The reasons hypoactive delirium is often overlooked: a reply

Abstract

Full text

We thank Li et al. [1] for their interest in our survey [2]. We agree that hypoactive delirium in the ICU is difficult to diagnose, often missed and leads to poor outcomes for patients. It would not be appropriate to cross‐tabulate results as Li et al. suggest. The survey was designed to capture ICU‐level practice and was completed by one individual on behalf of the whole ICU. The training questions reflect ICU‐level practice across different healthcare professions, while the confidence questions reflect belief at the individual level from a person already experienced in delirium care.

The survey was part of a package of projects funded by the UK National Institute of Health and Care Research. In addition to the survey, we conducted a qualitative study [3], a psychometric review of all instruments to detect delirium and systematic reviews of interventions and implementation methods to prevent and manage it [4, 5]. We are currently triangulating these different strands of evidence, which will then contribute to addressing some of the questions posed by Li et al. Our triangulation of the evidence does not support training in the CAM‐ICU as the most important means of improving the detection and treatment of hypoactive delirium. The survey and qualitative study show that the CAM‐ICU is implemented variably, and training is only a small part of why this occurs. There are systemic issues which need to be addressed, and these include enhanced training and awareness; protocol‐driven care; audit and feedback; computer‐generated prompts in clinical information systems; and the inclusion of families in the diagnostic and care processes.

The psychometric review answered the question of whether the CAM‐ICU (or indeed any other tool or instrument) possessed the necessary characteristics to detect or diagnose ICU delirium. This would answer a question earlier in any logic model, that is, are we using the right tool for the job – not just can we train people in it. These data have not yet been published, but we do not believe that increasing training in the CAM‐ICU would improve the detection of any ICU delirium or hypoactive delirium specifically.

Little has changed in over 20 years regarding the evidence for interventions to prevent, detect and manage ICU delirium or in the implementation of, or the adherence to, these tools and interventions [3, 6]. A rethink is required to improve patient care and, therefore, clinical outcomes that matter to patients and healthcare providers. Addressing the systemic issues, approached with behavioural science to make it easy for healthcare staff to provide the ‘right’ care that prevents, diagnoses and manages delirium would be the best way to improve care on ICUs.