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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 48-51

The role of Saudi Critical Care Trials Group in advancing delirium prevention and management

Neuro Critical Care Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

Date of Web Publication30-May-2019

Correspondence Address:
Maha Aljuaid
King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2543-1854.259481

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Delirium is common among intensive care unit (ICU) patients; studies showed that delirium is linked to poor outcomes. Few studies have discussed delirium in the Arabic-speaking patients' population. The Saudi Critical Care Trials Group (SCCTG) is a leading entity for research and quality at ICU in Saudi Arabia. The SCCTG has worked on advancing delirium prevention and management by establishing multiple quality improvement projects as well as conducting research. The aim of this review is to highlight the effort of the SCCTG to improve delirium care at the ICU in Saudi hospitals.

Keywords: Delirium Management, Delirium Screening, Practice Guidelines, Prevention Strategies

How to cite this article:
Aljuaid M. The role of Saudi Critical Care Trials Group in advancing delirium prevention and management. Saudi Crit Care J 2019;3:48-51

How to cite this URL:
Aljuaid M. The role of Saudi Critical Care Trials Group in advancing delirium prevention and management. Saudi Crit Care J [serial online] 2019 [cited 2022 Jul 6];3:48-51. Available from: https://www.sccj-sa.org/text.asp?2019/3/1/48/259481

  Introduction Top

Delirium is a common complication of intensive care unit (ICU) admissions which has detriment effect on the patients' outcomes. It has been associated with increase in mortality, morbidity, length of stay, and cost of care.[1] Many organizations have selected delirium as a quality indicator of care among vulnerable older adults.

Despite the fact that delirium has high prevalence (21%–84%), it is underrecognized and underdiagnosed by ICU clinicians due to limited experience and knowledge related to recognizing its symptoms or as a result of decreased buy-in from ICU clinicians to manage delirium and implement prevention measures.[2],[3]

The society of critical care medicine (SCCM) as well as the clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption for adult patients in the ICU advocated routine monitoring for delirium using a validated screening tool.[4]

  Definition Top

Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders 5 criteria as a disturbance in attention and awareness that fluctuates over a short period of time and accompanied by changes in cognition or perceptual disturbances.[5]

  Risk Factors Top

Imbalance of the neurotransmitters such as dopamine, acetylcholine, and gamma-aminobutyric acid is thought to be the primary cause of delirium as it alters the brain function. In addition, ICU patients are vulnerable to behavioral or neuropsychiatric disturbances because of sleep disturbance, exposure to sedatives, and analgesics as well as acuity of their illness.[6],[7]

Delirium is influenced by the patients' physical conditions such as age, dementia, acuity of the disease, and comorbidities, as well as iatrogenic factors such as a noisy ICU environment, isolation, use of benzodiazepine, blood transfusion, and restricted visiting hours. Few studies indicated that controlled family engagement on patients' care may increase the risk of delirium.[8]

  Screening Tools Top

Using validated screening tool is a key for delirium identification and treatment. Several studies discussed various screening tools; however, only few tools are designed to evaluate delirium in the ICU.[9],[10] [Table 1] summarizes the sensitivity and specificity of different delirium assessment tools.
Table 1: Sensitivity and specificity of different delirium assessment tools

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The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most commonly used tools and have shown to have high sensitivity and reliability and to be easy to use for delirium detection in the ICU.

ICDSC was developed by Bergeron et al. to provide ICU clinicians with a simple-to-use screening tool at the bedside. The screening composed of eight criteria that include alteration of mental status, inattention, disorientation, hallucination, psychomotor agitation, inappropriate mood, sleep disturbance, and symptoms fluctuation. During the assessment process, clinician gives 1 point to each criterion that is present; the patient is diagnosed as delirious if he/she has a score ≥4 out of 8.[11]

The CAM-ICU was introduced by Ely et al. as an adapted version of the bedside CAM assessment tool for nonpsychiatrists. The tool comprises four features to screen patients for delirium including acute onset of mental status changes or a fluctuating course, inattention, altered level of consciousness, or disorganized thinking. [Figure 1] illustrated the steps of delirium screening by using CAM-ICU. Delirium is present or CAM-ICU is positive if the patient has both acute changes of mental status accompanied by inattention as well as a change of consciousness (RASS other than zero) or the presence of disorganized thinking.[12]
Figure 1: Screening for delirium

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[Table 2] Provides summary and comparison of delirium criteria between the standardize psychiatric assessment (Diagnostic and Statistical Manual of Mental Disorders-5), Confusion Assessment Method-Intensive care units, and Intensive Care Delirium Screening Checklist.
Table 2: Summary and comparison of delirium criteria between the standardize psychiatric assessment (Diagnostic and Statistical Manual of Mental Disorders-5), Confusion Assessment Method-Intensive care units, and Intensive Care Delirium Screening Checklist

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Prevention and Management Strategies

Despite SCCM practice guidelines recommend for routine delirium monitoring in the ICU, studies showed that only 16% of ICU clinicians are routinely assessing patients for delirium.[3],[4] Devlin et al. in 2007 reported a number of strategies that could improve delirium prevention and management in the ICU:

  • Establish an ICU team who is responsible for routine delirium monitoring. Literature showed that ICU nurses are in the best position to conduct delirium screening because of their ability to detect fluctuations symptoms, agitation, as well as the changes in mood or sleep
  • Assign unit champions that work as the driving force for implementation and evaluation of delirium program
  • Utilize a standardized assessment tool and a unified prevention measures across the organization. Organization should have departmental policy and procedure that indicate the approved assessment tool, who should assess the patients, frequency of the assessment, and documentation procedure
  • Education is recognized as an integral component for delirium prevention; it improves the ICU clinicians' ability to assess delirium reliably
  • Quality monitoring and protocol-based sedation practices are essential for a successful delirium prevention program.

  Pharmacological Treatment Top

To date, evidence that support using of pharmacological agents to treat delirium in ICU is lacking. The SCCM guidelines do not recommend specific medications to treat delirium. However, for patients with delirium symptoms such as agitation or hallucination, short-term use of atypical antipsychotics or haloperidol may be beneficial.[4] Few studies looked into the effectiveness of valproic acid to reduce agitation among surgical-ICU patients with hyperactive and mixed delirium. Yet, further larger scale studies are warranted to evaluate the effectiveness of valproate in general ICU patients.[13],[14]

  Nonpharmacological Interventions Top

SCCM guidelines encouraged using multicomponent nonpharmacologic interventions to manage delirium risk factors such as improve cognition, optimize sleep, improve mobility, and use of hearing or vision aids in critically ill adults.[4]

  Saudi Experience With Delirium Assessment Top

The CAM-ICU is a rapid and reliable assessment tool that demonstrates good validity and reliability when used to assess delirium in ventilated and nonventilated patients. The tool has been translated into several languages and underwent extensive validation studies.[15],[16],[17] The Arabic translation of the CAM-ICU was carried out by investigators at the ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University Medical Center for Health Services Research.

In 2014, a group of researchers at King Abdulaziz Medical City Intensive Care Department (KAMCR-ICD) utilized the 2002 version of the Arabic CAM-ICU to screen delirium in 65 Arabic-speaking patients as a part of delirium prevention quality improvement project. The team faced some difficulties while evaluating delirium using this tool to assess patients with different levels of literacy and educational background. The team contacted Wesley Ely to discuss recommendations that may improve the clinical utility of the Arabic CAM-ICU as a language-dependent assessment tool aiming to make the tool more suitable for a larger population of Arabic-speaking patients. In 2015, Wesley Ely and his team updated the Arabic CAM-ICU tool and published it at the Delirium and Cognitive Impairment Study Group Website (http://www.icudelirium.org/delirium/languages.html).

The psychometric properties of the Arabic CAM-ICU were studied by a research team from KAMCR-ICD in collaboration with the Mental Health Department. The study highlighted the psychometric features of Arabic CAM-ICU in specific groups based on age, mechanical ventilation, and gender. Arabic CAM-ICU sensitivity was 56% for intensivist and 74% for ICU nurse, and specificity was 92% and 98% for both raters, respectively. The results showed that the Arabic CAM-ICU demonstrated good reliability and validity to assess delirium in Arabic-speaking critically ill patients. The psychiatrist evaluation indicated that 64% of the patients were diagnosed with delirium. Delirium types were 10.5% hyperactive, 46.1% hypoactive, and 43.4% mixed delirium.[18]

  Quality And Educational Initiatives To Improve Delirium Care Top

In 2014, KAMCR-ICD team conducted knowledge assessment survey related to delirium. One hundred and sixteen ICU clinicians (81% nurses and 19% physicians) responded to the survey questions. Sixty-five percent of the responders have ≥5 years of experience in the ICU. 46% of the responders indicated that they have limited knowledge related to delirium definition, signs and symptoms, whereas 44.3% were not familiar with delirium risk factors and 81% have not received education or training related to delirium prevention and assessment. Sixty-two percent of the responders were not familiar with delirium prevention measures and 64.2% did not feel competent in providing delirium quality care. In addition, 54% scored their knowledge and skills related to delirium assessment and management in the ICU as fair to poor. The leadership of KAMCR-ICD conducted several educational in-services and lectures to improve ICU clinicians' knowledge and to standardize delirium assessment in the ICU based on best practice recommendations. The CAM-ICU was chosen as a screening tool, ICU clinicians received training on how to use the tool, and the Arabic-speaking nurses were trained to assist non-Arabic-speaking nurses while communicating with the patients during the assessment. The CAM-ICU was incorporated into the electronic health-care system and nursing policy for the “standard of care” that mandated daily assessment of delirium to all ICU patients. Patient and family educational brochure was created to facilitate communication and to increase awareness of delirium among patients and families.

In 2016, KAMCR-ICD led a quality improvement project – “comprehensive unit-based safety program for mechanically ventilated patients and ventilator-associated pneumonia (CUSP-MVAP)” – in collaboration with Johns Hopkins Armstrong Institute for patient safety and quality. Delirium assessment was part of the “daily care process measures” data collection tool. The project raised the awareness among participating ICUs about the importance of including delirium assessment into the bundle of care for mechanically ventilated patients. CUSP allowed participating ICUs to measure their performances and benchmarked against other units.[19] More attention was generated by these units to implement the ABCDEF bundle to improve the quality of care provided to mechanically ventilated patients. [Figure 2] illustrated the ABCDEF bundle components.
Figure 2: The ABCDEF bundle

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Currently, Saudi investigator Professor Y. Arabi is leading a “National Approach to Standardize and Improve Mechanical Ventilation (NASAM)” – quality improvement project in collaboration with the Saudi Critical Care Trials Group and other health-care institutions in the Kingdom; delirium screening is a part of NASAM bundle of care. Such large-scale national project can open the door for further quality improvement initiatives and facilitate cooperation among ICUs to learn and share experiences to enhance the quality indicators and the outcomes of ICU patients in Saudi Arabia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007;33:66-73.  Back to cited text no. 1
Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L, et al. Risk factors for delirium in intensive care patients: A prospective cohort study. Crit Care 2009;13:R77.  Back to cited text no. 2
Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the critically ill. Intensive Care Med 2007;33:929-40.  Back to cited text no. 3
Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJ, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/Sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46:e825-73.  Back to cited text no. 4
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.. Arlington, VA: American Psychiatric Publishing; 2013. p. 596-602.  Back to cited text no. 5
Woten M, Heering H, Caple C, Richards S, Pravikoff D. Providing care for the patient with delirium. In: CINAHL Nursing Guide. Glendale, CA: Cinahl Information Systems; 2007.  Back to cited text no. 6
McCusker J, Cole M, Abrahamowicz M, Han L, Podoba JE, Ramman-Haddad L, et al. Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 2001;49:1327-34.  Back to cited text no. 7
Milton A, Brück E, Schandl A, Bottai M, Sackey P. Early psychological screening of intensive care unit survivors: A prospective cohort study. Crit Care 2017;21:273.  Back to cited text no. 8
Devlin JW, Fong JJ, Schumaker G, O'Connor H, Ruthazer R, Garpestad E, et al. Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Crit Care Med 2007;35:2721-4.  Back to cited text no. 9
Frenette AJ, Bebawi ER, Deslauriers LC, Tessier AA, Perreault MM, Delisle MS, et al. Validation and comparison of CAM-ICU and ICDSC in mild and moderate traumatic brain injury patients. Intensive Care Med 2016;42:122-3.  Back to cited text no. 10
Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Med 2001;27:859-64.  Back to cited text no. 11
Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703-10.  Back to cited text no. 12
Sher Y, Miller Cramer AC, Ament A, Lolak S, Maldonado JR. Valproic acid for treatment of hyperactive or mixed delirium: Rationale and literature review. Psychosomatics 2015;56:615-25.  Back to cited text no. 13
Bourgeois JA, Koike AK, Simmons JE, Telles S, Eggleston C. Adjunctive valproic acid for delirium and/or agitation on a consultation-liaison service: A report of six cases. J Neuropsychiatry Clin Neurosci 2005;17:232-8.  Back to cited text no. 14
Vreeswijk R, Toornvliet A, Honing ML, Bakker K, De Man T, Daas G, et al. Validation of the Dutch version of the confusion assessment method (CAM-ICU) for delirium screening in the intensive care unit. Neth J Crit Care 2009;13:73-8.  Back to cited text no. 15
Gaspardo P, Peressoni L, Comisso I, Mistraletti G, Ely EW, Morandi A, et al. Delirium among critically ill adults: Evaluation of the psychometric properties of the Italian 'confusion assessment method for the intensive care unit'. Intensive Crit Care Nurs 2014;30:283-91.  Back to cited text no. 16
Tobar E, Romero C, Galleguillos T, Fuentes P, Cornejo R, Lira MT, et al. Confusion assessment method for diagnosing delirium in ICU patients (CAM-ICU): Cultural adaptation and validation of the Spanish version. Med Intensiva 2010;34:4-13.  Back to cited text no. 17
Aljuaid MH, Deeb AM, Dbsawy M, Alsayegh D, Alotaibi M, Arabi YM, et al. Psychometric properties of the Arabic version of the confusion assessment method for the intensive care unit (CAM-ICU). BMC Psychiatry 2018;18:91.  Back to cited text no. 18
Khan RM, Aljuaid M, Aqeel H, Aboudeif MM, Elatwey S, Shehab R, et al. Introducing the comprehensive unit-based safety program for mechanically ventilated patients in Saudi Arabian intensive care units. Ann Thorac Med 2017;12:11-6.  Back to cited text no. 19
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