a mean age of 66.6 years  without delirium, and an expected ICU stay of at least two days. Setting: 21 ICUsIntervention Period: 28 days Outcome Measures: The primary outcome was the number of days that patients survived in 28 days. There were 15 secondary outcomes, including delirium incidence, 28-day delirium-free and coma-free days, duration of mechanical ventilation, and ICU and hospital length of stay. Follow up: follow-up was conducted at 90 daysThe use of prophylactic haloperidol compared with placebo did not improve survival at 28 days. Findings do not support the use of prophylactic haloperidol in critically ill adult. There was no difference in the median days patients survived in the 2-mg haloperidol group vs placebo group in 28 days. Delirium incidence mean difference, 1.5%, 95% CI, −3.6% to 6.7%, Delirium-free and coma-free days mean difference, 0 days, 95% CI, 0-0 days. Duration of mechanical ventilation, ICU, and hospital length of stay mean difference, 0 days, 95% CI, 0-0 days for all 3 measures.Researchers used z scores as a continuous variable double-blind, randomized, parallel-group, placebo to analyze the data collected from 10 sites.  Strengths: Multicenter randomized trial involving 1789 critically ill patients at high risk of delirium Limitations: The 1-mg haloperidol group was prematurely stopped because of futility. An average of 11 risk factors is present at the same time in ICU patients with delirium suggests the involvement of multiple pathways in its development. The duration of prophylactic therapy, median, 2 days, could be too short to prevent delirium and its deleterious outcome. The study population included severely ill ICU adults, whose brains may have been too seriously affected for haloperidol to exert a prophylactic effect, since in non-ICU adults, prophylactic haloperidol may have beneficial effect.


Synthesis of Findings

Deiner, Luo, Lin, Sessler, and Leif (2017) conductyed a study to examine “whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium”. In their findings, they established that there was no profound variation caused by post-operative cognitive performance between the treatment groups in the study.  This study is relevant to the study because it confirms the effects of the interventions on length of stay outcomes due to delirium treatment. No unique or else inconsistent findings were found in this article.

According to Martínez, Donoso, Marquez, and Labarca (2017), it is poosible to reduce derilium significantly if the right strategy is applied. The implication of this is that reducing the condition, then it is possible to reduce the lenth of stay in ICU after treatment. The study was based on a “before-and-after study conducted within an ICU setting. This article conatined unique findngs in that ), it is poosible to reduce hospital stay by reducing derilium significantly through the right strategy.

(Gorski, et al (2017) found that nonphramacoligical multi-componenr interventions geared towards risk factors associated with reduced hospitalization lengths significantly coupled with the initiation of antipsychotopic treatments. The unique and inconsisten aspect of this study based on experiments on controlled groups is that it considered the physcological aspects associated with prolonged hospitalization apart from other physical factors discussed herein. According to Boogaard, Slooter, Brüggemann, et al. (2018), the use of prophylactic haloperidol compared with placebo did not improve survival at 28 days. These findings do not support the use of prophylactic haloperidol in critically ill adult as it does not shorten the length of hospitalization following delirium treatment. This study is consistent with the research paper an d current research as it supports the notion that pharmacological interventions affect duration of stay positively.

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Clinical Implications

The study has selected Lewin’s Change Theory of Nursing to ensure that pharmacological measurements do not portend any positive impacts on the length of hospital stay by decreasing delirium. The theory was incorporated into the implementation plan through three principal conceptions: driving, retraining and equilibrium forces. Driving forces help the implementation process to focus on areas that are most essential for dictating the direction organizational change in nursing practice should take and occur. The forces direct patients towards the desired direction and therefore they are important facilitators of change by causing a shift in the organization’s equilibrium. Restraining forces on the other hand will allow the implementation change to counter the driving forces through some sort of stress test on the impact of change in clinical practice concerning interventions on length of stay outcomes due to delirium treatment. The inclusion of this concept in the implementation plan is meant to determine the effects of hindering change because they tend to push patients to the opposing direction by causing shifts in the equilibrium that oppose change. When the strength of both forces is equal, then an equilibrium is established. The incorporation of this concept in the implementation plan is meant to help facilitate an understanding of the impacts of not taking any change to improve the current status of lengthy ICU stays due to delirium treatments.

The implementation of this change theory is predicated on four critical stages. Firstly, the unfreezing stage involves determining the best method of allowing medical professionals to discontinue old patterns that are somehow counterproductive. The second phase of the plan is to the change phase that entails the process of moving away from old practices to new ones in terms of thoughts, behavior, feeling to more liberating and productive patient care. The third stage is the refreezing phase encompassing the establishment of new habits representative of the change and “standard operating procedures. The final stage in the plan is the evaluation phase where the project team assesses the success of the change against a set of pre-determined criteria to identify areas of weaknesses and strengths in implementation of the changes.  The change process will however be laden with a burden in that it is not always easy to implementation change. Change within an organization will always face resistance as evidenced by the restraining forces.

The change theory in nursing is visible because it allows healthcare organizations to understand human conduct with regard to change as well resistance patterns to change. It also ensures critical change is achieved not only in the creation of more effective as well as effective clinical practices but also alignment of financial resources to provide support to new processes.  The evaluation of the proposed implementation plan will be done through quantitative analysis regarding the impact of the organizational changes with a view of identifying additional areas that can support innovation in healthcare provision.

Conclusion

The current research has established that delirium is common among patients in intensive care and that it is a crucial determinant of the length of their stay there. The research and critical research consulted herein indicates that it is possible to reduce the length of hospitalization the right strategy as well as focussing on focusing nonphramacoligical multi-componenr intervetions geared towards risk factors associated with reduceding hospitalization lengths significantly together  with the initiation of antipsychotopic treatments.

References

Clegg, A., Siddiqi, N., & Heaven, A. (2014). Interventions preventing delirium in older people in institutional long-term care. Cochrane Database System Review, CD009537

Cole, M., McCusker, J., & Bellavance, F. (2002). Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ, 167 (753)

Deiner,, S., Luo, X., Lin, H.-M., Sessler, D. I., & Leif , L. (2017). Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial. JAMA Surgery, 1-18. doi:10.1001/jamasurg.2017.1505.

Delvin, J., Roberts, R., & Fong, J. (2010). Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double blind, placebo-controlled pilot study. Critical Care Medicine, 38 (419)

Gorski, S., Piotrowicz, K., Rewiuk, K., Halicka, M., Kalwak, W., Rybak, P., & Grodzicki, T. (2017). Nonpharmacological Interventions Targeted at Delirium Risk Factors, Delivered by Trained Volunteers (Medical and Psychology Students), Reduced Need for Antipsychotic Medications and the Length of Hospital Stay in Aged Patients Admitted to an Acute Inter. BioMed Research International, 1-8. doi:10.1155/2017/1297164

Hshieh, T., Yue, J., Oh, E., Puelle, M. & Dowal, S. (2015). Effectiveness of multicomponent non-pharmacological delirium interventions. JAMA Intern Med, 175(4) 512-520

Martínez, F., Donoso, A. M., Marquez, C., & Labarca, E. (2017). Implementing a Multicomponent Intervention to Prevent Delirium Among Critically Ill Patients. American Association of Critical-Care Nurses, 37(6), 36-46.

Robinson, T., Raeburn, C., & Tran, Z., (2009). Postoperative delirium in the elderly: Risk factors and outcomes. Annals of Surgery, 249 (173)

Swan, J.T. (2014). Decreasing inappropriate unable to assess ratings for the confusion assessment method for the intensive care unit. American Journal of Critical Care, 23, 60-69

Appendix

Table 1

Search results from CINAHL

Delirium TreatmentLength of stayPatients1+21+2+3
73    41,9322,95353

Table 2

Search results from PubMed

Delirium TreatmentLength of stayICU patients1+21+2+3
9,889112,73569,031930319
     
     

Table 3

Search results from Cochrane

Delirium TreatmentLength of stayICU patients1+21+2+3
234638874
     

Table 4

Search results from DyneMed

Delirium TreatmentLength of stayICU Patients1+21+2+3
2935575477346