Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation.

BACKGROUND: Delirium in the intensive care unit (ICU) is common, but reliable evidence-based recommendations are still limited.

OBJECTIVES: The aim of our study was to explore nurses' and physicians' experiences and approaches to ICU delirium management.

METHOD: Our study had a qualitative multicentre design using interdisciplinary focus groups and framework analysis. Participants were strategically selected to include nurses and physicians with experience in delirium management at five ICUs in four out of five regions in Denmark.

RESULTS: We conducted eight focus group interviews with 24 nurses and 15 physicians; median ICU experience was 9 years (range 1-35). The main issues identified were (1) the decision to treat or not to treat ICU delirium based on delirium phenotype, (2) the decision to act based on experience or evidence, and (3) the decision to intervene using nursing care or medications. ICU delirium was treated with pharmacological interventions in patients with signs of agitation, hallucinations, and sleep deprivation. The first choice of agent was haloperidol or olanzapine. Agitated and combative patients received benzodiazepines, propofol, or dexmedetomidine. Calm delirious patients were managed with non-pharmacological solutions. Physicians recommended pro re nata (PRN) orders to prevent over medication, whereas nurses opposed PRN orders with the fear that it would increase their responsibilities.

CONCLUSION: Our study described an algorithm of contemporary delirium management in Danish ICUs based on qualitative inquiry. When evidence-based solutions are unclear, nurses and physicians rely on personal experience, collective experience, and best available evidence to determine which patients to treat and what methods to use to treat ICU delirium. Delirium management still needs clear objectives and guidelines with evidence-based recommendations for first-line treatment and subsequent treatment options.