Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Kelley Jenkins

Dr. Christine Turner, PhD, RN

NUR 4322 – Nursing Research

Bon Secours Memorial College of Nursing

July 24, 2020

“I pledge…”
INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to understand the relationship between early

mobilization in the intensive care unit (ICU) and the prevention or duration of delirium during

admission.

Background: Delirium is a frequent complication of admission to the intensive care unit, but

mobilization of ICU patients has been proposed to aid in reducing the risk of delirium, though

implementation of such programs remains a challenge. Understanding the impact of mobility

protocols on rates of delirium may establish their benefit and reduce barriers to implementation.

Design and Search Method: The research design is an integrative review. PubMed, EBSCO

MEDLINE Complete, and Academic Search Complete were the computer-based database

searches used to locate articles for this research. A total of five quantitative articles were selected

for the purposes of this review.

Results and Findings: The evidence that was compiled for this review provides conflicting

results on the value of mobilization programs in reducing or preventing delirium.

Limitations: The researcher is inexperienced in conducting an integrative review. In addition,

due to academic restrictions, access to articles was limited making research more challenging.

Implications for practice: Mobilization programs initiated early on in appropriate intensive care

patients may provide adequate benefit in reducing frequency and duration of delirium.

Recommendations for future research: Future research should be conducted to explore if the

frequency of mobilization in patients impacts delirium outcomes. In addition, larger scale studies

with greater sample sizes should be performed because the smaller studies evaluated for this

review likely did not have enough statistical power to achieve significance due to small sample

size.
INTEGRATIVE LITERATURE REVIEW 3

Integrative Literature Review

The purpose of this integrative review is to understand the relationship between early

mobilization programs in the intensive care unit (ICU) and the incidence and duration of

delirium during admission. Delirium is defined as a “reduced ability to direct, focus, sustain, and

shift attention” coupled with changes in cognition and can present as memory deficits,

disorientation, or changes in perception (Hayhurst, Pandharipange, & Hughes, 2016, p. 1229).

Delirium has been well-established as a risk factor for several complications of critical illness,

including longer durations of mechanical ventilation, prolonged ICU and hospital lengths of stay,

and higher morbidity and mortality rates (Larsen, Moller, Petersen, & Egerod, 2020). Data

suggests that the incidence of delirium ranges from 45% to 87% in ICU patients, and

mechanically ventilated patients have a greater risk, equating to approximately an 80% incidence

of delirium (Alvarez et al., 2016; Hayhurst et al., 2016) Non-pharmacological interventions for

delirium have been gaining more attention, particularly early mobilization programs. The aim of

this review is to analyze current evidence on mobilization interventions for delirium related to

the researchers PICOT question, “In the ICU patient, does early mobilization reduce the risk or

duration of delirium during admission?”

Design and Methods

The research design is an integrative review. PubMed, EBSCO MEDLINE Complete,

and Academic Search Complete were the three computer-based search engines that were used to

find articles for this research. The search terms included, ‘delirium’, ‘intensive care unit’,

‘critical care’, ‘mobility’, ‘early mobility’, ‘early mobilization’, ‘physical therapy’, ‘occupational

therapy’, and ‘prevention’. Despite numerous combinations of search terms combined with the

Boolean operators of ‘AND’ and ‘OR’, each database yielded several hundred results. Additional
INTEGRATIVE LITERATURE REVIEW 4

limits that were added to further restrict the search included articles that were published within

the last five or 10 years, English language, and peer-reviewed. Article abstracts were reviewed to

ensure that the research evidence chosen for this review was qualitative or quantitative in nature.

Finally, the articles had to provide reasonable evidence pertaining to the PICOT question, “In

the ICU patient, does early mobilization reduce the risk or duration of delirium during

admission?” After these limits were set and articles were reviewed, they were selected based on

the following inclusion criteria: discussion of mobility intervention, study setting in an intensive

care unit with the ICU patient as the only sample analyzed, and delirium outcomes measured.

Articles that failed to meet all of these criteria were excluded from the review. Finally, a total of

five quantitative articles were selected for this integrative review.

Findings and Results

The findings and results of the five studies that were reviewed showed conflicting

evidence for the benefit of early mobilization interventions in reducing or preventing delirium. A

complete summary of the research articles is presented in Appendix 1. Following review of the

research articles, there were several themes that were identified from the five studies: decreased

prevalence of delirium, high level of usual or standard care, and incidence of mobility sessions.

Decreased Prevalence of Delirium

Three of the five studies that were evaluated for the purposes of this integrative review

showed statistically significant decreases in the prevalence of delirium during ICU admission

(Alvarez et al., 2017; Bounds et al., 2016; Needham et al., 2010). This result was identified as

the majority consensus of the five articles. Though the methods were quite different, each of the

three studies effectively showed substantial improvements in delirium outcomes.

INTEGRATIVE LITERATURE REVIEW 5

The study conducted by Needham et al. (2010) was a quality improvement (QI) project

designed to evaluate the effect of increasing staffing of physical and occupational therapists in

the intensive care setting to improve mobilization on different patient outcomes, including

delirium, functional mobility, and lengths of stay. The study was a quasi-experimental, before-

after design performed in a medical intensive care unit at The Johns Hopkins Hospital, an

academic hospital located in Baltimore, Maryland (Needham et al., 2010). The authors evaluated

data from a three-month pre-QI period and a four-month intervention period. The sample

included 57 patients admitted to the ICU who were cognitively intact and mechanically

ventilated (Needham et al., 2010). Delirium was assessed using the Confusion Assessment

Method for the Intensive Care Unit (CAM-ICU) at least once daily. Data analysis was performed

using descriptive statistics as well as Fisher’s exact test, Wilcoxon rank-sum tests, and Stata 10.0

software, and a p value of <0.05 was set as the measure for statistical significance (Needham et

al., 2010). The results of the study showed that patients were more frequently alert (p<0.001) and

not delirious (p=0.003), translating to statistically significant differences between the control and

intervention groups (Needham et al., 2010). Despite these noteworthy findings, the researchers

identified several limitations including lack of randomization to the interventions of changing

sedation or mobility, possibly leading to measurement bias and small sample size, which may

decrease generalizability of the results (Needham et al., 2010).

Alvarez et al. (2017) conducted a study with the goal of determining the impact of

occupational therapy interventions on the duration, incidence, and severity of delirium in elderly

patients admitted to the ICU. This study was a pilot randomized controlled trial that took place in

an ICU at the University of Chile Clinical Hospital from April 2011 to December 2012 (Alvarez

et al., 2017). The sample included 140 patients that were 60 years or older and hospitalized in the
INTEGRATIVE LITERATURE REVIEW 6

ICU for longer than 24 hours who were randomized to the control or intervention group (Alvarez

et al., 2017). Delirium was assessed using CAM-ICU twice daily for the first five consecutive

days of admission, and if the CAM-ICU result was positive, the Delirium Rating Scale was then

applied to determine the severity of delirium (Alvarez et al., 2017). Statistical analysis was

conducted using the Kolmogorov-Smirnov test, the Mann-Whitney U test, descriptive statistics,

X2 test, and a measure of statistical significance set as p<0.05 (Alvarez et al., 2017). In addition,

SPSS 19.0 software was used to analyze the data (Alvarez et al., 2017). The study found that the

density of delirium, defined as the ratio between duration of the event and the exposure time

(time spent in the protocol), was significantly lower (p=0.000) as well as the incidence of

delirium (p=0.001), though the severity of delirium did not differ significantly between groups

(Alvarez et al., 2017). After review of their study, the researchers identified one major limitation

which was the exclusion of mechanically ventilated, cognitively impaired, or demented patients

thereby limits the generalizability of the findings (Alvarez et al., 2017).

Finally, a study by Bounds et al. (2016) was conducted to assess the impact of

implementing an ABCDE bundle on the prevalence and duration of delirium in the ICU. The

bundle components include awakening, breathing, coordination, choice of analgesia/sedation,

delirium prevention and management, and early physical mobility. The study was a

retrospective, quasi-experimental quantitative design whereby the researchers reviewed medical

records to collect data for three months before implementation of the bundle (December 2012 –

February 2013) and then during the same three-month period exactly one year later after the

ABCDE bundle was implemented (December 2013 – February 2014). The sample included 150

ICU patients, 80 pre-implementation and 79 post-implementation, who were evaluated based on

several delirium outcomes (Bounds et al., 2016). Data analysis was performed using SAS version
INTEGRATIVE LITERATURE REVIEW 7

9.3 and StatXact version 9 with X2 and t tests, regression models, and post hoc comparison using

Bonferroni methods (Bounds et al., 2016). The study concluded that the ABCDE bundle, which

includes early mobilization as a key component, effectively reduced the incidence and

prevalence of delirium with the following evidence: significant decrease in delirium prevalence

(p=0.01) and mean number of delirium days (p<0.001) for all ICU patients, significant decrease

in delirium prevalence (p<0.001) and duration (p<0.001) in mechanically ventilated patients, and

significant increase in the number of delirium-free days in mechanically ventilated patients

(p<0.001) (Bounds et al., 2016). The researchers acknowledge that, despite the impressive

findings of their study related to delirium outcomes, there were several limitations. One

limitation was the lack of random assignment due to the retrospective nature of the study as well

as the application of the intervention in a small, rural hospital setting, which may limit the

generalizability of the findings to other types of ICUs (Bounds et al., 2016).

High Level of Usual or Standard Care

Two of the studies analyzed for this integrative review were unable to show statistically

significant results with regards to reducing or preventing delirium following early mobilization

in an intensive care unit (Larsen et al., 2020; Nydahl et al., 2019). In the discussion of results

within both of the studies, the authors identified that the control groups were already receiving

high levels of mobilization prior to implementation of the mobility intervention. For this reason,

there were smaller differences between the control and intervention groups with regards to the

delirium outcomes.

The purpose of the study by Larsen et al. (2020) was to determine how an intervention

bundle that targeted sedation, sleep, pain, and mobility would reduce delirium in patients

suffering from an acute brain injury in an intensive care unit. The prospective before-after, quasi-
INTEGRATIVE LITERATURE REVIEW 8

experimental intervention study evaluated a five-month period of standard care (August -

December 2015) followed by a six-month intervention phase (January - June 2016). The sample

included 39 patients in the standard care group and 50 patients in the intervention group who

were admitted with an acute brain injury to a neurointensive care unit in a hospital in

Copenhagen, Denmark (Larsen et al., 2020). Delirium was assessed using the Intensive Care

Delirium Screening Checklist (ICDSC) at the end of each nursing shift, providing two

assessments per day at a minimum (Larsen et al., 2020). Data analysis was performed using the

following statistical tests: Chi-Square statistics, Fisher’s exact test, t-test, and Mann-Whitney U

test (Larsen et al., 2020). The study concluded that the prevalence and incidence of delirium did

not change following the intervention protocol, and functional mobilization status did not change

though there was a trend towards more out-of-bed mobilization (Larsen et al., 2020). The authors

believe that part of the reason for this lack of significant difference was due to the high level of

early mobilization already provided to the standard care, or control, group (Larsen et al., 2020).

The researchers also identified the following limitations of the study: small sample size and

insufficient implementation of the interventions which weakened the effect of the study as well

as it being conducted in a single hospital and thereby affecting the study’s external validity

(Larsen et al., 2020).

The purpose of the stepped-wedge, cluster, randomized pilot study performed by Nydahl

et al. (2019) was to evaluate the effect of implementing an early mobilization protocol in an ICU

on different patient outcomes, including rate of out-of-bed mobilizations, delirium, and

mechanical ventilation days. Five unnamed ICUs in three different hospitals in Germany were

included in the study and each participated in a control period of usual care at the same time.

Three were university hospitals, one was a general hospital, and one was university-affiliated.
INTEGRATIVE LITERATURE REVIEW 9

Following this control period, the ICUs implemented a mobility intervention in a step-wise,

randomized fashion until all the ICUs had completed the intervention (Nydahl et al., 2019). The

sample included 272 patients from all five ICUs, 152 patients during the control period and 120

during the intervention period (Nydahl et al., 2019). Delirium was assessed using CAM-ICU or

the Intensive Care Delirium Screening Checklist (Nydahl et al., 2019). Data analysis was

performed using Fisher’s exact test and Mann-Whitney U test through the use of IBM SPSS 21.0

software, and a p value of statistical significance was set as p<0.05 (Nydahl et al., 2019).

According to Nydahl et al. (2019), the number of delirium-free days did not differ significantly

between the control and intervention groups and may be, in part, due to the fact that a higher

number of patients than expected were already being mobilized in the control group. This can be

considered one limitation of the study in addition to the lack of achieving the target sample size,

which limits the generalizability of the findings.

Incidence of Out-of-bed Mobilizations

Four out of the five articles analyzed also looked at how implementation of mobility

interventions impacted the overall number of mobilizations out-of-bed (Alvarez et al., 2017;

Bounds et al., 2016; Larsen et al., 2020; Nydahl et al., 2019). They showed that despite focus on

mobility interventions, there were no significant increases in the overall number of patients who

had out-of-bed mobilization (Alvarez et al., 2017; Bounds et al., 2016; Larsen et al., 2020;

Nydahl et al., 2019). This was explained by several factors including high levels of standard care

and small sample size (Bounds et al., 2016; Larsen et al., 2020; Nydahl et al., 2019).

Discussion and Implications for Practice

The articles that were selected for the purposes of this integrative review provided a

thorough evaluation of the impact of mobilization protocols on the patient outcome of delirium
INTEGRATIVE LITERATURE REVIEW 10

in the intensive care setting. Three of the five studies did note statistically significant reductions

in the prevalence of delirium following early mobilization (Alvarez et al., 2017; Bounds et al.,

2016; Needham et al., 2010). The findings also suggest that early mobility programs are feasible

and that, with appropriate patient screening, they can be safely implemented (Needham et al.,

2010; Nydahl et al., 2019). The implication of these findings is that early mobility may be an

appropriate non-pharmacological intervention to reduce delirium. Future research should focus

on the implementation of a designated early mobility team specifically designed to improve the

frequency of early mobilization in intensive care patients so that delirium assessments and

mobility interventions are consistently applied to all study participants. In addition, there is

limited evidence on the impact of mobilization on delirium severity making this an ideal topic of

future research.

Limitations

In conducting this integrative review, the researcher faced several limitations. First and

foremost is the lack of experience in conducting an integrative review as well as limited

knowledge in performing research. In addition, access to journal articles was challenged by the

inability to retrieve all of the articles that the researcher wanted to assess for applicability to the

PICOT question. Due to limited access to online journals in the academic setting, the college

librarian was vital in providing full-text articles for review, however, not all articles that the

researcher desired could be obtained. Third, due to the nature of the PICOT question, all of the

articles selected were quantitative studies, and though they provided good evidence, they did not

offer an overview of the lived experiences that qualitative research would have provided.

Several of the studies identified small sample size as a limitation of their research

(Bounds et al., 2016; Larsen et al., 2020; Needham et al., 2010; Nydahl et al., 2019). This could
INTEGRATIVE LITERATURE REVIEW 11

impact the ability to achieve statistical significance of results and also affect the generalizability

of the findings. In addition, three of the articles implemented bundle interventions which were

not limited to mobility (Bound et al., 2016; Larsen et al., 2020; Needham et al., 2010). Therefore,

other interventions that were performed, such as reducing sedation and narcotics, could have

affected the delirium outcomes, and the impact of mobilization alone could not be measured

(Bound et al., 2016; Larsen et al., 2020; Needham et al., 2010). Finally, due to the nature of

certain illnesses that can place a patient in the intensive care setting, some study participants

were admitted with conditions that may have had a pathophysiology resulting in symptoms

similar to delirium who were not actually delirious (Bounds et al., 2016; Larsen et al, 2020).

Conclusion

This integrative review was performed to explore the impact of early mobilization on the

prevention and duration of delirium in the intensive care unit. Findings from the five articles

provide conflicting evidence on whether mobilization in critical care patients may help to

prevent or reduce delirium during admission. The evidence from this review suggests that this

may be a result of high standards of usual care by ICU staff, which reduced the ability of

mobility interventions to show statistically significant improvements (Larsen et al., 2020; Nydahl

et al., 2019). This may also explain why out-of-bed mobilizations did not increase significantly

following the implementation of mobility programs (Alvarez et al., 2017; Bounds et al., 2016;

Larsen et al., 2020; Nydahl et al., 2019). After examining the findings of the five articles studied

for this review relative to the PICOT question, “In the ICU patient, does early mobilization

reduce or prevent delirium during admission?”, it can be concluded that early mobility programs

are safe, feasible, and beneficial in the intensive care setting and may reduce the risk and

duration of delirium, but it cannot be definitively concluded that they do. Suggestions for future
INTEGRATIVE LITERATURE REVIEW 12

research on this topic include evaluating the impact of early mobilization on the severity of

delirium as well as implementing designated early mobility teams to ensure consistent

mobilization and delirium assessment methods for all patients.

INTEGRATIVE LITERATURE REVIEW 13

References

Alvarez, E., Garrido, M., Tobar, E., Prieto, S., Vergara, S., Briceno, C., & Gonzalez, F. (2017).

Occupational therapy for delirium management in elderly patients without mechanical

ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical

Care, 37, 85-90. doi: 10.1016/j.jcrc.2016.09.002

Bounds, M., Kram, S., Speroni, K., Brice, K., Luschinski, M.A., Harte, S., & Daniel, M. (2016).

Effect of ABCDE bundle implementation on prevalence of delirium in intensive care unit

patients. American Journal of Critical Care, 25, 535-544. doi: 10.4037/ajcc2016209

Hayhurst, C., Pandharipande, P., & Hughes, C. (2016). Intensive care unit delirium: A review of

diagnosis, prevention, and treatment. Anesthesiology, 125, 1229-1241. doi:

10.1097/ALN.0000000000001378. Retrieved from

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2566230

Larsen, L., Moller, K., Petersen, M., & Egerod, I. (2020). Delirium prevalence and prevention in

patients with acute brain injury: A prospective before-and-after intervention study.

Intensive & Critical Care Nursing, 59. doi: 10.1016/j.iccn.2020.102816

Needham, D., Korupolu, R., Zanni, J., Pradhan, P., Colantuoni, E., Palmer, J.,…Fan, E. (2010).

Early physical medicine and rehabilitation for patients with acute respiratory failure: A

quality improvement project. Archives of Physical Medicine and Rehabilitation, 91(4),

536-542. doi: 10.1016/j.apmr.2010.01.002

Nydahl, P., Gunther, U., Diers, A., Hesse, S., Kerschensteiner, C., Klarmann, S.,…Kopke, S.

(2019). PROtocol-based MObilizaTION on intensive care units: Stepped-wedge, cluster-

randomized pilot study (Pro-Motion). Nursing in Critical Care. doi: 10.111/nicc/12438

Running head: INTEGRATIVE LITERATURE REVIEW 14

Appendix 1: Summary of the Literature Table

APA Citation Nydahl, P., Gunther, U., Diers, A., Hesse, S., Kerschensteiner, C., Klarmann, S.,…Kopke,
Author Qualifications S. (2019). PROtocol-based MObilizaTION on intensive care units: Stepped-wedge, cluster-
randomized pilot study (Pro-Motion). Nursing in Critical Care. doi: 10.111/nicc/12438
 Nydahl: RN, MScN, Nursing Research, Department of Anesthesiology and Intensive
Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
 Gunther: MD, University Clinic of Anaethesiology, Intensive Care, Emergency
Medicine, Pain Therapy, Klinikum Oldenburg AoR, European Medical School
Oldernburg-Groningen, Oldenburg, Germany
 Diers: M.Sc.PH, University Clinic of Anaesthesiology, Intensive Care, Emergency
Medicine, Pain Therapy, Klinikum Oldenburg AoR, European Medical School
Oldernburg-Groningen, Oldenburg, Germany
 Hesse: RN, Department of Intensive Care, Stadtisches Krankenhaus, Kiel, Germany
 Kerschensteiner: RN, B.A., Department of Intensive Care, Helios Klinik Kipfenberg,
Germany
 Klarmann:Physiotherapist, Department of Physical Therapy, University Hospital of
Schleswig-Holstein, Kiel, Germany
 Borzikowsy: PhD, Statistician, Institute of Medical Informatics and Statistics, Kiel
University, University Hospital Schleswig-Holstein, Kiel, Germany
 Kopke:PhD, RN, Nursing Research Unit, Institute of Social Medicine and
Epidemiology, University of Lubeck, Lubeck, Germany
Background/Problem Statement  Early mobilization in ICUs remains challenging despite the improvements that are
seen in patient recovery
 The purpose of the study is to evaluate the effect of implementing a protocol for
early mobilization on the rate of out-of-bed mobilization and other outcomes of ICU
patients
Conceptual/Theoretical  No conceptual or theoretical framework identified
Framework

Design/Method/Philosophical  Quantitative study, experimental – stepped-wedge study, a form of randomized

Underpinnings controlled trial
INTEGRATIVE LITERATURE REVIEW
Sample/Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
15
 A brief literature review was provided which discussed previous studies suggesting
benefits of early mobilization in ICUs but also studies that highlighted barriers to
implementation of early mobility programs.
 Setting: Five different acute-care ICUs in Germany
 Sample included 272 patients; 152 patients were analyzed during control period and
120 patients were analyzed during intervention period
 Inclusion/exclusion criteria defined
 All ICUs participated in one-month control period followed by implementation
period where one ICU per month was randomized to the intervention.
 Per German law, consent for participation in this type of study was not required but
consent for using the data for research purposes was required and obtained.
 Study was approved by local ethics committees and committees of all five ICUs.
 Trial registered in the German Register of Clinical Studies
 There was no mention regarding participant’s autonomy, protection from harm, or
confidentiality.
 Primary study outcome: percentage of patients with at least one active out-of-bed
mobilization
 Secondary outcomes: presence/duration of mechanical ventilation (MV), delirium,
ICU or hospital stay, and unwanted safety events
 ICU Mobility Scale used to assess mobility status of ICU patients, with a range of 0
(lying in bed) to 10 (ambulating without assistance)
 Reliability and validity discussed
 Delirium assessed using Confusion Assessment Method for the Intensive Care Unit
or Intensive Care Delirium Screening Checklist
 Reliability and validity not discussed
 Data reported as numbers and percentages
 Medians, interquartile ranges, and relative risk with a 95% confidence interval
established
 Fisher’s exact test used for dichotomous data; Mann-Whitney U-test and Kruskal-
Wallis test used for metric data
 P-value <0.05 considered statistically significant
 Analysis performed using IBM SPSS 21.0 Statistics
INTEGRATIVE LITERATURE REVIEW
Findings/Discussion
Appraisal/Worth to Practice
16
 No discussion of validity or reliability of these data analysis tools
 No significant difference in delirium-free days
 Highlighted that there is conflicting data on whether early mobilization reduces
delirium, likely due to a baseline high level of ‘usual care’ relative to intervention
care
 Does not support a positive impact of early mobilization on delirium reduction
INTEGRATIVE LITERATURE REVIEW 17

APA Citation Larsen, L., Moller, K., Petersen, M., & Egerod, I. (2020). Delirium prevalence and
Author Qualifications prevention in patients with acute brain injury: A prospective before-and-after intervention
study. Intensive & Critical Care Nursing, 59. doi: 10.1016/j.iccn.2020.102816
 Larsen: Department of Neuroanaesthesiology, Rigshospitalet, University Hospital of
Copenhagen, Copenhagen, Denmark
 Moller: Department of Neuroanaesthesiology, Rigshospitalet, University Hospital of
Copenhagen, Copenhagen, Denmark
 Petersen: Department of Surgery, Sealand University Hospital, Koge, Denmark
 Egerod: Department of Intensive Care, Rishospitalet, University Hospital of
Copenhagen, Copenhagen, Denmark
Background/Problem Statement  Knowledge is limited regarding the prevention of delirium in patients with acute
brain injury in the ICU setting
 The purpose of the study was the test the hypothesis that an intervention bundle
targeting sedation, sleep, pain, and mobilization would reduce the duration of
delirium in patients with acute brain injury in the neurointensive care unit
Conceptual/Theoretical  No conceptual or theoretical framework identified
Framework

Design/Method/Philosophical  Quantitative, quasi-experimental - prospective before and after intervention study

Underpinnings  Brief literature review provided which discussed the limited evidence on delirium
prevention in patients with acute brain injury but does discuss the risks associated
with delirium with regards to certain patient outcomes, like duration of mechanical
ventilation and ICU length of stay
Sample/Setting/Ethical  Setting: neurointensive care unit at Rigshospitalet in Copenhagen, Denmark
Considerations  Sample: 89 patients with acute brain injury; 44 patients in standard care (control)
group and 45 patients in intervention group
 Inclusion/exclusion criteria clearly defined
 Study approved by National Committee on Health Research Ethics and the Danish
Data Protection Agency
 Surrogate consent obtained from patient’s next of kin as well as general practitioner
in patients with impaired decision-making capacity
 Informed written consent obtained from all participants who regained capacity for
INTEGRATIVE LITERATURE REVIEW
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to Practice
18
decision-making during their ICU stay
 No mention regarding patient’s protection from harm
 Primary outcome: delirium duration during ICU stay
 Secondary outcomes: delirium subtype and prevalence, ICU length of stay, one-year
mortality
 Delirium assessed using the Intensive Care Delirium Screening Checklist at the end
of each nursing shift (at least twice daily)
 Reliability and validity discussed for this tool
 RASS scale used to assess consciousness level
 Visual hierarchy model for mobilization inspired by previous research (Balas et al.,
2012) used to classify five different activity levels
 Data reported as numbers, mean (standard deviation), or median (inter-quartile
range)
 Chi-Square statistics or Fisher’s exact test used if there were fewer than five
observations
 T-test and Mann-Whitney U test used to assess variables
 Kaplan-Meier curve generated
 Log-rank test used to compare time to event for mobilization data
 No discussion provided regarding validity or reliability of any of these data analysis
tools
 Neither prevalence nor duration of delirium differed between groups
 No difference in delirium subtypes found between groups
 Due to small sample size, type II error likely as primary and secondary outcomes of
study pointed towards improvement but statistical significance not achieved
 Possible that delirium symptoms in neurocritically ill patients have pathophysiology
that differs from other critically ill patients, which may make them less amenable to
similar approaches for delirium reduction
 Lack of statistical significance in delirium reduction may also be due to high level of
standard or usual care
 Unable to support positive impact of mobilization in delirium reduction, particularly
in neurologically critical patients
INTEGRATIVE LITERATURE REVIEW 19

APA Citation Bounds, M., Kram, S., Speroni, K., Brice, K., Luschinski, M.A., Harte, S., & Daniel, M.
Author Qualifications (2016). Effect of ABCDE bundle implementation on prevalence of delirium in intensive
care unit patients. American Journal of Critical Care, 25, 535-544. doi:
10.4037/ajcc2016209
 Bounds: Former nurse manager at University of Maryland Shore Medical Center at
Dorchester, Cambridge, Maryland
 Kram: Former nurse manager at University of Maryland Shore Regional Health,
Easton, Maryland
 Speroni: Chair of the nursing research council, University of Maryland Shore
Regional Health
 Brice: Intensive Care Unit (ICU)/telemetry clinical educator/ICU staff nurse at
University of Maryland Shore Medical Center at Easton, Easton, Maryland
 Luschinski: ICU staff nurse at University of Maryland Shore Medical Center at
Easton
 Harte: Former physical therapist at University of Maryland Shore Medical Center at
Dorchester and Easton
 Daniel: Biostatistician at University of Maryland Shore Regional Health
Background/Problem Statement  The ABCDE bundle is a multidisciplinary intervention that helps improve and/or
preserve patient’s physical, functional, and cognitive status
 The purpose of this study is to quantify the prevalence and during of delirium in ICU
patients before and after implementation of the ABCDE bundle
Conceptual/Theoretical  No conceptual or theoretical framework identified
Framework

Design/Method/Philosophical  Quantitative, quasi-experimental – retrospective study

Underpinnings  Literature review provided to support use of ABCDE bundle for delirium prevention
but limited evidence for use in smaller, rural hospitals where implementing bundle
can be more difficulty due to limited resources
Sample/Setting/Ethical  Setting: University of Maryland Shore Medical Center at Dorchester (8 ICU beds)
Considerations and University of Maryland Shore Medical Center at Easton (10 ICU beds), a non-
for-profit, rural, 2-hospital community health system
 Sample: 159 ICU patients; 80 pre-implementation, 79 post-implementation
INTEGRATIVE LITERATURE REVIEW
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to Practice
20
 Inclusion and exclusion criteria clearly defined
 Study reviewed by the institutional review board and deemed exempt
 There was no mention of consent obtained from patients, protection from harm,
confidentiality, or patient autonomy
 Primary outcomes: duration and prevalence of delirium, length of ICU and hospital
stay, days of mechanical ventilation
 Delirium prevalence: percentage of patients with at least 1 positive Intensive Care
Delirium Screening Checklist (ICDSC) score during their ICU stay
 Delirium duration: number of days a patient had a positive ICDSC score while in
ICU
 Delirium assessed using Intensive Care Delirium Screening Checklist scores
 Reliability, sensitivity, and specificity of this tool discussed
 Means and frequencies used to describe sample
 X2 and 2-sample t tests were used
 Linear and logistic regression models used to test for associations between main
independent variable of interest and selected dependent variable
 Statistical assumptions were tested to ensure validity of models
 Post hoc error rates were adjusted by Bonferroni methods
 Analysis performed using SAS version 9.3 and StatXact version 9
 Prevalence of delirium decreased significantly after ABCDE bundle in all ICU
patients (p = 0.01)
 Prevalence of delirium decreased significantly after ABCDE bundle in mechanically
ventilated patients (p=<0.001)
 Mean number of delirium days decreased significantly in all ICU patients (p<0.001)
 Duration of delirum decreased significantly in mechanically ventilated patients
(p=<0.001)
 Number of patients with delirium-free days increased significantly (p=0.01)
 Percentage of patients receiving mechanical ventilation who had delirium-free days
increased significantly after ABCDE bundle (p=<0.001)
 Discussion lacks significant interpretation of the findings pertaining to delirium
 Provides excellent evidence that early mobility in conjunction with other practice
INTEGRATIVE LITERATURE REVIEW 21

changes can reduce delirium in the ICU

INTEGRATIVE LITERATURE REVIEW 22

APA Citation Needham, D., Korupolu, R., Zanni, J., Pradhan, P., Colantuoni, E., Palmer, J.,…Fan, E.
Author Qualifications (2010). Early physical medicine and rehabilitation for patients with acute respiratory failure:
A quality improvement project. Archives of Physical Medicine and Rehabilitation, 91(4),
536-542. doi: 10.1016/j.apmr.2010.01.002
 Needham: MD, PhD, Department of Physical Medicine and Rehabilitation, the
OACIS Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins
University, Baltimore, MD
 Korupolu: MBBS, MS, the OACIS Group, Division of Pulmonary and Critical Care
Medicine, Johns Hopkins University, Baltimore, MD
 Zanni: PT, MSPT, Department of Physical Medicine and Rehabilitation, Johns
Hopkins University, Baltimore, MD
 Pradhan: MBBS, MPH, the OACIS Group, Division of Pulmonary and Critical Care
Medicine, Johns Hopkins University, Baltimore, MD
 Colantuoni: PhD, Department of Anesthesiology and Critical Care Medicine, School
of medicine, Department of Biostatistics, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, MD
 Palmer: MD, Department of Physical Medicine and Rehabilitation, Johns Hopkins
University, Baltimore, MD
 Brower: MD, the OACIS Group, Division of Pulmonary and Critical Care Medicine,
Johns Hopkins University, Baltimore, MD
 Fan: MD, the OACIS Group, Division of Pulmonary and Critical Care Medicine,
Johns Hopkins University, Baltimore, MD
Background/Problem Statement  Mobilizing mechanically ventilated patients in the ICU has previously been
demonstrated as safe, feasible, and beneficial in improving physical function
 The purpose of this study is to improve physical mobility and rehabilitation services
in the ICU and evaluate the impact on patient outcomes including sedation, delirium,
and medications
Conceptual/Theoretical  There is no conceptual or theoretical framework identified
Framework

Design/Method/Philosophical  Quantitative, quasi-experimental – quality improvement project

Underpinnings
INTEGRATIVE LITERATURE REVIEW
Sample/Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to Practice
23
 Setting: medical intensive care unit (MICU), 16 beds, at Johns Hopkins University
 Sample: 57 MICU patients, 27 pre-quality improvement and 30 post-quality
improvement
 Study proposal was reviewed by institutional review board and deemed exempt from
approval due to “quality improvement” design
 QI project reported in accordance with Standards for Quality Improvement
Reporting Excellence guidelines
 There is no mention of patient consent, autonomy, confidentiality, or protection from
harm in the study
 Primary outcomes: benzodiazepine and narcotic drug doses received, sedation and
delirium status, patient pain status
 Benzodiazepine and narcotic drug doses were converted to midazolam- and
morphine-equivalent doses, respectively, using standard conversion factors
 RASS for sedation measure
 Confusion Assessment Method for the ICU (CAM-ICU) used for delirium measure
 Numerical Rating Scale used for pain
 Retrospective chart reviews used to compare post-QI to pre-QI using same period in
the year prior to QI project
 Descriptive statistics including proportions and medians with interquartile ranges
 Fisher exact and Wilcoxin rank-sum tests used to compare patient-level demographic
and MICU outcomes
 Linear regression analysis performed
 T tests used to evaluate difference in ICU and hospital lengths of stay
 Analysis performed using Stata 10.0
 2-sided p value of <0.05 used as value of statistical significane
 Patients were more frequently alert and not delirious (p=0.003)
 ICU delirium substantially lower
 Lacked randomization, outcomes were not evaluated in blinded manner
 Results may not be generalizable to great population due to small size of study
 Provides good evidence to suggest that physical mobility practices in critically ill
patients can reduce duration of delirium in the ICU
INTEGRATIVE LITERATURE REVIEW 24

APA Citation Alvarez, E., Garrido, M., Tobar, E., Prieto, S., Vergara, S., Briceno, C., & Gonzalez, F.
Author Qualifications (2017). Occupational therapy for delirium management in elderly patients without
mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of
Critical Care, 37, 85-90. doi: 10.1016/j.jcrc.2016.09.002
 Alvarez: MS, School of Occupational Therapy, Faculty of Health Sciences, Central
University of Chile, Santiago Centro, Chile; Department of Occupational Therapy
and Occupational Science, University of Chile, Independence, Chile
 Garrido: MS, Physical Medicine and Rehabilitation Service, Clinical University
Hospital of Chile, Independence, Chile
 Tobar: MD, Critical Care Unit, Internal Medicine, Clinical University Hospital of
Chile, Independence, Chile
 Prieto: MS, School of Occupational Therapy, Faculty of Health Sciences, Central
University of Chile, Santiago Centro, Chile; Physical Medicine and Rehabilitation
Service, Clinical University Hospital of Chile, Independence, Chile
 Vergara: MS, Physical Medicine and Rehabilitation Service, Clinical University
Hospital of Chile, Independence, Chile
 Briceno: MS, Department of Occupational Therapy and Occupational Science,
Physical Medicine and Rehabilitation Service, Clinical University of Chile,
Independence, Chile
 Gonzalez: MD, Internal Medicine, Clinical University Hospital of Chile,
Independence, Chile

Background/Problem Statement
Conceptual/Theoretical
Framework
 Delirium has negative consequences on patient outcomes, such as cognitive and
functional status.
 The purpose of this study is to determine the impact of occupational therapy
interventions on duration, incidence, and severity of delirium in elderly patients in
the intensive care unit
 There is no conceptual or theoretical framework identified

Design/Method/Philosophical  Quantitative, experimental – randomized controlled trial

Underpinnings
INTEGRATIVE LITERATURE REVIEW
Sample/Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
25
 Setting: University of Chile Clinical Hospital Medical and Surgical ICUs
 Sample: 140 patients, 70 control (standard care) and 70 intervention (reinforced non-
pharmacological prevention)
 Approved by hospital’s ethics committee
 Patient consent received
 No discussion of harm, autonomy, confidentiality in article.
 Primary outcome: management of delirium, including duration, incidence, and
severity
 Expressed as density of delirium – ratio between duration of the event and
the exposure time (time spent in the protocol)
 Patient-days with delirium defined as the ratio between the number of days
with positive result for delirium and the total days when the protocol was performed
 Secondary outcomes: functional independence, grip strength, cognitive status
 Delirium evaluated using Confusion Assessment Method (CAM) twice daily for first
5 consecutive days
 Sensitivity, specificity, positive predictive accuracy, negative predictive
accuracy, and interrater reliability discussed
 Functional independence measure scores collected using FIM scale which measures
18 activities of daily living and ranks patient’s level 1-7; higher scores indicate
higher levels of independence
 Kolmogorov-Smirnov test used to determine distribution of variables
 Descriptive statistics including median, mean, standard deviations, frequencies, and
percentages were used depending on the characteristics of each variable
 Poisson regression used for density of delirium
 Risk incidence ratio (RIR) used to compare groups
 Mann-Whitney U test used for numerical variables
 X2 test used for categorical variables
 2-talied significance level of p<0.05 set
 Analysis performed using SPSS 19.0
 Protocol compliance similar in both groups, suggesting high level of implementation
and consistency throughout study
 Delirium density significant lower in experimental group (p=0.000)
INTEGRATIVE LITERATURE REVIEW
Appraisal/Worth to Practice
26
 Most common day of delirium was 2nd day in control group, 3rd day in experimental
group
 Incidence of delirium significant decreased (p=0.001)
 Delirium severity did not differ significantly
 Patient-days with delirium reduced substantially
 Valuable evidence to support use of occupational therapy mobility interventions in
the ICU to reduce incidence and duration of delirium in non-mechanically ventilated
elderly ICU patients