Original article
Intensive care delirium monitoring and standardised treatment: A complete survey of Dutch Intensive Care Units

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Summary

Objective

Delirium is a frequent and serious problem in the Intensive Care Unit (ICU). Several international guidelines recommend daily monitoring for ICU-delirium. The purpose of this article is to give an up-to-date overview of the current status of monitoring and treatment of ICU-delirium in the Netherlands.

Design

Nation-wide, telephone-based questionnaire survey.

Participants

Head nurse of all ICUs and a random sample of intensivists.

Results

Only 14% (n = 14) of all Dutch ICUs (n = 103) monitored for ICU-delirium. Of these, only half (7%) used a tool that is validated in ICU patients. In 31% of Dutch ICUs, a protocol was used to treat ICU-delirium. Responses were obtained from 100% of ICUs.

Conclusion

Despite an international guideline, not more than 7% of ICUs in our study routinely evaluated the presence of delirium with a validated instrument. Fewer than one-third of Dutch ICUs use a protocol to treat ICU-delirium.

Introduction

Delirium is a frequent problem in the Intensive Care Unit (ICU) and associated with increased mortality, prolonged duration of ICU stay and increased cost (Ely et al., 2004a, Milbrandt et al., 2004, Ouimet et al., 2007). ICU-delirium, formerly known as ICU psychosis or syndrome, is characterised by an acute disturbance of consciousness and change in cognition with typically a fluctuating course. Pro-active preventive and therapeutic interventions should therefore be undertaken in order to reduce the burden of delirium in the ICU. However, the capability of critical care nurses and intensivists to recognise delirium appears to be limited (Cheung et al., 2008) which may hamper adequate treatment. In 2002, the Society of Critical Care Medicine (SCCM) published a clinical practice guideline on the use of analgesics and sedatives in the ICU (Jacobi et al., 2002). In this guideline the authors strongly recommended routine evaluation of delirium in ICU patients, as ICU-delirium is often missed when no standard routine screening method is incorporated. The American Psychiatric Association (APA) drew the same conclusion in their 2004 ‘guideline watch on delirium’ (Cook, 2004). Various delirium assessment tools have been developed for use in ICU patients with proven reliability, that can be completed quickly and easily, and that do not require the presence of psychiatric personnel (Devlin et al., 2007). Of these, the (abbreviated) Cognitive Test for Delirium (CTD) (Hart et al., 1996, Hart et al., 1997), the Confusion Assessment Method adapted for the ICU (CAM-ICU) (Ely et al., 2001), the Intensive Care Delirium Screening Checklist (ICDSC) (Bergeron et al., 2001), the NEECHAM scale (Immers et al., 2005) and the Delirium Detection Score (DDS) (Otter et al., 2005) have been validated in ICU patients. Although it is not clear what the best treatment for delirium is, the use of a standardised delirium treatment protocol seems to reduce the frequency of delirium in non-ICU patients (Inouye et al., 1999). It is yet unknown how many institutions actually monitor for delirium in the ICU routinely and how many use a standardised protocol for the treatment of delirium. The aim of this survey was to study the frequency of delirium monitoring and standardised treatment, in order to provide an overview of ICU-delirium awareness in the Netherlands.

Section snippets

Methods

The authors undertook a telephone survey of all Dutch ICUs. Addresses and telephone numbers of all hospitals with an ICU were retrieved using a government initiated public website (www.kiesbeter.nl). From 1 September to 1 December 2007 all ICUs were contacted and the head ICU-nurse was subjected to a standardised, telephone-based, interview, with the following questions: (1) are you routinely evaluating for delirium in your ICU? If yes: (2) what method do you use? If no: (3) are you planning

Results

A complete response was accomplished for this survey of Dutch ICUs (n = 103). These included 24 level 3 ICUs (i.e. university hospitals and large teaching hospitals), 51 level 2 ICUs (i.e. small teaching hospitals) and 28 level 1 ICUs (i.e. regional public hospitals).

A small minority of ICUs in the Netherlands routinely evaluated the presence of delirium. Only 14 ICUs (14%) were assessing delirium at the moment of contact (Table 1) and another 18 ICUs (17%) were planning standardised delirium

Discussion

In this study, we show that in the large majority of Dutch ICUs regular delirium monitoring is not performed and there is no protocol for standardised treatment.

Based on a nation-wide survey, we were able to provide a complete assessment of the current status of ICU-delirium monitoring and standardised treatment in the Netherlands. A telephone interview is the easiest and most complete approach to conducting a survey, as a written questionnaire is often subject to low response rates (Cummings

Conclusion

Despite several international guidelines that advocate regular delirium evaluation in the ICU, not more than 7% of ICUs in our study of ICUs in the Netherlands routinely evaluated the presence of delirium with a validated instrument. Less than one-third of Dutch ICUs used a protocol to treat ICU-delirium. Ongoing support of standard screening and scientific attention to ICU-delirium may increase the frequency of standardised screening.

Acknowledgement

The authors would like to thank the interviewed ICU personal. The authors declare that they have no competing interests

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