title: A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units.
abstract: OBJECTIVE
  The objective of this review is to examine the effectiveness, implementation, and costs of multifaceted care approaches, including care bundles, for the prevention and mitigation of delirium in patients hospitalized in intensive care units (ICUs).
  
  
  METHODS
  A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted utilizing PubMed, EMBASE, and CINAHL. Searches were limited to studies published in English from January 1, 1988, to March 31, 2014. Randomized controlled trials and comparative studies of multifaceted care approaches with the reduction of delirium in ICU patients as an outcome and evaluations of the implementation or cost-effectiveness of these interventions were included.
  
  
  METHODS
  Data on study methods including design, cohort size, interventions, and outcomes were abstracted, reviewed, and summarized. Given the variability in study design, populations, and interventions, a qualitative review of findings was conducted.
  
  
  RESULTS
  In all, 14 studies met our inclusion criteria: 6 examined outcomes, 5 examined implementation, 2 examined outcomes and implementation, and 1 examined cost-effectiveness. The majority of studies indicated that multifaceted care approaches were associated with improved patient outcomes including reduced incidence and duration of delirium. Additionally, improvements in functional status and reductions in coma and ventilator days, hospital length of stay, and/or mortality rates were observed. Implementation strategies included structured quality improvement approaches with ongoing audit and feedback, multidisciplinary care teams, intensive training, electronic reporting systems, and local support teams. The cost-effectiveness analysis indicated an average reduction of $1000 in hospital costs for patients treated with a multifaceted care approach.
  
  
  CONCLUSIONS
  Although multifaceted care approaches may reduce delirium and improve patient outcomes, greater improvements may be achieved by deploying a comprehensive bundle of care practices including awakening and breathing trials, delirium monitoring and treatment, and early mobility. Further research to address this knowledge gap is essential to providing best care for ICU patients.
authors.affiliation: Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX, USA ashley.collinsworth@baylorhealth.edu.
authors.forename: Ashley W
authors.initials: AW
authors.lastname: Collinsworth
authors.affiliation: Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX, USA.
authors.forename: Elisa L
authors.initials: EL
authors.lastname: Priest
authors.affiliation: School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA.
authors.forename: Claudia R
authors.initials: CR
authors.lastname: Campbell
authors.affiliation: Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, TN, USA VA Tennessee Valley Healthcare System-Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.
authors.forename: Eduard E
authors.initials: EE
authors.lastname: Vasilevskis
authors.affiliation: Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX, USA.
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Masica
mesh_terms: D003422:Critical Care / Q000191:economics / Q000379:methods; D003693:Delirium / Q000517:prevention & control*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D011787:Quality of Health Care; D016896:Treatment Outcome
keywords: delirium; evidence-based practice; intensive care units; patient care bundles; ventilator weaning