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Kenntnis und Umsetzung der S3-Leitlinie zum Delirmanagement in Deutschland

Knowledge and implementation of the S3 guideline on delirium management in Germany

Zusammenfassung

Hintergrund

Das Delir ist eine häufige Komplikation auf Intensivstationen. Das Syndrom wird häufig unterschätzt. Die aktuellen S3-Leitlinien fordern daher ein strukturiertes, regelmäßiges und routinemäßiges Screening auf allen Intensivstationen. Wird ein Delir diagnostiziert, soll eine symptomorientierte Therapie zeitnah begonnen werden.

Ziele

Ziel der vorliegenden Arbeit ist die Darstellung der bisherigen Strategien deutscher Kliniken im Bereich Delirmanagement.

Methode

Anhand einer online-basierten Umfrage wurden leitende Anästhesisten deutscher Kliniken (n = 922) zur Anwendung der vorgenannten Leitlinien in Deutschland für den Teilbereich des Delirmanagements befragt.

Ergebnis

Die 249 Antwortenden repräsentieren ein Viertel der deutschen Intensivstationen. In jeder zehnten Klinik, die eine Intensivstation führt, waren die Inhalte der bis 2015 gültigen Leitlinie unbekannt (86,3 %). Mehr als die Hälfte der intensivmedizinischen Behandler gibt einen bevorzugten Delirscore an, häufig wird der CAM-ICU (49 %) verwendet. Allerdings erheben nur 53,6 % der Befragten alle acht Stunden einen Score. Der jeweilige Goldstandard zur Therapie nach Symptomatik wird bei Kenntnis der Leitlinien besser realisiert.

Schlussfolgerung

Insgesamt werden die Leitlinien für den Teilbereich Delir weniger gut umgesetzt als im Bereich Sedierungsmanagement. Bei Kenntnis der Leitlinie erfolgen Diagnose und Behandlung von Delirien häufig leitliniengerecht. Die geringe Zahl an Kliniken, die die Leitlinie in eine klinikinterne Handlungsanweisung (40 %) implementiert haben, zeigt jedoch, dass dringend Optimierungsbedarf besteht. Ein Umdenken unter Einbeziehung aller Berufsgruppen, die intensivmedizinisch und perioperativ Patienten behandeln, könnte die Implementierung von Leitlinien auf Intensivstationen verbessern.

Abstract

Background

Delirium is a common complication in critical care. The syndrome is often underestimated due to its potentially no less dangerous course as a hypoactive delirium. Therefore, current guidelines ask for a structured, regular and routine screening in all intensive care units. If delirium is diagnosed, symptomatic therapy should be initiated promptly.

Objectives

The aim of the current study was to evaluate recent German anesthetists’ strategies regarding delirium care compared to the German guidelines for sedation and delirium in intensive care.

Methods

In an online survey German hospitals’ senior anesthetists (n = 922) were interviewed anonymously between May and June 2015 regarding guideline use in delirium management in German intensive care units. In 33 direct questions the anesthetists were invited to answer items regarding the structure of their hospitals, intensive care and delirium therapy in order to review their knowledge of the German delirium guidelines that expired in 2014.

Results

The 249 senior anesthetists who responded to the survey, can be associated with (or represent) a quarter of German intensive care beds and cases, respectively. In every tenth clinic that runs an intensive care unit the guideline was unknown. In three of four intensive care units physicians specified a preferred delirium score, the CAM-ICU (49.4 %) is used most frequently. With knowledge of the guidelines more often a recommended delirium score is used (p = 0.017). However, only 53.6 % of the respondents ascertain a score every eight hours and 36 % have no facility for standardized documentation in the records. At intensive care rounds, a possible diagnosis of delirium is an inherent part in only 34.9 % of the responders even with guideline knowledge. The particular gold standard for the therapy of delirium (alphaagonists for vegetative symptoms; 89.6 %, benzodiazepines for anxiety, 77.5 %; antipsychotics in 86.7 % for psychotic symptoms) is implemented more often with growing knowledge of the guidelines. The latter applies to the implementation of structured programs for delirium prophylaxis, cognition and therapy.

Conclusion

For the first time, this study documents knowledge and implementation of the German S3 guidelines for delirium in intensive care. Overall, the guidelines for delirium care are less well executed than those for sedation. With growing knowledge of the guidelines, diagnosis and treatment of delirium fits the guidelines more frequently. The facility to document a delirium score in intensive records is insufficient. Especially a nursing-based delirium strategy could possibly improve implementation of the guidelines, claiming an eight-hour screening and documentation. However, the small number of hospitals that have integrated the guidelines into in-house standard operating procedures (40 %) shows urgent need for optimization. A re-evaluation involving all relevant caretakers could probably improve the implementation of guidelines in intensive care and perioperative medicine.

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Correspondence to T. Saller.

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Interessenkonflikt

T. Saller und K. Hofmann-Kiefer geben an, dass kein Interessenkonflikt besteht. V. v. Dossow erhielt Teilnahmegebühren- und Reisekostenerstattung sowie Vortragshonorare von den Firmen Köhler Chemie GmbH und Orion Pharma GmbH sowie Sachmittelunterstützung von der Firma Köhler Chemie GmbH.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Saller, T., v. Dossow, V. & Hofmann-Kiefer, K. Kenntnis und Umsetzung der S3-Leitlinie zum Delirmanagement in Deutschland. Anaesthesist 65, 755–762 (2016). https://doi.org/10.1007/s00101-016-0218-8

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Schlüsselwörter

  • Delir
  • Intensivstation
  • Leitlinien
  • CAM-ICU
  • Umfrage

Keywords

  • Delirium
  • Critical care
  • Guidelines
  • CAM-ICU
  • Survey