title: A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes.
abstract: BACKGROUND
  Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes.
  
  
  METHODS
  We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described.
  
  
  RESULTS
  We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioral change, was also associated with reduced mortality.
  
  
  CONCLUSIONS
  Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.
authors.affiliation: Department of Intensive Care, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, CA, 3000, the Netherlands. z.trogrlic@erasmusmc.nl.
authors.forename: Zoran
authors.initials: Z
authors.lastname: Trogrlić
authors.affiliation: Department of Intensive Care, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, CA, 3000, the Netherlands. m.vanderjagt@erasmusmc.nl.
authors.forename: Mathieu
authors.initials: M
authors.lastname: van der Jagt
authors.affiliation: Department of Intensive Care, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, CA, 3000, the Netherlands. jan.bakker@erasmusmc.nl.
authors.forename: Jan
authors.initials: J
authors.lastname: Bakker
authors.affiliation: College of Nursing, Center of Excellence in Critical and Complex Care, The Ohio State University, Ballantrae Place Dublin Ohio 43016, Columbus, Ohio, 6756, USA. balas.17@osu.edu.
authors.forename: Michele C
authors.initials: MC
authors.lastname: Balas
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care, Health Services Research Center, Vanderbilt University Medical Center, Nashville, TN, 37232, USA. wes.ely@vanderbilt.edu.|Veteran's Affairs Tennessee Valley Geriatric Research Education Clinical Center (GRECC), 1215 21st Avenue South MCE Suite 6100, Nashville, TN, 37232, USA. wes.ely@vanderbilt.edu.
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
authors.affiliation: Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, Amsterdam, 1090 HM, The Netherlands. phjvdvoort@chello.nl.
authors.forename: Peter H J
authors.initials: PH
authors.lastname: van der Voort
authors.affiliation: Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center, P.O. Box 2060, Rotterdam, 3000 CB, The Netherlands. w.ista@erasmusmc.nl.
authors.forename: Erwin
authors.initials: E
authors.lastname: Ista
mesh_terms: D002986:Clinical Trials as Topic / Q000379:methods; D003422:Critical Care / Q000379:methods*; D003693:Delirium / Q000175:diagnosis* / Q000517:prevention & control*; D019468:Disease Management; D006801:Humans; D007362:Intensive Care Units; D016896:Treatment Outcome