Delirium is common disorder among ICU patients [3, 6, 8, 11, 12, 16, 17]. Doctors and nurses were the direct healthcare providers for critically ill patients. In addition to nurses, doctors were involved in delirium assessment and reporting as mentioned by Pisani MA et al. [5]. Lack of knowledge among staff was reported as one of the individual barriers [3], hence, our study tackled the knowledge of doctors about delirium and delirium management.
Society of Critical Care Medicine recommended delirium assessment for all patients in the ICU through the use of a validated assessment instrument [4, 5]. However, in our study, most doctors (76.4%) had not used any specific tool for delirium assessment and relied on signs and symptoms alone. As in the study of Depetris et al. 57% of the doctors did not use any specific tool for delirium assessment [19]. Delirium was usually assessed using either the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) [7, 18]. Although usefulness of the Confusion Assessment Method for the ICU (CAM-ICU) for delirium detection was documented in recent studies [5, 17], only 18.1% of our participants used CAM-ICU for delirium assessment. Nevertheless, ICDSC was used by only 1.4% of the doctors. Furthermore, in a systematic review, CAM-ICU was the tool used for assessing delirium in 65% of delirium clinical trials, while, ICDSC was used in only 6% of the trials [6]. In a meta-analysis study, both CAM-ICU and ICDSC could be used to screen for delirium and diagnose it. Yet, the study favored CAM-ICU as ICDSC showed lower specificity and sensitivity compared to CAM-ICU [20]. Comparatively, in a national multicenter study in china, 34% of the doctors used delirium tools; of which, CAM-ICU was the most commonly used (83%) tool [23]. Nevertheless, in another study, CAM-ICU was used by 27.5% of the doctors, while ICDSC was used by 5% [19].
Delirium among ICU patients must be assessed every 8 hours or at least every 12 hours [7, 18]. Less than half of ICU doctors (40.3%) in our study assessed delirium every 8-12 hours, this was the practice in 60% of the clinical trials of delirium as reported by Colantuoni E et al. Moreover, 45.8% of our doctors assessed delirium daily, that was higher than what was reported (35%) by Colantuoni E et al. [6]. Only 13.9% of our doctors had non-regular assessments for delirium, this was the case for 30% of the physicians in a multi-national study [19]. Among our study participants, one of the reasons for irregular delirium assessment was the increased workload. Such issue was interpreted as an environmental barrier; especially among ICU staff [3]. This issue was addressed in a study that recommended, in such case of limited resources, delirium management strategies may be prioritized for patients with high risk of delirium [7]. In our study, association between practice of ICU doctors and their years of experience was studied. Regarding delirium assessment, a statistically significant difference (p=0.012) was found. Contrary to the study of Wang et al. showing no statistically significant difference (p=0.074) between experienced and less experienced clinicians [23].
Delirium preventive measures are important for all ICU patients [7]. This was the case for most of our doctors, however, two doctors reported that they had not conducted such measures unless the patient develops signs and symptoms of delirium.
Non-pharmacological approach for delirium management (treatment and/or prevention) was the preferred approach [18]. This approach was the first-line choice for 76.4% of the doctors in our study, higher than percentage reported (22.5%) by Depetris et al. [19]. Communication with ICU patients to prevent delirium was the most frequent non-pharmacological approach applied by the ICU doctors of our study (75%). This approach was discussed in a systematic review by Deemer K et al. assessing the early cognitive interventions for delirium among ICU patients [12]. Moreover, participation of family members in delirium preventive strategies could be complimentary to the communication interventions done by doctors and nurses [12]. This approach of using family member support was practiced by one doctor in our study. Sleep and circadian rhythm regulation among ICU patients was a target therapy approach for these patients [24]; however, it was applied by only 18.1% of our doctors. Another important risk factor for delirium was the use of benzodiazepines [16, 18]. Midazolam is the most commonly used sedative for ICU patients prescribed as high as 72%- 90.5% of the sedatives [16, 19, 25]. Hence, reduction in their use was considered an important non-pharmacological approach for prevention of delirium among critically ill patients [18]. However, among our ICU doctors, reduction of benzodiazepines was adopted by only 6.9% of the doctors. Surprisingly, sedatives were used by 20% of our doctors to manage delirium, similarly, midazolam was one of the agents used by clinicians in China (31%) for treating delirium [23]. This issue needed to be addressed because use of sedatives for patients with delirium worsens the case and their use should be reduced [17, 18].
Based on the systematic review of Barbateskovic M, et al., evidence for using pharmacological interventions in the management and prevention of delirium was poor [26]. Nonetheless, this approach was not superior in delirium management [9]. Pharmacological approach for delirium treatment was used as first-line management by 22.2% of our study participants. This was higher than reported (2.5%) in a multi-national study [19]. Anti-psychotics were the most commonly used agents (69.4%) among our study doctors. Haloperidol was, by far, the most commonly used agent among ICU doctors (83.3%) for delirium treatment. This was consistent with a cohort study using haloperidol alone on in combination with clonidine [15]. Furthermore, studies reported that haloperidol use was the highest for patients with delirium (30%, 43.3%) [4, 23, 26]. The second commonly used agent in our study was olanzapine (5.6%), similarly to that reported (5.9%) by Swan et al [4]. In the other hand, quetiapine and risperidone were used by only 1.4% of our study participants, this was much lower than the frequencies reported by Swan et al. (12.7% and 5% respectively) [4].
Continuation of delirium medication after ICU discharge was common (50.2%) as per study [27]. Of our doctors, 40.3% had not stopped delirium medications on discharge, this was lower than what reported above [27]. But, continuation of such medications beyond hospital stay could lead to harmful and deleterious events, hence, medication reconciliation is crucial in such cases [18].
The limitations of our study were the lack of comparison of doctors practice to nurses practice. Furthermore, the data collection tool was not validated through Cronbach test of reliability. Although this study was a multi-center study, selection bias might be a risk as we focused on the Hospitals of the Military section as they were bigger and more populated hospitals.