A rapid scoping review of barriers and facilitators of implementing delirium prevention practices in adult critical care

Abstract

Background: Delirium is a serious complication of critical care that can have lasting effects on the patient’s life. Much of the work to date about delirium has been focused on identifying delirium risk factors, developing tools for screening and recognizing delirium, and testing interventions to treat those diagnosed with delirium. Despite evidence, implementing known delirium prevention and management strategies remains abysmal. This review aimed to identify and summarize literature reporting on the barriers and facilitators of implementing delirium prevention and management practices in adult critical care.

Methods: A rapid scoping review of the literature was conducted. The databases CINAHL and Ovid Medline were searched, and forward and backward reference checking was completed.  Data abstraction and analysis were performed by one reviewer and verified by a second reviewer.

Results: After review of 74 full-text papers, 32 articles were included in the review. The articles were published between 2008 and 2022, with the majority conducted in the United States (53%). The barriers and facilitators of delirium prevention and management practices described in the reviewed articles were categorized as patient-level, clinician-level, and organizational-level factors.

Conclusion: The review found consistency among the published results.  However, opportunities to continue to grow research in this area remain; specifically in examining the opportunity to understand better the decision-making process surrounding how care is prioritized when taking into consideration the present barriers and facilitators and the opportunity to use implementation science to create and sustain change in the practice of delirium prevention and management strategies.

Implications for Nursing

This rapid scoping review summarizes the facilitators and barriers to implementing delirium prevention related practices into critical care which will better equip critical care nurses to improve care outcomes for patients at risk for or experiencing delirium.

The summary of facilitators and barriers equips critical care leaders and teams to implement delirium prevention practices.

This review also highlights the ongoing need for a focus on improving delirium in critical care.

Key Words: Delirium, Facilitators, Barriers, Critical Care, Nursing

Background

Delirium is a serious complication associated with hospitalization and particularly with a critical care stay (Collet, Thomsen & Egerod, 2018). In Canada, there are approximately three million hospitalizations annually, roughly 11% of which include a stay in critical care (CIHI, 2016). The incidence of delirium in hospitalized adults ranges from 20 – 30% (Collet et al., 2018; Piao et al., 2018). However, delirium rates in critical care are significantly higher, particularly in those who receive mechanical ventilation, wherein incidence can be as high as 80% (Collet et al., 2018; Piao et al., 2018). Delirium is a syndrome characterized by an acute disturbance in consciousness and changes in cognition that fluctuates during the day with three subtypes identified – hyperactive, hypoactive, and mixed hyper and hypoactive (Collet et al., 2018; Piao et al., 2018). Delirium-associated complications are profound for patients and the healthcare system and include prolonged length of stay in critical care and hospital and increased mortality and morbidity (Chaplin & Mcluskey, 2020; Fowler, 2019). In a meta-analysis of 28 studies comparing delirious versus non-delirious patients, those with delirium had a higher severity of illness, a longer length of stay in critical care (risk ratio 1.38), and a greater overall risk of death (risk ratio 2.19) (Salluh et al., 2015). Long-term health outcomes were also worse, with delirious patients having poorer global cognition at three- and twelve-months post-hospital discharge (Salluh et al., 2015).

Delirium is a significant complication, and researchers have focused on identifying delirium risk factors, developing tools for screening and recognizing delirium, and testing interventions to treat those diagnosed with delirium (Collet et al., 2018; Fowler, 2019; Birge & Aydin, 2017; Devlin et al., 2018; Martinez, Donoso, Marquez & Labarca, 2017). Multiple risk factors have been associated with increased risk for developing delirium. These risk factors include sepsis, shock, blood glucose fluctuation, hypoxia, electrolyte imbalances, as well as untreated pain, agitation, and previous history of delirium (Barr & Pandharipande, 2013).  Adverse drug reactions and environmental factors also increased the risk of delirium (Barr & Pandharipande, 2013). Consistent screening for delirium using a validated tool and a bundled approach to implementing delirium prevention and management practices has been shown to improve patient outcomes (Pun et al., 2019). Delirium prevention and management practices that have been proven effective include assessing, preventing, and adequately treating pain, use of spontaneous breathing trials to evaluate the need for mechanical ventilation, appropriate choice of analgesic and sedative agents, delirium screening, early mobilization, and family engagement (Sosnowski et al., 2023). These items comprise the ABCDEF bundle (Pun et al., 2019; Sosnowski et al., 2023). Implementing the ABCDEF bundle has shown meaningful improvements in patient outcomes related to delirium (Pun et al., 2019; Sosnowski et al., 2023).

Despite evidence that delirium prevention and management strategies are effective, such as the ABCDEF bundle, maintenance of a day-night routine, and sensory and orientation support, their implementation remains low. Hospitals implementing multicomponent processes for preventing, assessing, and treating delirium have reduced delirium incidence (Collinsworth et al., 2016). However, few critical care units in Canada have consistently adopted these practices (Collinsworth et al., 2016).  Implementation of delirium prevention and management practices depends on nurses prioritizing and integrating these strategies within the context of multiple competing care demands and established critical care practices and routines. Evidence to support nurses in prioritizing delirium prevention and management strategies needs to be more robust, as does evidence to identify barriers and facilitators to inform changes in critical care work environments that would make delirium prioritization possible.

This rapid scoping review identified and synthesized literature reporting on the barriers and facilitators to implementing delirium prevention and management practices in adult critical care environments. The findings of this review will inform research examining how critical care nurses prioritize patient care and the relation to delirium prevention and management.

Methodology and Review Design

Scoping reviews are a popular method for conducting knowledge synthesis “which incorporate a range of study designs to comprehensively summarize and synthesize evidence with the aim of informing practice, programs, and policy and providing direction to future research priorities” (Colquhoun et al., 2014, p. 1291).  Rapid reviews are a form of review in which some of the traditional review processes are simplified or omitted to yield information quickly (Tricco et al., 2015). Rapid scoping reviews are generally conducted in a shorter timeframe to answer context-specific clinical questions (Tricco et al., 2015; Colquhoun et al., 2014). For this project, a rapid scoping review process was chosen as it met the project’s needs and due to the limitation of funding and time.

Search

A search strategy was developed in consultation with a hospital librarian to locate recent literature reporting on barriers and facilitators of delirium prevention and management practices in adult critical care settings. The search strategy was applied to the databases CINAHL and Ovid Medline only due to the rapid nature of this review. Initially, a comprehensive search was conducted to identify articles published from before 1946 to 2023, then narrowed to 2000 to 2023 to reflect the period when the importance of delirium in critical care emerged. The search was limited to publications in English.  Table 1 describes the inclusion and exclusion criteria, while Table 2 provides an outline of the search strategy. A grey literature search was not conducted.

Screening

Citations were downloaded for screening. Because this was a rapid review, the initial screening was done by one author (C.S.) to eliminate duplicates, followed by a title and abstract review to determine if the inclusion/exclusion criteria were met. Following this initial review, 74 full-text manuscripts were reviewed to determine if they met inclusion criteria, with a resulting 23 manuscripts being included. Using forward and backward reference checking, the reference lists of 23 manuscripts were also reviewed to identify relevant articles not captured in the database searches. A subsequent review of the reference titles and abstracts was conducted. Nine additional articles were included from this secondary search (see Figure 1 for PRISMA Flow Diagram).

Data Extraction

A data extraction template was created using Microsoft Word. The primary author extracted data from each of the included articles, including the year of publication, study location, research methodology, and identified barriers and facilitators.

Results

A total of thirty-two articles were included in this scoping review (see supplemental Table). The articles reported on published work from 2008 to 2022 (see Figure 2), conducted in the United States (n = 17), Australia (n = 6), United Kingdom (n = 3), Canada (n = 2), Netherlands (n = 1), Italy (n  = 1), China (n = 1), and Thailand (n = 1); and used a variety of research methodologies (qualitative and quantitative) and quality improvement projects.

The barriers and facilitators of implementing delirium prevention and management practices evident in the reviewed articles were categorized as patient-level, clinician-level, and organizational-level factors.

Patient-Level Factors

Patient-level factors impacting implementation of delirium-related prevention and management practices had to do with the patient’s acuity level and potential for deterioration, existing delirium, and physical characteristics (Table 3). According to the articles, increasing patient complexity resulted in greater barriers to implementing delirium-related practices (Anekwe et al., 2019; Balas, 2019; Brock et al., 2018; Costa et al., 2017; Davis & MacLullich, 2009; Devlin et al., 2008; Dubb et al., 2016; Lin et al., 2020; Parker et al., 2021; Parry et al., 2017; Potter, Miller & Newman, 2021; Weber et al., 2017; Winkelman & Peereboom, 2010). It was reported that it was easier to deliver delirium prevention or care practices to more awake, cooperative, and stable patients (Brock et al., 2018; Winkelman & Peereboom, 2010). Existing delirium was reported in 13 articles to be a barrier to delirium-related practices (Anekwe et al., 2019; Balas, 2019; Brock et al., 2018; Costa et al., 2017; Davis & MacLullich, 2009; Devlin et al., 2008; Dubb et al., 2016; Lin et al., 2020; Parker et al., 2021; Parry et al., 2017; Potter, Miller & Newman, 2021; Weber et al., 2017; Winkelman & Peereboom, 2010).

Clinician-Level Factors

This category includes information about facilitators and barriers delirium prevention and management practices that are related to clinician capacity (see Table 3 for summary). According to 14 articles, clinician lack of training or knowledge coupled with delirium perceived as a low priority, was highlighted as a significant barrier to implementing delirium practices (Anekwe et al., 2019; Balas, 2019; Costa et al., 2017; Dafoe et al., 2015; Devlin et al., 2008; Fowler, 2019; Goddard et al., 2018; Law et al., 2012; Lin et al., 2020; Parker et al., 2021; Parry et al., 2017; Riekerk et al., 2009; Rowley-Conwy, 2018; Sinvani et al., 2021). Six articles identified that nurses reported concerns about personal musculoskeletal injury, increased workload, and general work stress to be barriers to implementing delirium practices (Balas et al., 2013; Carrothers et al., 2013; Collinsworth et al., 2021; Costa et al., 2017; Lin et al., 2020; Negro et al., 2022). Feeling supported and autonomous in practice was also identified in three articles as a facilitator of delirium practices (Boehm et al., 2020; Collinsworth et al., 2021; Costa et al., 2017).

Organization-Level Factors

Among the factors influencing the implementation of delirium-related practices, the functionality of interdisciplinary teams emerged as a critical element. As observed across the reviewed literature (see Table 3 for summary), the collaborative efforts of healthcare providers from diverse disciplines play a pivotal role in delirium care. The effectiveness of these teams hinges on the availability of organizational resources, such as equipment and technology, as well as the presence of skilled staff (Anekwe et al., 2019; Balas, 2019; Balas et al., 2013; Barber et al., 2015; Boehm et al., 2020; Brummel et al., 2013; Carrothers et al., 2013; Collinsworth et al., 2021; Costa et al., 2017; Dafoe et al., 2015; Davis & MacLullich, 2009; Devlin et al., 2011; Dubb et al., 2016; Elliot, 2014; Fowler, 2019; Goddard et al., 2018; Law et al., 2012; Lin et al., 2020; Negro et al., 2022; Parker et al., 2021; Parry et al., 2017; Riekerk et al., 2009; Rowley-Conwy, 2018; Sinvani et al., 2021; Wang et al., 2020; Weber et al., 2017). However, a lack of cohesion within these teams, compounded by high patient acuity and workload, presents a significant barrier to effective delirium management (Barber et al., 2015; Negro et al., 2022; Parry et al., 2017). Additionally, organizational or unit culture plays a crucial role, with a supportive environment being conducive to the adoption of delirium-related practices (Balas, 2019; Barber et al., 2015; Brummel et al., 2013; Carrothers et al., 2013; Collinsworth et al., 2021; Costa et al., 2017; Dubb et al., 2016; Goddard et al., 2018; Parker et al., 2021; Weber et al., 2017). Organizations fostering a culture of quality improvement or research demonstrate higher levels of implementation success (Lin et al., 2020; Negro et al., 2022; Parker et al., 2021), often driven by engaged leadership that recognizes the significance of delirium management and prevention (Lin et al., 2020; Negro et al., 2022; Parker et al., 2021). Thus, acknowledging and fostering the functionality of interdisciplinary teams within supportive organizational cultures are essential steps towards enhancing delirium care practices.

Discussion

There is a wealth of evidence demonstrating the adverse effects of delirium on patient outcomes in critical care settings (Balas, 2019; Devlin et al., 2018). Consequently, the implementation of effective delirium prevention and management practices is paramount for ensuring optimal care for critically ill patients. Research identifying the barriers and facilitators to delirium prevention and management practices in adult critical care is foundational to developing successful implementation strategies.  

Across the thirty-two studies included in our scoping review, various factors at different levels were found to be facilitators or barriers to the implementation of delirium prevention and management practices. Patient-level factors primarily focused on the patient’s acuity of illness, physical characteristics, and clinical behaviors, including the presence of delirium itself (Anekwe et al., 2019; Balas, 2019; Brock et al., 2018; Costa et al., 2017; Davis & MacLullich, 2009; Devlin et al., 2008; Dubb et al., 2016; Lin et al., 2020; Parker et al., 2021; Parry et al., 2017; Potter, Miller & Newman, 2021; Weber et al., 2017; Winkelman & Peereboom, 2010). These patient-level factors often intersect with clinician-level barriers, such as personal beliefs that delirium was not a priority, safety concerns over the ability to implement delirium mitigation strategies (e.g. mobilizing critically ill patients), and inadequate training, which further compound the challenges of delirium care (Anekwe et al., 2019; Balas et al., 2013; Balas, 2019; Boehm et al., 2020; Carrothers et al., 2013; Collinsworth et al., 2021; Costa et al., 2017; Dafoe et al., 2015; Devlin et al., 2008; Fowler, 2019; Goddard et al., 2018; Law et al., 2012; Lin et al., 2020; Negro et al., 2022; Parker et al., 2021; Parry et al., 2017; Riekerk et al., 2009; Rowley-Conwy, 2018; Sinvani et al., 2021).

Furthermore, organizational-level factors, including unit culture and resource availability, significantly shape the environment for delirium care (Anekwe et al., 2019; Balas, 2019; Balas et al., 2013; Barber et al., 2015; Boehmet al., 2020; Brummel et al., 2013; Carrothers et al., 2013; Collinsworth et al., 2021; Costa et al., 2017; Dafoe et al., 2015; Davis & MacLullich, 2009; Devlin et al., 2011; Dubb et al., 2016; Elliot, 2014; Fowler, 2019; Goddard et al., 2018; Law et al., 2012; Lin et al., 2020; Negro et al., 2022; Parker et al., 2021; Parry et al., 2017; Riekerk et al., 2009; Rowley-Conwy, 2018; Sinvani et al., 2021; Wang et al., 2020; Weber et al., 2017). Although the numerous barriers and facilitators to implementing delirium-related practices were categorized into three overarching factors, the interconnectedness among these factors and the impact on guideline uptake should not be discounted.

It is important to describe how barriers at all levels interact with each other. Clinicians often report difficulty in adhering to recommended strategies outlined in guidelines due to safety concerns associated with managing hyperactive delirium (Anekwe et al., 2019; Devlin et al., 2011). These safety concerns may stem from organizational barriers such as inadequate staffing or poor collaboration among interdisciplinary team members (Fowler, 2019; Negro et al., 2022). Furthermore, the relationship between clinician-level and organizational-level barriers can exacerbate the challenges of guideline implementation. For instance, clinicians’ perceptions of inadequate support from their organizations may deter them from prioritizing delirium care, leading to suboptimal adherence to guidelines (Fowler, 2019; Negro et al., 2022). Conversely, organizational initiatives aimed at fostering a culture of safety and providing adequate resources can facilitate guideline uptake among clinicians (Negro et al., 2022; Parker et al., 2021).

The interconnectedness among these factors underscores the complexity of implementing delirium-related practices. While patient-level factors may influence the feasibility and appropriateness of implementing recommended interventions, clinician-level barriers can lead to suboptimal adherence to guidelines. Similarly, organizational factors, such as resource constraints and cultural norms, may impede the integration of best practices into routine care. Addressing these barriers necessitates a comprehensive approach that acknowledges their multifaceted nature and considers strategies at all levels. Interventions aimed at improving clinician education, fostering a supportive organizational culture, and optimizing resource allocation are essential for enhancing guideline uptake and improving delirium care in critical care settings.

This review highlights the need for comprehensive strategies to overcome the barriers to implementing delirium prevention and management practices in critical care. By addressing patient, clinician, and organizational-level factors, healthcare systems can enhance the quality of care and improve patient outcomes in this vulnerable population. Understanding the complexity of delirium prevention and management in critical care and the associated literature surrounding barriers and facilitators, makes it evident that an integrated knowledge translation framework is needed to create and sustain a change of practice successfully. The Society of Critical Care Medicine (2022) has completed work to improve delirium in critical care and advocated for the use of knowledge translation frameworks to assist in the implementation and sustainment of delirium practices. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is designed explicitly for knowledge translation in complex healthcare systems and utilizes four key domains (Harvey & Kitson, 2016; Hunter et al., 2020; Roberts et al., 2021; Rycroft-Malone, 2004). While not specifically used for delirium related practice changes, the i-PARIHS framework has previously been successfully utilized in complex critical care environments to implement other evidence-based practices changes (Alostaz et al., 2022; Qin et al., 2020; Steffan et al., 2021). The core domains of the i-PARIHS framework include facilitation, innovation, context and recipients (Roberts et al., 2021). The i-PARIHS differs from the original PARIHS by using facilitators to adapt and mould the innovative change in such a way that the new practice fits the contextual uniqueness as a result of feedback from the recipients involved in the implementation, which can aid in the consideration and planning to help address identified barriers (Harvey & Kitson, 2016; Roberts et al., 2021). This framework would be practical due to the innate flexibility provided, the consideration for contextual factors, and the inclusion of the internal facilitator roles that act as change agents which are embedded in the practice area that promote adaption and encourage sustainment through ongoing engagement (Harvey & Kitson, 2016; Hunter et al., 2020).

Strengths/Limitations

Due to the rapid nature of this scoping review, which was chosen due to time constraints and a single reviewer conducting the review, there are potential limitations in the search strategy. However, forward and backward reference checking was completed, and the extracted data demonstrated consistent findings aligned with the identified themes. Another limitation was that the search included only  English-language publications and the lack of a grey literature search.

Conclusion

This rapid scoping review  describes the barriers and facilitators of delirium prevention and management practices in adult critical care. While our findings provide a comprehensive overview of the factors influencing the implementation of delirium-related practices, it’s crucial to acknowledge the limited exploration of nurses’ decision-making processes in managing delirium. Understanding the specific barriers experienced by nurses and other healthcare providers, and how these barriers influence decision-making, warrants further investigation. By delving deeper into the challenges faced by frontline caregivers, we can better tailor interventions to address their needs and enhance the implementation of evidence-based delirium prevention and management strategies. This represents an important avenue for future research, bridging the gap between research findings and clinical practice to optimize patient care in critical care settings.

Author Notes:

Sarah Crowe, MN, PMD-NP (F), NP, CNCC(C), Surrey Memorial Hospital, Fraser Health, Surrey, BC.

A. Fuchsia Howard, PhD, RN, University of British Columbia School of Nursing, Vancouver, BC.

Corresponding Author:

Sarah Crowe, MN, PMD-NP (F), NP, CNCC(C), Surrey Memorial Hospital, Fraser Health, Surrey, BC.  Email: sarah.crowe@fraserhealth.ca.

Funding and conflict of interest:

There are no conflicts of interest to declare.  This manuscript is part of a larger study that was funded by the Michael Smith Foundation for Health Research (Trainee Grant).  The foundation was not involved in the study design, data collection, analysis or preparation of the results. 

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PRISMA Scoping Review Flow Diagram

Figure 2

Publications per Year

Table 1

 Inclusion and Exclusion Criteria

Table 2

Search Strategy

Table 3

Barriers and Facilitators of Implementing Delirium Practices

(Anekwe et al., 2019; Balas et al., 2013; Balas, 2019; Barber et al., 2015; Boehm et al., 2020; Brock et al., 2018; Brummel et al., 2013; Carrothers et al., 2013; Collinsworth et al., 2021; Costa et al., 2017; Dafoe et al., 2015; Davis & MacLullich, 2009; Devlin et al., 2008; Devlin et al., 2011; Dubb et al., 2016; Elliot, 2014; Fowler , 2019; Goddard et al., 2018; Law et al., 2012; Lin et al., 2020; Negro et al., 2022; Parker et al., 2021; Parry et al., 2017; Potter, Miller & Newman, 2021; Riekerk et al., 2009; Rowley-Conwy, 2018; Sinvani et al., 2021Weber et al., 2017, Wang et al., 2020; Weber et al., 2017Winkelman & Peereboom, 2010)

Supplemental Table

Literature Summary

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