Authors’ Response

We appreciate the response we received from Drs Cole and Stark regarding our publication “A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units.” We agree that it is important to educate staff and to identify and address barriers to optimal uptake when implementing new care processes and quality improvement initiatives. As noted by Drs Cole and Stark, there are several evidence-based practices for the prevention and mitigation of delirium, yet uptake and use of these practices remain low. Although there are some common barriers to the implementation of these practices, many barriers are site specific and must be uncovered in order to design effective implementation strategies. In their survey of 1 hospital, Cole and Stark found that barriers to intensive care unit (ICU) delirium prevention and assessment protocols included lack of knowledge about clinical guidelines, delirium assessment tools, and the impact of delirium on patient outcomes as well as failure to view delirium prevention measures as a matter of routine care. Other studies have found knowledge deficits to be a barrier to implementation of ICU delirium prevention initiatives as well as other factors including communication and care coordination challenges, workload concerns, staff morale issues, and lack of leadership. ^1,2

Use of “care bundles” has been advocated as a means to accelerate the adoption of multiple care processes into routine clinical practice, benchmark performance, and improve patient outcomes. We recently implemented the Awakening and Breathing Coordination, Delirium Monitoring, and Early Mobility (ABCDE) bundle in 12 Baylor Scott and White Health ICUs and found that bundling these care processes was associated with improved adherence to the individual care processes for delirium prevention and mitigation within the bundle and improved patient outcomes. Although some sites participated in structured educational workshops during the early phases of bundle implementation, we found that the greatest improvement in bundle uptake occurred after we modified the electronic health record (EHR) to facilitate clinical workflow around bundle delivery and documentation. ³ This finding suggests that establishing tools that facilitate integration of delirium prevention measures into clinical workflow, such as structured forms for documentation of bundle elements within the EHR, should be the first step in the implementation process followed by educational sessions on the importance of delirium prevention and use of the tools.

Similar to trends observed in studies examining the use of other types of care bundles in the ICU, such as those for the prevention of central line infections, ^4,5 we found that consolidating ABCDE care processes facilitated their implementation and use. In our qualitative study of the ABCDE bundle implementation, ICU staff reported that they viewed the bundle as a standardized approach to care that gave them specific guidelines for treatment of critically ill patients and increased their autonomy and confidence in care delivery. The majority of clinical staff believed that use of the bundle was advantageous as it represented best care for patients and was compatible with the way they felt care should be delivered. They also thought that use of the bundle resulted in improved outcomes for patients, including observable benefits such as reduced length of time on the ventilator. The most commonly reported barrier to bundle adoption was EHR documentation. Other barriers included staff shortages, time constraints, and lack of coordination among care providers.

Health care systems must recognize that delirium is a common and serious patient safety issue that negatively impacts patient outcomes and costs and find ways to incorporate delirium prevention and mitigation strategies into routine care. We have found that implementation of these care processes can be improved through the use of a structured process for integrating delirium prevention and mitigation strategies into routine care (the ABCDE bundle), tools that incorporate these strategies into clinical workflow (structured documentation of bundle care processes in the EHR and regular reporting and feedback of adherence levels), education of clinical staff, and vested leadership. Several resources and tools are available to educate clinicians about delirium prevention and management and facilitate implementation of initiatives such as the ABCDE bundle including the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Units and the websites of the Society of Critical Care Medicine and the ICU Delirium and Cognitive Impairment Study Group. ^{6 –8}