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VOLUME 25 , ISSUE 7 ( July, 2021 ) > List of Articles

Original Article

A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial

Anil K Malik, Rajeshwari Subramaniam

Citation Information : Malik AK, Subramaniam R. A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial. Indian J Crit Care Med 2021; 25 (7):754-760.

DOI: 10.5005/jp-journals-10071-23881

License: CC BY-NC 4.0

Published Online: 07-07-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Introduction: Although various preventive strategies have been advocated, delirium is common in critically ill patients and is associated with increased morbidity, mortality, and long-term adverse effects. The efficacy of a novel delirium prevention bundle in mechanically ventilated critically ill patients was investigated in this study. Methods: In this randomized controlled trial, 50 mechanically ventilated adult patients in a tertiary care medical-surgical intensive care unit (ICU) were randomized to receive either delirium prevention bundle protocol or standard of care protocol. Delirium was assessed daily using the Confusion Assessment Method for the ICU (CAM-ICU) score by an independent investigator up to 28 days or death or discharge. The primary outcome was the incidence of new-onset delirium. Secondary outcomes were duration of mechanical ventilation, ICU length of stay (ICU-LOS), hospital LOS, and other adverse events. Results: There was a 20% reduction in the incidence of delirium in the intervention group (36 vs 56%; p = 0.156). The 28-day mortality (28 vs 24%; p = 0.747), duration of mechanical ventilation (9 vs 12 days; p = 0.281), ICU-LOS (11 vs 12 days; p = 0.221), and hospital LOS (16 vs 20 days; p = 0.062) were similar between the groups. Conclusion: Implementation of delirium prevention bundle does not reduce the incidence of delirium compared to standard of care protocol in mechanically ventilated critically ill patients.

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington (DC): American Psychiatric Association; 1994. 866 p. Available from:
  2. 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(21):2703–2710. DOI: 10.1001/jama.286.21.2703.
  3. Pandharipande P, Cotton BA, Shintani A, Thompson J, Pun BT, Morris JA Jr, et al. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma 2008;65(1):34–41. DOI: 10.1097/TA.0b013e31814b2c4d.
  4. Page VJ, Navarange S, Gama S, McAuley DF. Routine delirium monitoring in a UK intensive care unit. Crit Care 2009;13(1):R16. DOI: 10.1186/cc7714.
  5. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291(14):1753–1762. DOI: 10.1001/jama.291.14.1753.
  6. Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, et al. Outcome of delirium in critically ill patients: systemic review and meta-analysis. BMJ 2015;350:h2538. DOI: 10.1136/bmj.h2538.
  7. Lin SM, Liu CY, Wang CH, Lin HC, Huang CD, Huang PY, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004;32(11):2254–2259. DOI: 10.1097/
  8. Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42(8):809–815. DOI: 10.1111/j.1532-5415.1994.tb06551.x.
  9. O'Keeffe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc 1997;45(2):174–178. DOI: 10.1111/j.1532-5415.1997.tb04503.x.
  10. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013;369:1306–1316. DOI: 10.1056/NEJMoa1301372.
  11. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of post discharge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010;304(4):443–451. DOI: 10.1001/jama.2010.1013.
  12. McCusker J, Cole MG, Voyer P, Monette J, Champoux N, Ciampi A, et al. Prevalence and incidence of delirium in long-term care. Int J Geriatr Psychiatry 2011;26(11):1152–1161. DOI: 10.1002/gps.2654.
  13. Buss MK, Vanderwerker LC, Inouye SK, Zhang B, Block SD, Prigerson HG. Associations between caregiver-perceived delirium in patients with cancer and generalized anxiety in their caregivers. J Palliat Med 2007;10(5):1083–1092. DOI: 10.1089/jpm.2006.0253.
  14. Shankar KN, Hirschman KB, Hanlon AL, Naylor MD. Burden in caregivers of cognitively impaired elderly adults at time of hospitalization: a cross-sectional analysis. J Am Geriatr Soc 2014;62(2):276–284. DOI: 10.1111/jgs.12657.
  15. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Arch Intern Med 2008;168(1):27–32. DOI: 10.1001/archinternmed.2007.4.
  16. Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004;32(4):955–962. DOI: 10.1097/01.ccm.0000119429.16055.92.
  17. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996;275(11):852–857. PMID: 8596223.
  18. Zaal IJ, Devlin JW, Peelen LM, Slooter AJ. A systematic review of risk factors for delirium in the ICU. Crit Care Med 2015;43(1):40–47. DOI: 10.1097/CCM.0000000000000625.
  19. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41(1):263–306. DOI: 10.1097/CCM.0b013e3182783b72.
  20. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29(7):1370–1379. DOI: 10.1097/00003246-200107000-00012.
  21. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Care Med 2002;166(10):1338–1344. DOI: 10.1164/rccm.2107138.
  22. Avendano-Cespedes A, Garcia-Cantos N, Gonzalez-Teruel Mdel M, Martinez-Garcia M, Villarreal-Bocanegra E. Pilot study of a preventive multicomponent nurse intervention to reduce the incidence and severity of delirium in hospitalized older adults. Maturitas 2016;86:86–94. DOI: 10.1016/j.maturitas.2016.02.002.
  23. Barnes-Daly MA, Phillips D, Ely EW. Improving hospital survival and reducing brain dysfunction at seven California community hospital: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med 2017;45(2):171–178. DOI: 10.1097/CCM.0000000000002149.
  24. Sanchez-Hurtado LA, Hernandez-Sanchez N, Moral-Armengol MD, Guevara-Garcia H, Garcia-Guillen FJ, Herrera-Gomez A, et al. Incidence of delirium in critically ill cancer patients. Pain Res Manag 2018;Article ID 4193275. DOI: 10.1155/2018/4193275.
  25. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007;298(22):2644–2653. DOI: 10.1001/jama.298.22.2644.
  26. Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009;301(5):489–499. DOI: 10.1001/jama.2009.56.
  27. Jiang YK, Wang S, Lam TS, Hanna A, DeMuro JP, Calixte R, et al. Prevalence of delirium and coma in mechanically ventilated patients sedated with dexmedetomidine or propofol. Pharm Therapeut 2016;41(7):442–445. PMID: 27408521, PMCID: PMC4927019.
  28. Louie JM, Lonardo NW, Mone MC, Stevens VW, Deka R, Shipley W, et al. Outcomes when using adjunct dexmedetomidine with propofol sedation in mechanically ventilated surgical intensive care patients. Pharmacy 2018;6(3):93. DOI: 10.3390/pharmacy6030093.
  29. Emond M, Boucher V, Carmichael PH, Voyer P, Pelletier M, Gouin E, et al. Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicenter cohort study. BMJ Open 2018;8(3):e018190. DOI: 10.1136/bmjopen-2017-018190.
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