Delirium management and current practice among Intensive Care Units Doctors, Khartoum

Sheema Hamid Seidna Hamid; Ghada Omer Hamad Abd El-Raheem; Hana  Eltayeb Salih Elamin; Mudawi Mohammed Ahmed  Abdallah

doi:10.12688/f1000research.142233.1

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Research Article

Delirium management and current practice among Intensive Care Units Doctors, Khartoum

[version 1; peer review: 1 not approved]

Sheema Hamid Seidna Hamid¹, Ghada Omer Hamad Abd El-Raheem ², Hana Eltayeb Salih Elamin³, Mudawi Mohammed Ahmed Abdallah⁴

PUBLISHED 07 May 2024

Author details Author details

¹ Clinical Pharmacy, Omdurman Islamic University, Omdurman, Khartoum, 11115, Sudan
² Clinical pharmacy, Soba University Hospital, Khartoum, Khartoum, 11111, Sudan
³ Research methodology and Biostatistics, University of Medical Sciences and Technology, Khartoum, Khartoum, 11111, Sudan
⁴ Medical Manager of Critical Care, Military Hospital, Omdurman, Khartoum, 11115, Sudan

Sheema Hamid Seidna Hamid
Roles: Conceptualization, Data Curation, Methodology

Ghada Omer Hamad Abd El-Raheem
Roles: Conceptualization, Formal Analysis, Software, Writing – Original Draft Preparation

Hana Eltayeb Salih Elamin
Roles: Validation, Writing – Review & Editing

Mudawi Mohammed Ahmed Abdallah
Roles: Project Administration, Resources

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Delirium is a brain dysfunction characterized by attention and cognitive disturbances in a fluctuating manner. The international guidelines recommend daily screening for delirium. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) are the most commonly used methods for assessing delirium. This study aimed to identify barriers and gaps in knowledge and practice. This was a hospital-based Cross-Sectional study. Stratified random sampling was used in this study. 72 ICU doctors were randomly selected. Statistical analyses were performed using IBM SPSS version 23. Descriptive data were presented, and the chi-squared test was used to determine the associations among variables. Statistical significance was set at p < 0.05. More than 70% of the doctors were ≤ 30 years of age and female. A total of 69.4% of the participants had < 1year of experience. In total, 94.4% of the participants worked in medical ICUs. Less than 20% of the doctors used delirium assessment tools, with a statistically significant difference based on experience (p=0.012). Delirium was not regularly assessed in 13.9% of the patients. Non-pharmacological management was applied by 76.4% of doctors, and communication with patients was the most frequent (75%). Haloperidol was the most commonly used drug (83.3%). A total of 40.3% of doctors did not stop delirium medication on ICU discharge. A regular delirium assessment was performed. However, the use of validated assessment tools is uncommon. Nonpharmacological management of delirium is important and is mostly performed. Our doctors prescribed antipsychotics for the treatment of both forms of delirium, and almost half of them did not stop the medications on ICU discharge. Medication reconciliation and contact with the next in-charge of the patients are important.

Keywords

Delirium, CAM-, ICDSC, critically ill patients, ICU, current practice, Intensive Care Units, Doctors.ICU

Corresponding author: Ghada Omer Hamad Abd El-Raheem

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Seidna Hamid SH et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Seidna Hamid SH, Abd El-Raheem GOH, Salih Elamin HE and Ahmed Abdallah MM. Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 1; peer review: 1 not approved]. F1000Research 2024, 13:456 (https://doi.org/10.12688/f1000research.142233.1) First published: 07 May 2024, 13:456 (https://doi.org/10.12688/f1000research.142233.1) Latest published: 19 Feb 2025, 13:456 (https://doi.org/10.12688/f1000research.142233.4)

Background

Delirium is a state of brain dysfunction characterized by attention and cognition disturbances in a fluctuating pattern,¹^–⁷ with an acute onset of confusion and decline in cognitive ability, often occurring in hospitalized patients.⁸ Delirium is related to many factors, such as the pre-existing vulnerable state of patients or medication-induced delirium that occurs during hospital stay.⁹ Delirium is a common disorder among intensive care unit (ICU) patients because of many factors such as old age, multiple medical interventions, and critical illness severity.⁵^,¹⁰ Critically ill patients who are complicated with delirium, in addition to their critical illness, have been associated with prolonged mechanical ventilation (MV), longer hospital and ICU stays, and increased mortality.³^,⁴^,⁶^,⁸^,¹¹^–¹³ The severity of adverse delirium outcomes was associated with the duration of delirium; the longer the duration, the worse the outcomes.¹¹ Prolonged delirium in the ICU is considered a risk factor for developing post-intensive care syndrome, which is characterized by worsened or new impairments in cognitive, physical, and mental health.¹² Acute delirium can persist for a few hours; however, it can persist for weeks to months after hospital discharge.¹⁴ Clinically, delirium can be hyperactive or hypoactive. In the hyperactive form, agitation is prominent, with frequent aggression and risk of self-harm. In the hypoactive form, the patient presents with a low level of consciousness, which is usually prostrate and uncommunicative. A mixed form may also occur with alternation between the two poles.¹⁴

Its incidence varies widely; however, it has a high rate of 70–87%.³^,⁶^,⁸^,¹¹^,¹²^,¹⁵^,¹⁶ Although delirium is common, it is preventable. Prevention or early management of delirium is crucial to reverse the delirium state and minimize adverse clinical outcomes.⁷^,¹¹

The nature of the underlying critical illness, as well as the lack of any verbal communication among ICU patients, poses a difficulty in delirium assessment in the ICU.⁵ Furthermore, delirium is associated with long-term cognitive impairments.⁸^,¹⁷ Systematic assessment of delirium among ICU patients is considered a very important approach to deliver patient care and allows clinicians and other healthcare staff to detect delirium at an early stage.¹^,²

From another perspective, patients with delirium are more likely to bear increased healthcare costs than those without delirium.¹²^,¹⁵^,¹⁷

Management of delirium might be challenging for ICU clinicians, as an established treatment plan is yet lacking.¹⁷ International guidelines recommend daily screening for delirium using validated delirium assessment tools.¹⁸ Several methods have been developed and validated to assess delirium in patients in the ICU. Of these tools, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) are the most commonly used for delirium assessment.¹⁹ In the CAM-ICU, four features were screened at a single point in time. The ICDSC has a screening checklist composed of eight features.¹⁶^,¹⁸ These are the most frequently used tools for delirium screening.¹⁹ Furthermore, these instruments could also be used in patients with primary neurological injury, as growing evidence suggests.²⁰

In particular, screening is mandatory for patients at moderate to high risk of delirium.¹⁸

Barriers and gaps in practice were addressed by assessing the current status to identify the areas that need focusing on.²¹ Several studies have focused on delirium assessment by clinicians.³^,¹⁸^,²² In Sudan, no studies have been conducted in the ICU, particularly regarding delirium. This study assessed the current status of ICU doctors’ knowledge and practice of ICU doctors about delirium. This study aimed to identify barriers and gaps in knowledge and practice.

Methods

Study design

A hospital-based cross-sectional study was conducted to assess the knowledge and practices of intensive care unit doctors at the Military Hospital of Khartoum State, Sudan.

Setting

The Military Hospital is a complex of seven specialized hospitals totalizing 722 beds and 8 ICUs. The ICUs that met the inclusion criteria were involved in the study; neonatal and maternal ICUs were excluded from the study.

Participants

A stratified random sampling technique was used to select 72 participants in proportion to the type of ICU: medical, surgical, and cardiac ICU, after excluding all administrative staff.

Variables

The outcome variables were the knowledge and practices of intensive care unit doctors. The related factor to the outcome variable was the years of experience of the participants.

Data sources/measurement

The characteristics of the participants were reported as categorical variables; age, gender, ICU type and years of experience. Knowledge and practice of participants were assessed through closed questions entered as categorical variables.

Bias

Potential source of bias was that the study depended on the self-reporting of the participants through filling the questionnaire.

Study size

The formula for the known population was used to select the sample size for each stage. The equation of known population was used to estimate the sample size: n=N/1+Nd², where n is the estimated sample size, N is the total number of doctors in each ICU, and d is the degree of accuracy set at 0.05.

Quantitative variables

All variables included in the study were quantitative; they were handled in the analysis as categorical variables.

Statistical methods

The Statistical Package for Social Sciences (SPSS version-23) was used to describe and analyze the data. Descriptive data are presented. Statistical analysis was performed using the chi-square test to determine the associations among variables. All tests were considered statistically significant at p < 0.05.

The ethics committee of Omdurman Islamic University reviewed and approved the proposal on 28.May.2021 after full board review (IRB name: Omdurman Islamic University Ethics Committee, Reference number: 2021/2). Approval from the Military Hospital was obtained and authorization to implement the research was granted by the administration of the ICUs. All methods were performed in accordance with the relevant guidelines and regulations of the Declarations of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/). Participants were informed about the research objectives and signed written informed consent was obtained from each participant prior to data collection. They were assured about their confidentiality through the use of an anonymous research tool and that the data collected from each of them were not to be used for any purposes other than those assigned to the research. Participants were free to accept or reject participation in this study.

Results

Characteristics of intensive care unit (ICU) doctors

Seventy-two intensive care unit (ICU) doctors were assessed for their current knowledge and practice towards delirium among critically ill patients. Most doctors (70.8%, 51/72) were aged 30 years or less, and 86.1% (62/72) were female. On assessing experience, 69.4% (50/72) had less than one year of experience. Most doctors (94.4%, 68/72) had been working in medical ICUs. Table 1 below illustrates the demographic characteristics of the study participants.

Table 1. Characteristics of ICU doctors (n=72).

Characteristics	n	%
Age
≤30 Years	51	70.8
>30 Years	21	29.2
Total	72	100
Gender
Male	10	13.9
Female	62	86.1
Total	72	100
Years of experience
<1 Year	50	69.4
1-2 Years	7	9.7
>2 Years	15	20.8
Total	72	100
ICU type
Medical ICU	68	94.4
Surgical ICU	2	2.8
Cardiac ICU	2	2.8
Total	72	100

Assessment of current knowledge and practice of ICU doctors towards delirium

The knowledge and practice of ICU doctors was assessed with regard to delirium. 38.9% of doctors were aware of delirium assessment tools, while 61.1% (44/72) had no knowledge of delirium assessment tools. Of the ICU doctors, 76.4% (55/72) stated that the non-pharmacological approach was their first-line management, whereas 22.2% (16/72) chose the pharmacological approach as shown in Table 2 below.

Table 2. Assessment of current practice of ICU doctors about delirium (n=72).

Knowledge and practice	n	%	Knowledge and practice	n	%
Knowledge about delirium assessment tools			Agitation treatment used
Aware	28	38.9	Anti-psychotics	39	54.2
Unaware	44	61.1	Sedatives	24	33.3
Total	72	100	Opioids	3	4.2
Knowledge about first line management			Antipsychotics+ Sedatives	4	5.6
Non-pharmacological	55	76.4	Do not know	2	2.8
Pharmacological treatment	16	22.2	Total	72	100
Do not know	1	1.4	Delirium treatment used
Total	72	100	Anti-psychotics	50	69.4
Delirium assessment			Sedatives	15	20.8
CAM-ICU	13	18.1	Opioids	1	1.4
ICDSC	1	1.4	Antipsychotics+ Sedatives	2	2.8
Signs+ Symptoms	55	76.4	Do not know	4	5.6
None	3	4.2	Total	72	100
Total	72	100	Stopping delirium medications on ICU discharge
Frequency of delirium assessment			Yes	41	56.9
Every 8-12 Hours	29	40.3	No	29	40.3
Every 24 Hours	33	45.8	Do not know	2	2.8
Not regularly	10	13.9	Total	72	100
Total	72	100

As for ICU doctors, the delirium assessment tools used were CAM-ICU (18.1%, 13/72) and ICDSC used by only one doctor. Signs and Symptoms were used by (76.4% (55/72) of the patients for delirium assessment (Table 2). The frequency of delirium assessment varied among doctors; 40.3% (29/72) of the doctors assessed delirium every 8-12 hours, while 45.8% (33/72) assessed delirium every 24 h. In contrast, 13.9% (10/72) of the doctors did not regularly assess delirium in critically ill patients (Table 2).

Moreover, the practice of doctors towards delirium management was assessed. More than half of doctors used antipsychotics to manage agitation and delirium (54.2% and 69.4%, respectively). This was followed by sedatives prescribed by 33.3% (24/72) of doctors to treat agitation. For delirium, sedatives were prescribed by 20.8% (15/72) of doctors. Doctors were asked about their practice towards stopping delirium medications for patients on ICU discharge; 56.9% (41/72) of them stopped medications on discharge, while 40.3% (29/72) did not stop them from patients upon ICU discharge (Table 2).

Reasons for irregular delirium assessment and not using non-pharmacological approach management among doctors

Ten doctors reported that delirium assessment might be irregular for ICU patients. They were asked to report their reasons for not regularly assessing delirium. Only five doctors mentioned the reasons for this. The first reason was that only after the patient developed signs and symptoms, reported by two doctors, difficulty in assessment was the reason for one doctor, and a high workload was reported by 1doctor. Additionally, the use of family member support was the reason for one doctor.

Doctors were asked to report their reasons for not using the nonpharmacological approach in their delirium management. The lack of knowledge about the non-pharmacological approach was the reason for this.

Non-pharmacological interventions applied by doctors to reduce delirium

The most frequent nonpharmacological intervention used by ICU doctors for delirium management was communication with patients to prevent confusion. This was illustrated in Figure 1 below. This approach was used by 75% of the doctors. The second most common approach was early mobility of ICU patients, reported by 22.2% of doctors. Reducing nighttime sleep disturbances was used by 18.1% of the doctors. Benzodiazepine use was reduced by 6.9% of ICU doctors (Figure 1).

Figure 1. Non-pharmacological interventions applied by doctors to reduce delirium.

Pharmacological agents used by ICU doctors to treat delirium

The doctors were asked to identify the pharmacological agents used for delirium treatment. As shown in Figure 2 below, the most commonly used agent was haloperidol, which was prescribed by 83.3% of the ICU doctors to treat delirium. The second most commonly used agent was olanzapine (5.6%), followed by a combination of olanzapine and haloperidol (4.2%). On the other hand, resperidone and quetiapine were prescribed by only 1.4% of the doctors (Figure 2).

Figure 2. Pharmacological agents used by doctors to reduce delirium.

Association between knowledge of doctors and their experience

With regard to the experience of doctors, their knowledge was assessed to determine if there was any difference in knowledge about delirium between experienced and non-experienced doctors. Doctors were grouped into two groups based on their years of experience: ≤2 years of experience and >2 years of experience. Interestingly, there was no statistically significant difference in ICU doctors’ knowledge about delirium tools and first-line treatment between experienced and non-experienced doctors (p= 0.059 and p=0.797, respectively).

Doctors’ practice was assessed based on their experience. Among the 13 doctors who used the CAM-ICU as an assessment tool for delirium, 53.8% had >2 years of experience. Among the 55 doctors who assessed delirium using no tool and only by signs and symptoms, 85.5% had less experience (≤2 years). This difference in practice was statistically significant between experienced and less experienced doctors (p=0.012).

Regarding the frequency of delirium assessment, no statistically significant difference was found between doctors based on their years of experience (p=0.636). In addition, no difference in practice towards agitation and delirium treatment was found among doctors based on their experience (p=0.496 and p=0.246, respectively). In addition, stopping delirium treatment at ICU discharge did not differ between doctors with different years of experience (p=0.121). Table 3 below details all the percentages of doctors with different experiences and practices towards delirium.

Table 3. Association between knowledge and practice about delirium and years of experience among doctors.

	Years of experience
Knowledge and practice	≤2 Years	%	>2 Years	%	Total	%	Chi²	p-value
Knowledge about delirium tools
Aware	19	67.9	9	32.1	28	38.9	3.55	0.059
Unaware	38	86.4	6	13.6	44	61.1
Total	57	79.2	15	20.8	72	100.0
First-line management
Non-pharmacological	44	80.0	11	20.0	55	76.4	0.455	0.797
Pharmacological treatment	12	75.0	4	25.0	16	22.2
Do not know	1	100.0	0	0.0	1	1.4
Total	57	79.2	15	20.8	72	100.0
Delirium assessment							10.961	0.012*
CAM-ICU	6	46.2	7	53.8	13	18.1
ICDSC	1	100.0	0	0.0	1	1.4
By signs and symptoms	47	85.5	8	14.5	55	76.4
None	3	100.0	0	0.0	3	4.2
Total	57	79.2	15	20.8	72	100.0
Frequency of delirium assessment
Every 8-12 Hours	22	75.9	7	24.1	29	40.3	0.906	0.636
Every 24 Hours	26	78.8	7	21.2	33	45.8
Not regularly	9	90.0	1	10.0	10	13.9
Total	57	79.2	15	20.8	72	100.0
Agitation treatment
Anti-psychotics	31	79.5	8	20.5	39	54.2	3.381	0.496
Sedatives	17	70.8	7	29.2	24	33.3
Opioids	3	100.0	0	0.0	3	4.2
Antipsychotics+ Sedatives	4	100.0	0	0.0	4	5.6
Do not know	2	100.0	0	0.0	2	2.8
Total	57	79.2	15	20.8	72	100.0
Delirium treatment
Anti-psychotics	41	82.0	9	18.0	50	69.4	5.427	0.246
Sedatives	9	60.0	6	40.0	15	20.8
Opioids	1	100.0	0	0.0	1	1.4
Antipsychotics+ Sedatives	2	100.0	0	0.0	2	2.8
Do not know	4	100.0	0	0.0	4	5.6
Total	57	79.2	15	20.8	72	100.0
Stopping delirium medications on ICU discharge							4.229	0.121
Yes	29	70.7	12	29.3	41	56.9
No	26	89.7	3	10.3	29	40.3
Do not know	2	100.0	0	0.0	2	2.8
Total	57	79.2	15	20.8	72	100.0

* Statistically significant.

Discussion

Delirium is common disorder among ICU patients.³^,⁶^,⁸^,¹¹^,¹²^,¹⁵^,¹⁶ Doctors and nurses are direct healthcare providers for critically ill patients. In addition to nurses, doctors are involved in delirium assessment and reporting, as mentioned by Pisani et al.⁵ Lack of knowledge among staff has been reported as one of the individual barriers³; hence, our study tangled the knowledge of doctors.

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%) did not use any specific tools for delirium assessment and relied on signs and symptoms alone. As in the study by Depetris et al., 57% of doctors did not use any specific tool for delirium assessment.¹⁸ 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^,²³ Although the usefulness of the Confusion Assessment Method for the ICU (CAM-ICU) for delirium detection has been documented in recent studies,⁵^,¹⁶ only 18.1% of our participants used CAM-ICU for delirium assessment. Nevertheless, ICDSC was used by only 1.4% of the doctors. Interestingly, in a systematic review, the CAM-ICU was the tool used for assessing delirium in 65% of delirium clinical trials, while the ICDSC was used in only 6% of the trials.⁶ In a meta-analysis study, both the CAM-ICU and ICDSC could be used to screen for delirium and diagnose it. However, the study favored CAM-ICU as ICDSC showed lower specificity and sensitivity than CAM-ICU.¹⁹ This was the case among our study participants, as only 1.4% used the ICDSC in assessing delirium, while 18.1% used the CAM-ICU tool. Comparatively, in a national multi-center study in China, 34% of doctors used delirium tools; of these, CAM-ICU was the most commonly used (83%) tool.²² Nevertheless, in another study, CAM-ICU was used by 27.5% of doctors, while ICDSC was used by 5%.¹⁸

Presence of delirium among ICU patients must be assessed every 8 hours or at least every 12 hours.⁷^,²³ Less than half of the ICU doctors (40.3%) in our study assessed delirium every 8-12 hours, which was the practice in 60% of the clinical trials of delirium, as reported by Colantuoni et al. Furthermore, 45.8% of our doctors assessed delirium daily, which was higher than that reported (35%) by Colantuoni et al.⁶ Only 13.9% of our doctors had no regular assessments for delirium; this was the case for 30% of physicians in a multinational study.¹⁸ Among our study participants, one of the reasons for irregular delirium assessment was increased workload. This issue has been interpreted as an environmental barrier, especially among ICU staff.³ This issue was addressed in a study recommended that, in such case of limited resources, delirium management strategies may be prioritized for patients with high risk of delirium.⁷ In our study, the association between ICU doctors’ practice and their years of experience was studied. A statistically significant difference (p=0.012) was found in delirium assessment. Contrary to the study by Wang et al., there was no statistically significant difference (p=0.074) between experienced and less-experienced clinicians.²²

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 had developed signs and symptoms of delirium.

The non-pharmacological approach to delirium management (treatment and/or prevention) is the preferred approach.²³ It was the first-line choice for 76.4% of the doctors in our study, which was higher than the percentage (22.5%) reported by Depetris et al.¹⁸ Communication with ICU patients to prevent confusion was the most frequent nonpharmacological approach applied by ICU doctors in our study (75%). This approach was discussed in a systematic review by Deemer et al. assessing early cognitive interventions for delirium in ICU patients.¹² Moreover, participation of family members in delirium prevention strategies could be complementary to the communication interventions performed by doctors and nurses.¹² In our study, this approach of using family member support was practiced by a single doctor. Sleep and circadian rhythm regulation among ICU patients was a targeted therapy approach for these patients²⁴; however, it was applied by only 18.1% of our doctors. Another important risk factor for delirium was the use of benzodiazepines.¹⁵^,²³ Midazolam is the most commonly used sedative for ICU patients, prescribed as high as 72%–90.5% of sedatives.¹⁵^,¹⁸^,²⁵ Hence, reducing their use is considered an important non-pharmacological approach for the prevention of delirium in critically ill patients.²³ However, among our ICU doctors, only 6.9% adopted a reduction in benzodiazepines. Surprisingly, sedatives were used by 20% of our doctors to manage delirium and midazolam was one of the agents used by clinicians in China (31%) for treating delirium.²² This issue needs to be addressed because the use of sedatives for patients with delirium worsens the case and their use should be reduced.¹⁶^,²³

Based on a systematic review by Barbateskovic et al., evidence for the use of pharmacological interventions in the management and prevention of delirium is sparse or poor.²⁶ Nonetheless, this approach is not superior to delirium management.⁹ The pharmacological approach for delirium treatment was used as the first-line management in 22.2% of our study participants. This was higher than reported (2.5%) in a multi-national study.¹⁸ Antipsychotics were the most commonly used agents (69.4%) among our study doctors. Haloperidol was the most commonly used agent among ICU doctors (83.3%) for delirium treatment. This was consistent with a cohort study that used haloperidol alone in combination with clonidine.¹⁷ Furthermore, studies have reported that haloperidol use was the highest in patients with delirium (30%, 43.3%).⁴^,²²^,²⁶ The second most commonly used agent in our study was olanzapine (5.6%), similar to that reported (5.9%) by Swan et al.⁴ In contrast, quetiapine and risperidone were used by only 1.4% of our study participants, which was much lower than the frequencies reported by Swan et al. (12.7% and 5% respectively).⁴

Not to forget that, delirium clinically has two states; hyperactive state mostly characterized by agitation, besides the hypoactive state,¹⁴ our study assessed current practice of doctors towards agitation treatment. More than half of the study participants (54.2%) prescribed antipsychotics for agitation treatment, while 33.3% prescribed sedatives. This practice of our doctors was not in line with recommended treatments, as sedatives were considered treatment agents for agitation.²³

Continuation of delirium medication after ICU discharge was common (50.2%), as per a previous study.²⁷ Of our doctors, 40.3% had not stopped delirium medications on discharge, which was lower than that reported above.²⁷ However, continuation of such medications beyond the hospital stay could lead to harmful and deleterious events, and medication reconciliation is crucial in such cases.²³

The limitations of our study were the lack of a comparison between doctors’ practice and nurses’ practice. Furthermore, the data collection tool was not validated using Cronbach’s reliability test. 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 larger and more populated.

Conclusions

Less than half of ICU doctors assessed delirium every 8-12 hours. Non-pharmacological preventive measures were applied by the majority of participants (976.4%). Communication with patients is important for delirium prevention, as was done by most of the study participants. However, the involvement of family members in communicating with ICU patients is an important approach; yet, it is only applied by one doctor. Delirium assessment tools were used by less than 20% of the ICU doctors. Delirium may fluctuate between agitation and hypoactive states. More than half of the ICU doctors prescribed antipsychotics for the treatment of both forms. This was not the case; sedation is the preferred approach for agitated patients. Only 33.3% of the participants were prescribed sedatives to treat agitation. Medication reconciliation and contact with the next in-charge of the patients must be conducted to reduce the use of these medications after hospital discharge.

Instead of using signs and symptoms alone, ICU staff should focus on the use of delirium assessment tools. Non-pharmacological preventive measures must be implemented for all ICU patients, especially those with a high risk of developing delirium. The involvement of family members in communicating with ICU patients should be encouraged as a complementary approach to prevent delirium. A more frequent assessment of delirium is desirable among healthcare staff: 8 hours or 12 hours instead of once-daily assessment. Delirium may fluctuate between agitation and hypoactive states. Treatments for each form must be established by ICU doctors.

Declarations

Ethics and consent

The proposal was reviewed and approved by the Ethical Committee of Omdurman Islamic University. The ethics committee of Omdurman Islamic University reviewed and approved the proposal on 28.May.2021 after full board review (IRB name: Omdurman Islamic University Ethics Committee, Reference number: 2021/2). Approval from the Military Hospital was obtained and authorization to implement the research was granted by the administration of the ICUs. All methods were performed in accordance with the relevant guidelines and regulations of the Declarations of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/). Participants were informed about the research objectives and signed written informed consent was obtained from each participant prior to data collection. They were assured about their confidentiality through the use of an anonymous research tool and that the data collected from each of them were not to be used for any purposes other than those assigned to the research. Participants were free to accept or reject participation in this study.

Availability of supporting data

All supporting data are available.

Authors’ contributions

Sheema Hamid Seidna Hamid: Conceptualization, Data curation, Methodology.

Ghada Omer Hamad Abd El-Raheem: Conceptualization, Software, Formal analysis, and writing-original Draft Preparation.

Hana Eltayeb Salih Elamin: Validation, Writing-Review and Editing.

Mudawi Mohammed Ahmed Abdallah: Project adminstration, Resources.

Data availability

Underlying data

Figshare: Delirium current practice among Intensive Care Units Doctors, Khartoum- Underlying data; https://doi.org/10.6084/m9.figshare.24938505.v1.²⁸

Data are available under the terms of the Creative Commons Attribution International license (CC BY 4.0).

Preprint available at: https://www.researchsquare.com/article/rs-1070778/v3.pdf

DOI: https://doi.org/10.21203/rs.3.rs-1070778/v3

Reporting guidelines

Methods section had provided sufficient details of the materials and methods used so that the work can be repeated by others. The section was developed based on STROBE checklist of cross-sectional studies (https://www.equator-network.org/reporting-guidelines/strobe/).

Acknowledgements

The authors are grateful to Shurouq O. H. Abdelraheem, Faculty of Engineering, University of Khartoum, for her assistance with the data-entry process. The authors also acknowledge the cooperation of the departments of Military Hospitals during data collection.

References

1. Wassenaar A, van den Boogaard M , van Achterberg T , et al.: Multinational development and validation of an early prediction model for delirium in ICU patients. Intensive Care Med. 2015 Jun; 41(6): 1048–56. Epub 2015 Apr 18. PubMed Abstract | Publisher Full Text | Free Full Text
2. van den Boogaard M , Peters SA, van der Hoeven JG , et al.The impact of delirium on the prediction of in-hospital mortality in intensive care patients. Crit. Care. 2010; 14(4): R146. Epub 2010 Aug 3. Publisher Full Text | PubMed Abstract | Free Full Text
3. Rowley-Conwy G: Barriers to delirium assessment in the intensive care unit: A literature review. Intensive Crit. Care Nurs. 2018 Feb; 44: 99–104. Epub 2017 Oct 17. PubMed Abstract | Publisher Full Text
4. Swan JT, Fitousis K, Hall JB, et al.: Antipsychotic use and diagnosis of delirium in the intensive care unit. Crit. Care. 2012 May 16; 16(3): R84. PubMed Abstract | Publisher Full Text | Free Full Text
5. Pisani MA, Araujo KL, Van Ness PH, et al.: A research algorithm to improve detection of delirium in the intensive care unit. Crit. Care. 2006; 10(4): R121. PubMed Abstract | Publisher Full Text | Free Full Text
6. Colantuoni E, Koneru M, Akhlaghi N, et al.: Heterogeneity in design and analysis of ICU delirium randomized trials: a systematic review. Trials. 2021 May 20; 22(1): 354. PubMed Abstract | Publisher Full Text | Free Full Text
7. Wassenaar A, Schoonhoven L, Devlin JW, et al.: Delirium prediction in the intensive care unit: comparison of two delirium prediction models. Crit. Care. 2018 May 5; 22(1): 114. PubMed Abstract | Publisher Full Text | Free Full Text
8. Brown KN, Soo A, Faris P, et al.: Association between delirium in the intensive care unit and subsequent neuropsychiatric disorders. Crit. Care. 2020 Jul 31; 24(1): 476. PubMed Abstract | Publisher Full Text | Free Full Text
9. Khan, et al.: Pharmacological Management of Delirium in the ICU: A Randomized Pragmatic Clinical Trial. J. Am. Geriatr. Soc. 2019 May; 67(5): 1057–1065. PubMed Abstract | Publisher Full Text | Free Full Text
10. Wintermann GB, Weidner K, Strauss B, et al.: Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany. BMJ Open. 2020; 10(10): e035733. Published 2020 Oct 8. PubMed Abstract | Publisher Full Text | Free Full Text
11. Zhang S, Han Y, Xiao Q, et al.: Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis. Crit. Care Med. 2021 Feb 1; 49(2): 335–346. PubMed Abstract | Publisher Full Text | Free Full Text
12. Deemer K, Zjadewicz K, Fiest K, et al.: Effect of early cognitive interventions on delirium in critically ill patients: a systematic review. Can. J. Anaesth. 2020 Aug; 67(8): 1016–1034. Epub 2020 Apr 24. PubMed Abstract | Publisher Full Text | Free Full Text
13. Rosgen BK, Krewulak KD, Stelfox HT, et al.: The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review. Age Ageing. 2020 Jul 1; 49(4): 549–557. PubMed Abstract | Publisher Full Text | Free Full Text
14. Bastos AS, Beccaria LM, Silva DC, et al.: Identification of delirium and subsyndromal delirium in intensive care patients. Rev. Bras. Enferm. 2019; 72(2): 463–467. PubMed Abstract | Publisher Full Text
15. Shafiekhani M, Mirjalili M, Vazin APsychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review. Ther. Clin. Risk Manag. 2018; 14: 1799–1812. Published 2018 Sep 28. PubMed Abstract | Publisher Full Text | Free Full Text
16. Page VJ, Navarange S, Gama S, et al.: Routine delirium monitoring in a UK critical care unit. Crit. Care. 2009; 13(1): R16. Epub 2009 Feb 9. PubMed Abstract | Publisher Full Text | Free Full Text
17. Smit L, Dijkstra-Kersten SMA, Zaal IJ, et al.: Haloperidol, clonidine and resolution of delirium in critically ill patients: a prospective cohort study. Intensive Care Med. 2021 Mar; 47(3): 316–324. Epub 2021 Feb 16. PubMed Abstract | Publisher Full Text | Free Full Text
18. Depetris N, Raineri S, Pantet O, et al.: Management of Pain, Anxiety, Agitation and Delirium in Burn patients: A survey of clinical practice and a review of the current literature. Annals of Burns and Fire. Disasters. June 2018; XXXI(2).
19. Gusmao-Flores D, Salluh JI, Chalhub RÁ, et al.: The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Crit. Care. 2012 Jul 3; 16(4): R115. PubMed Abstract | Publisher Full Text | Free Full Text
20. Patel MB, Bednarik J, Lee P, et al.: Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review. Crit. Care Med. 2018 Nov; 46(11): 1832–1841. PubMed Abstract | Publisher Full Text | Free Full Text
21. Zimmerman LH: Practice administration and development: Protocol development and quality improvement.Bass S, Benken ST, et al., editors. Critical Care Pharmacy Preparatory Review and Recertification Course. Lenexa, KS: American College of Clinical Pharmacy; 2019 ed.2019; pp. 247–282.
22. Wang J, Peng ZY, Zhou WH, et al.: A National Multicenter Survey on Management of Pain, Agitation, and Delirium in Intensive Care Units in China. Chin. Med. J. 2017; 130: 1182–1188. PubMed Abstract | Publisher Full Text | Free Full Text
23. Stollings JL, Gill KV: Management of Pain, Agitation, Delirium, and Neuromuscular Blockade in Adult Intensive Care Unit Patients.Bass S, Benken ST, et al., editors. Critical Care Pharmacy Preparatory Review and Recertification Course. Lenexa, KS: American College of Clinical Pharmacy; 2019 ed.2019; pp. 247–282.
24. Sun T, Sun Y, Huang X, et al.: Sleep and circadian rhythm disturbances in intensive care unit (ICU)-acquired delirium: a case-control study. J. Int. Med. Res. 2021 Mar; 49(3): 300060521990502. PubMed Abstract | Publisher Full Text | Free Full Text
25. Ürkmez S, Erdoğan E, Utku T, et al.: Sedation Practices and Preferences of Turkish Intensive Care Physicians: A National Survey. Turk J Anaesthesiol Reanim. 2019; 47(3): 220–227. PubMed Abstract | Publisher Full Text | Free Full Text
26. Barbateskovic M, et al.: Pharmacological interventions for prevention and management of delirium in intensive care patients: a systematic overview of reviews and meta-analyses. BMJ Open. 2019; 9: e024562. PubMed Abstract | Publisher Full Text | Free Full Text
27. Karamchandani, et al.: Gender differences in the use of atypical antipsychotic medications for ICU delirium. Crit. Care. 2018; 22: 220. PubMed Abstract | Publisher Full Text | Free Full Text
28. Hamid S, Abd El-Raheem G, Elamin H, et al.: Delirium current practice among Intensive Care Units Doctors, Khartoum - Underlying data. figshare. [Dataset]. 2024. Publisher Full Text

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Version 4

VERSION 4 PUBLISHED 07 May 2024

Author details Author details

Sheema Hamid Seidna Hamid
Roles: Conceptualization, Data Curation, Methodology

Ghada Omer Hamad Abd El-Raheem
Roles: Conceptualization, Formal Analysis, Software, Writing – Original Draft Preparation

Hana Eltayeb Salih Elamin
Roles: Validation, Writing – Review & Editing

Mudawi Mohammed Ahmed Abdallah
Roles: Project Administration, Resources

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (4)

version 4

Revised

Published: 19 Feb 2025, 13:456

https://doi.org/10.12688/f1000research.142233.4

version 3

Revised

Published: 21 Nov 2024, 13:456

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Published: 31 Oct 2024, 13:456

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Published: 07 May 2024, 13:456

https://doi.org/10.12688/f1000research.142233.1

© 2024 Seidna Hamid SH et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Seidna Hamid SH, Abd El-Raheem GOH, Salih Elamin HE and Ahmed Abdallah MM. Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 1; peer review: 1 not approved]. F1000Research 2024, 13:456 (https://doi.org/10.12688/f1000research.142233.1)

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Reviewer Report 29 Jul 2024

Richard E Kennedy, University of Alabama at Birmingham, Birmingham, USA

Not Approved

https://doi.org/10.5256/f1000research.155756.r295363

This manuscript reports on the barriers and gaps in knowledge about delirium among a sample of ICU physicians in Sudan. A random selection of providers were queried regarding their knowledge and practice in management of delirium, which were summarized and related to provider characteristics. The authors found that formal assessment of delirium was uncommon. Nonpharmacological management was commonly used, but pharmacological management was also frequent.

The topic is potentially an important one, as difficulties recognizing delirium are common across a number of settings, and are associated with a number of adverse patient and healthcare system outcomes. However, the methods are often not specified in sufficient detail, and the contribution of this particular study to the existing literature is not well delineated.

The background is generally well done, but a bit disorganized in a few spots. In particular, the statement "Furthermore, delirium is associated with long-term cognitive impairments." seems out of placer from the rest of the material in the paragraph, and would be better placed with other material about adverse consequences. Similarly, the statement "From another perspective, patients with delirium are more likely to bear increased healthcare costs than those without delirium." could be combined with material about adverse consequences rather than a separate paragraph. Reference 18 is for burn patients and it is not clear that these findings are applicable to the ICU setting. And noting that the mixed form of delirium is actually the most common would be helpful.

Most importantly, the background does not clearly lay out the case for the current study. There have been multiple publications in the literature noting that delirium is often missed by clinicians, that assessment is often not performed, and many clinicians lack sufficient understanding of delirium. Given these previous studies, why is this study needed? Are there particular aspects of practice in Sudan that are different from previous studies? If so, this should be more clearly delineated to show the importance of this investigation.

Several aspects of the methods are not sufficiently described. The setting notes several different types of ICUs being studied but these are not delineated. The stratified random sampling needs to be described more fully. The questionnaire used for assessing knowledge and practice is not well described - was this a standard questionnaire (in which case it should be referenced)? Or a questionnaire developed by the investigators (in which case the questions should be provided in detail, along with the validation of the questionnaire for adequately assessing the outcomes of interest)? Why were the predictor variables selected, and are these 4 sufficient for describing the associations in the sample? Is the chosen sample size formula appropriate for a series of chi-square tests?

The results are generally straightforward. However, in the description of the sample, did all of the randomized participants complete the questionnaire? Or were there refusals? A description of the flow of participants (or a flow diagram, if it is complicated) would be helpful. In addition, the sample was overwhelmingly young, inexperienced, and female. Is this typical of ICU doctors in Sudan? Or were there biases in the sample?

When an ICU doctor determined delirium based on "signs and symptoms", does this mean that DSM-5 (or a comparable system) was used? Or does this mean an informal assessment with no specific criteria?

Similarly, what does "communication with the patient to prevent confusion" mean? Does this mean established protocols such as frequent reorientation, or is this an informal communication without a specific protocol? Such information is helpful in being able to understand and replicate the study findings.

It would be helpful to present odds ratios from the chi-square tests to indicate the direction of the associations, rather than just p values.

The discussion would benefit from more depth. There is a rather extensive literature on the recognition of delirium by physicians, the barriers to recognition, and attitudes towards management. However, the discussion only references a few studies (often a comparison to just 1 other study) rather than providing an overview of previous findings. Furthermore, the authors often only compare their results to a previous study, but do not place this in context - what does it mean if their results are similar or different from previous studies? Does this have implications for the recognition and management of delirium generally, or does this show specific aspects of management of delirium in Sudanese hospitals?

Under limitations, the authors should not just note the limitations, but also how these impact the study - do these affect the reliability or generalizability of the findings? Also under limitations, is the military hospital setting a limitation? Are the patient characteristics for military hospitals significantly different from the patient characteristics in non-military hospitals in Sudan, the way that there are differences in other countries?

Overall, I think that this manuscript has the potential to make a contribution to the literature, particularly since delirium and other cognitive disorders are not well studied in settings outside of a few developed countries. However, more details are needed in several places to fully understand the study, be able to replicate their processes, and place the findings in context.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Delirium phenomenology, diagnosis, and clinical trials

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Author Response 31 Oct 2024

Ghada Abd El-Raheem, Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan

31 Oct 2024

Author Response

Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn ... Continue reading Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn patients is changed. As well as, the aim was well described.
The methods section is detailed to be more reproducible. the details of the sampling process and the questionnaire are all detailed and provided reference for the questions asked. Also differences in the study population between military and civilian hospitals was detailed. Types of patients in military hospitals were described.
Risk estimate analysis can not be computed, they are only computed for 2x2 tables without empty cells.
Discussion was rewritten to be more in depth and showing all the aspects of delirium management among Sudanese doctors.
Limitations were adjusted to detail the impact of limitations on the reliability and generalizability.
Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn patients is changed. As well as, the aim was well described.
The methods section is detailed to be more reproducible. the details of the sampling process and the questionnaire are all detailed and provided reference for the questions asked. Also differences in the study population between military and civilian hospitals was detailed. Types of patients in military hospitals were described.
Risk estimate analysis can not be computed, they are only computed for 2x2 tables without empty cells.
Discussion was rewritten to be more in depth and showing all the aspects of delirium management among Sudanese doctors.
Limitations were adjusted to detail the impact of limitations on the reliability and generalizability.
Competing Interests: No competing interests were disclosed. Close
Report a concern
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COMMENTS ON THIS REPORT

Author Response 31 Oct 2024

Ghada Abd El-Raheem, Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan

31 Oct 2024

Author Response

Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn ... Continue reading Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn patients is changed. As well as, the aim was well described.
The methods section is detailed to be more reproducible. the details of the sampling process and the questionnaire are all detailed and provided reference for the questions asked. Also differences in the study population between military and civilian hospitals was detailed. Types of patients in military hospitals were described.
Risk estimate analysis can not be computed, they are only computed for 2x2 tables without empty cells.
Discussion was rewritten to be more in depth and showing all the aspects of delirium management among Sudanese doctors.
Limitations were adjusted to detail the impact of limitations on the reliability and generalizability.
Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn patients is changed. As well as, the aim was well described.
The methods section is detailed to be more reproducible. the details of the sampling process and the questionnaire are all detailed and provided reference for the questions asked. Also differences in the study population between military and civilian hospitals was detailed. Types of patients in military hospitals were described.
Risk estimate analysis can not be computed, they are only computed for 2x2 tables without empty cells.
Discussion was rewritten to be more in depth and showing all the aspects of delirium management among Sudanese doctors.
Limitations were adjusted to detail the impact of limitations on the reliability and generalizability.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Comments on this article Comments (0)

Version 4

VERSION 4 PUBLISHED 07 May 2024

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Reviewer Reports

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	1	2	3
Version 4 (revision) 19 Feb 25			read
Version 3 (revision) 21 Nov 24		read	read
Version 2 (revision) 31 Oct 24	read
Version 1 07 May 24	read

Richard E Kennedy, University of Alabama at Birmingham, Birmingham, USA
Helmut Frohnhofen, University Hospital Düsseldorf, Düsseldorf, Germany
Hiroyoshi Takeuchi, Keio University, Tokyo, Japan

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Reviewer Report

5 Views

20 Feb 2025 | for Version 4

Hiroyoshi Takeuchi, Keio University, Tokyo, Japan

5 Views Cite this report Responses(0)

Approved

As the authors adequately revised the manuscript according to the reviewer's comments, I have no further comments.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Schizophrenia and delirium

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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8 Views

06 Feb 2025 | for Version 3

Hiroyoshi Takeuchi, Keio University, Tokyo, Japan

8 Views Cite this report Responses(1)

Approved With Reservations

This study examines the barriers and knowledge gaps in delirium assessment and management among ICU physicians. Despite international guidelines recommending daily delirium screening, fewer than 20% of doctors utilized validated assessment tools, with their use significantly associated with clinical experience. Non-pharmacological management strategies were commonly employed, while haloperidol was the most frequently prescribed medication. Additionally, nearly half of the physicians did not discontinue delirium medications upon ICU discharge. This topic is clinically significant, the methodology is clear, and the manuscript is well-structured. I hope the following comments will help further enhance its quality:

Please provide the means and standard deviations for age and years of experience in Table 1.
Please specify what is meant by "sedatives" (e.g., benzodiazepines).
Please correct the spelling of “resperidone” to “risperidone.”

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Schizophrenia and delirium

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report

4 Views

24 Jan 2025 | for Version 3

Helmut Frohnhofen, University Hospital Düsseldorf, Düsseldorf, Germany

4 Views Cite this report Responses(0)

Approved

Thank you for inviting me to review the paper: Delirium management and current practice among Intensive Care Units Doctors, Khartoum.

The study is a hospital based cross sectional study. The investigators selected randomly 72 ICU physicians.

The results show that most physicians are younger (<30 years of age). Validated tools to detect delirium are rarely applied. Treatment for delirium is often conducted by haloperiodol and this drug is continued at discharge from the ICU.

The study is well designed and conducted. Analysis is adequately done.

The conclusion is convincing and recommend to use validated tool for detection of delirium in ICU patients more often.

My decision: accept as it is.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Internal medicine, intensive care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

12 Views

12 Nov 2024 | for Version 2

Richard E Kennedy, University of Alabama at Birmingham, Birmingham, USA

12 Views Cite this report Responses(1)

Approved With Reservations

This is a revision of a manuscript examining the barriers and gaps in knowledge about treatment of delirium among ICU physicians in Sudan. The authors have generally responded well to the previous concerns, providing additional details on the setting and questionnaires used in the study; the justification for examining this topic specifically in Sudan; and the potential limitations.

The remaining concern I would have is that Reference 18, which is cited in the text as an international guideline, is for patients with burns rather than patients in the ICU, and it is not clear how well these recommendations would apply to the ICU population. The authors state in their response that this has been corrected but it is still a reference to burn patients; it would seem a guideline for the ICU should be cited instead.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Delirium phenomenology, diagnosis, and clinical trials

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Reviewer Report

13 Views

29 Jul 2024 | for Version 1

Richard E Kennedy, University of Alabama at Birmingham, Birmingham, USA

13 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Delirium phenomenology, diagnosis, and clinical trials

Respond to this report

Responses (1)

Author Response

31 Oct 2024

Ghada Abd El-Raheem, Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan

Dear reviewer Richard Kennedy,
Thank you for your valuable time and comments. We revised all your comments and fulfilled them.
The introduction was corrected and rephrased and ref. describing burn patients is changed. As well as, the aim was well described.
The methods section is detailed to be more reproducible. the details of the sampling process and the questionnaire are all detailed and provided reference for the questions asked. Also differences in the study population between military and civilian hospitals was detailed. Types of patients in military hospitals were described.
Risk estimate analysis can not be computed, they are only computed for 2x2 tables without empty cells.
Discussion was rewritten to be more in depth and showing all the aspects of delirium management among Sudanese doctors.
Limitations were adjusted to detail the impact of limitations on the reliability and generalizability.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Wassenaar A, van den Boogaard M , van Achterberg T , et al.: Multinational development and validation of an early prediction model for delirium in ICU patients. Intensive Care Med. 2015 Jun; 41(6): 1048–56. Epub 2015 Apr 18. PubMed Abstract | Publisher Full Text | Free Full Text

[2] 2. van den Boogaard M , Peters SA, van der Hoeven JG , et al.The impact of delirium on the prediction of in-hospital mortality in intensive care patients. Crit. Care. 2010; 14(4): R146. Epub 2010 Aug 3. Publisher Full Text | PubMed Abstract | Free Full Text

[3] 3. Rowley-Conwy G: Barriers to delirium assessment in the intensive care unit: A literature review. Intensive Crit. Care Nurs. 2018 Feb; 44: 99–104. Epub 2017 Oct 17. PubMed Abstract | Publisher Full Text

[4] 4. Swan JT, Fitousis K, Hall JB, et al.: Antipsychotic use and diagnosis of delirium in the intensive care unit. Crit. Care. 2012 May 16; 16(3): R84. PubMed Abstract | Publisher Full Text | Free Full Text

[5] 5. Pisani MA, Araujo KL, Van Ness PH, et al.: A research algorithm to improve detection of delirium in the intensive care unit. Crit. Care. 2006; 10(4): R121. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Colantuoni E, Koneru M, Akhlaghi N, et al.: Heterogeneity in design and analysis of ICU delirium randomized trials: a systematic review. Trials. 2021 May 20; 22(1): 354. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Wassenaar A, Schoonhoven L, Devlin JW, et al.: Delirium prediction in the intensive care unit: comparison of two delirium prediction models. Crit. Care. 2018 May 5; 22(1): 114. PubMed Abstract | Publisher Full Text | Free Full Text

[8] 8. Brown KN, Soo A, Faris P, et al.: Association between delirium in the intensive care unit and subsequent neuropsychiatric disorders. Crit. Care. 2020 Jul 31; 24(1): 476. PubMed Abstract | Publisher Full Text | Free Full Text

[9] 9. Khan, et al.: Pharmacological Management of Delirium in the ICU: A Randomized Pragmatic Clinical Trial. J. Am. Geriatr. Soc. 2019 May; 67(5): 1057–1065. PubMed Abstract | Publisher Full Text | Free Full Text

[10] 10. Wintermann GB, Weidner K, Strauss B, et al.: Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany. BMJ Open. 2020; 10(10): e035733. Published 2020 Oct 8. PubMed Abstract | Publisher Full Text | Free Full Text

[11] 11. Zhang S, Han Y, Xiao Q, et al.: Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis. Crit. Care Med. 2021 Feb 1; 49(2): 335–346. PubMed Abstract | Publisher Full Text | Free Full Text

[12] 12. Deemer K, Zjadewicz K, Fiest K, et al.: Effect of early cognitive interventions on delirium in critically ill patients: a systematic review. Can. J. Anaesth. 2020 Aug; 67(8): 1016–1034. Epub 2020 Apr 24. PubMed Abstract | Publisher Full Text | Free Full Text

[13] 13. Rosgen BK, Krewulak KD, Stelfox HT, et al.: The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review. Age Ageing. 2020 Jul 1; 49(4): 549–557. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Bastos AS, Beccaria LM, Silva DC, et al.: Identification of delirium and subsyndromal delirium in intensive care patients. Rev. Bras. Enferm. 2019; 72(2): 463–467. PubMed Abstract | Publisher Full Text

[15] 15. Shafiekhani M, Mirjalili M, Vazin APsychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review. Ther. Clin. Risk Manag. 2018; 14: 1799–1812. Published 2018 Sep 28. PubMed Abstract | Publisher Full Text | Free Full Text

[16] 16. Page VJ, Navarange S, Gama S, et al.: Routine delirium monitoring in a UK critical care unit. Crit. Care. 2009; 13(1): R16. Epub 2009 Feb 9. PubMed Abstract | Publisher Full Text | Free Full Text

[17] 17. Smit L, Dijkstra-Kersten SMA, Zaal IJ, et al.: Haloperidol, clonidine and resolution of delirium in critically ill patients: a prospective cohort study. Intensive Care Med. 2021 Mar; 47(3): 316–324. Epub 2021 Feb 16. PubMed Abstract | Publisher Full Text | Free Full Text

[18] 18. Depetris N, Raineri S, Pantet O, et al.: Management of Pain, Anxiety, Agitation and Delirium in Burn patients: A survey of clinical practice and a review of the current literature. Annals of Burns and Fire. Disasters. June 2018; XXXI(2).

[19] 19. Gusmao-Flores D, Salluh JI, Chalhub RÁ, et al.: The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Crit. Care. 2012 Jul 3; 16(4): R115. PubMed Abstract | Publisher Full Text | Free Full Text

[20] 20. Patel MB, Bednarik J, Lee P, et al.: Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review. Crit. Care Med. 2018 Nov; 46(11): 1832–1841. PubMed Abstract | Publisher Full Text | Free Full Text

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Delirium management and current practice among Intensive Care Units Doctors, Khartoum

Abstract

Keywords

Background

Methods

Study design

Setting

Participants

Variables

Data sources/measurement

Bias

Study size

Quantitative variables

Statistical methods

Results

Characteristics of intensive care unit (ICU) doctors

Table 1. Characteristics of ICU doctors (n=72).

Assessment of current knowledge and practice of ICU doctors towards delirium

Table 2. Assessment of current practice of ICU doctors about delirium (n=72).

Reasons for irregular delirium assessment and not using non-pharmacological approach management among doctors

Non-pharmacological interventions applied by doctors to reduce delirium

Figure 1. Non-pharmacological interventions applied by doctors to reduce delirium.

Pharmacological agents used by ICU doctors to treat delirium

Figure 2. Pharmacological agents used by doctors to reduce delirium.

Association between knowledge of doctors and their experience

Table 3. Association between knowledge and practice about delirium and years of experience among doctors.

Discussion

Conclusions

Declarations

Ethics and consent

Availability of supporting data

Authors’ contributions

Data availability

Underlying data

Reporting guidelines

Acknowledgements

References

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