Prospective multicentre multifaceted before-after implementation study of ICU delirium guidelines: a process evaluation

BMJ Open Qual. 2020 Sep;9(3):e000871. doi: 10.1136/bmjoq-2019-000871.


Objective: We aimed to explore: the exposure of healthcare workers to a delirium guidelines implementation programme; effects on guideline adherence at intensive care unit (ICU) level; impact on knowledge and barriers, and experiences with the implementation.

Design: A mixed-methods process evaluation of a prospective multicentre implementation study.

Setting: Six ICUs.

Participants: 4449 adult ICU patients and 500 ICU professionals approximately.

Intervention: A tailored implementation programme.

Main outcome measure: Adherence to delirium guidelines recommendations at ICU level before, during and after implementation; knowledge and perceived barriers; and experiences with the implementation.

Results: Five of six ICUs were exposed to all implementation strategies as planned. More than 85% followed the required e-learnings; 92% of the nurses attended the clinical classroom lessons; five ICUs used all available implementation strategies and perceived to have implemented all guideline recommendations (>90%). Adherence to predefined performance indicators (PIs) at ICU level was only above the preset target (>85%) for delirium screening. For all other PIs, the inter-ICU variability was between 34% and 72%. The implementation of delirium guidelines was feasible and successful in resolving the majority of barriers found before the implementation. The improvement was well sustained 6 months after full guideline implementation. Knowledge about delirium was improved (from 61% to 65%). The implementation programme was experienced as very successful.

Conclusions: Multifaceted implementation can improve and sustain adherence to delirium guidelines, is feasible and can largely be performed as planned. However, variability in delirium guideline adherence at individual ICUs remains a challenge, indicating the need for more tailoring at centre level.

Keywords: clinical practice guidelines; critical care; evaluation methodology; evidence-based practice; implementation science.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Clinical Competence / standards
  • Clinical Competence / statistics & numerical data
  • Delirium / therapy*
  • Female
  • Guideline Adherence
  • Guidelines as Topic
  • Humans
  • Intensive Care Units / organization & administration
  • Intensive Care Units / trends
  • Male
  • Mass Screening / methods
  • Program Development / methods*
  • Program Evaluation / methods
  • Prospective Studies