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Clinical practice guideline for nonpharmacological prevention and management of patient agitation in the adult intensive care unit (CALM ICU).

A. M. Adams,D. Chamberlain,Matthew J. Maiden,C. Thorup,Marianne W. Nørgaard,B. Laugesen,Mette Grønkjær,Kay Bruce,Cherie Waite,Cornelia Lamprecht,Tiffany Conroy

Published 2025 in Australian Critical Care

ABSTRACT

BACKGROUND Agitation affects 32-70% of adult patients in the intensive care unit (ICU) and is associated with disruption of life-saving treatment, prolonged hospitalisation, and psychological trauma. While nonpharmacological interventions are increasingly encouraged to reduce the reliance on sedatives, existing guidelines predominantly focus on pharmacological management. This contributes to inconsistent practices and underutilisation of effective person-centred nonpharmacological alternatives. OBJECTIVE The objective of this study was to develop evidence-based recommendations for the nonpharmacological prevention and management of patient agitation in the adult ICU. METHOD The clinical practice guideline for non-pharmacological prevention and management of patient agitation in the adult ICU (CALM ICU) was developed following the Australian National Health and Medical Research Council Guidelines for Guidelines and the Danish Health Authority's manual on guideline development. The process included stakeholder consultation with ICU clinicians, researchers, patients, and family members on the initial scope of the guideline, a systematic review and an umbrella review, a three-round modified Delphi study involving 114 participants from Denmark and Australia, and finally, stakeholder and methodological reviews of the draft guideline. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the certainty of the evidence. RESULTS The guideline offers 14 recommendations, including four conditional recommendations and 10 consensus recommendations. These address early and systematic assessment, identifying and treating underlying causes of agitation, prioritising nonpharmacological interventions, and using multicomponent interventions. The recommendations also include using de-escalation strategies, reorientation, promoting sleep, adjusting stimuli, supporting comfort and relaxation, encouraging mobilisation, and involving family members. The guideline also includes two additional recommendations highlighting the importance of fundamental person-centred care and organisational support for ICU staff. CONCLUSIONS The CALM ICU guideline provides the best available evidence for reducing patient agitation through nonpharmacological strategies. It should be integrated into standard ICU care and serve as a foundation for education and practice. Further research is needed to strengthen the evidence base and explore implementation in diverse ICU settings. This guideline has been endorsed by the Australian College of Critical Care Nurses.

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