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

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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." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-456/v4", "name": "Delirium management and current practice among Intensive Care Units..." } } ] } Home Browse Delirium management and current practice among Intensive Care Units... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article 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 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.12688/f1000research.142233.4 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] Sheema Hamid Seidna Hamid 1 , Ghada Omer Hamad Abd El-Raheem https://orcid.org/0000-0001-5668-0859 2 , Hana Eltayeb Salih Elamin 3 , Mudawi Mohammed Ahmed Abdallah 4 Sheema Hamid Seidna Hamid 1 , Ghada Omer Hamad Abd El-Raheem https://orcid.org/0000-0001-5668-0859 2 , Hana Eltayeb Salih Elamin 3 , Mudawi Mohammed Ahmed Abdallah 4 PUBLISHED 19 Feb 2025 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 DETAILS 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. READ ALL READ LESS Keywords Delirium, CAM-, ICDSC, critically ill patients, ICU, current practice, Intensive Care Units, Doctors.ICU Corresponding Author(s) Ghada Omer Hamad Abd El-Raheem ( [email protected] ) Close 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: © 2025 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 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.12688/f1000research.142233.4 ) 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 ) Revised Amendments from Version 3 Age and years of experience were expressed as mean and SD. Specified sedatives as benzodiazepines. Age and years of experience were expressed as mean and SD. Specified sedatives as benzodiazepines. See the authors' detailed response to the review by Hiroyoshi Takeuchi See the authors' detailed response to the review by Richard E Kennedy READ REVIEWER RESPONSES 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 adverse consequences such as 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 knowledge and practice of ICU doctors about delirium. The reasons why this study was developed were to identify the barriers and gaps in knowledge and practice among doctors in Sudan. No similar study was done in Sudan and little is known about Sudanese doctors ICU practice for delirium. This study involved military hospitals in Khartoum, however the types of patients involved citizens. Military hospitals provide healthcare services for all types of patients not only military. 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 At first level, simple random sampling was applied to select the hospitals. Out of the four military hospitals in Khartoum, three hospitals were selected randomly out of all Military hospitals in Khartoum State. At second level, based on the types of ICUs. Three types of ICUs were defined in the military hospitals; surgical, medical and mixed. The stratified random sampling technique was used to select 72 participants proportionally to the type of ICU (68 doctors in medical ICUs, 2 doctors in surgical ICUs and 2 doctors in mixed ICUs). Administrative staff were excluded. 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. Knowledge and practice were assessed through a questionnaire developed by the researchers after reviewing the literature. The questionnaire was then validated by an expert in research methodology ( https://orcid.org/0000-0003-1772-2686 ). Characteristics of the participants were assessed first, then delirium questions involved assessment tools, first line management, delirium assessment frequency, treatments used and duration of treatment. These predictors for knowledge and practice were important as per the American College of Clinical Pharmacy. 18 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+Nd 2 , 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. All participants had completed the questionnaire with zero refusals. The formula for known population was used to select the sample size at each stage. 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 % Mean ±SD Min.- Max. Age ≤30 Years 51 70.8 29.7± 3.7 25-42 >30 Years 21 29.2 Total 72 100 Gender Male 10 13.9 Female 62 86.1 Total 72 100 Years of experience 2 Years 15 20.8 Total 72 100 ICU type Medical ICU 68 94.4 Surgical ICU 2 2.8 Surgical and Medical ICUs 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 Benzodiazepines 24 33.3 Total 72 100 Opioids 3 4.2 Knowledge about first line management Antipsychotics+ Benzodiazepines 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 Benzodiazepines 15 20.8 CAM-ICU 13 18.1 Opioids 1 1.4 ICDSC 1 1.4 Antipsychotics+ Benzodiazepines 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 Benzodiazepines prescribed by 33.3% (24/72) of doctors to treat agitation. For delirium, Benzodiazepines 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, risperidone 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 % Chi 2 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 Benzodiazepines 17 70.8 7 29.2 24 33.3 Opioids 3 100.0 0 0.0 3 4.2 Antipsychotics+ Benzodiazepines 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 Benzodiazepines 9 60.0 6 40.0 15 20.8 Opioids 1 100.0 0 0.0 1 1.4 Antipsychotics+ Benzodiazepines 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 Awareness about delirium assessment in ICU is considered a milestone. Delirium is common disorder among ICU patients. 3 , 6 , 8 , 11 , 12 , 15 , 16 Doctors and nurses were the direct healthcare providers for critically ill patients. In addition to nurses, doctors were involved in delirium assessment and reporting as mentioned by Pisani MA et al. 5 Lack of awareness among staff was reported as one of the individual barriers. 3 An issue to be highlighted in this study was the lack of awareness of Sudanese doctors about delirium assessment tools. Moreover, the ICU staff doctors are mostly young (< 30 years) and inexperienced (< 2 years). This study had put light on that point about the working staff in governmental hospitals in Sudan. Depending only on signs and symptoms to assess delirium was a common practice among Sudanese doctors. This non protocol-based practice was commonly used by the participants. 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%) had not used any specific tool for delirium assessment and relied on signs and symptoms alone without a specific protocol. 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 practice involved frequent reorientation of the patients and allowing relatives to come and talk to their patients. 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 patients 24 ; 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 Benzodiazepines. 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, Benzodiazepines 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 Benzodiazepines 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 Benzodiazepines. This practice of our doctors was not in line with recommended treatments, as Benzodiazepines 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 comparison of doctors practice to nurses practice. Doctors and nurses were the direct healthcare providers for critically ill patients and nurses play crucial rule in ICU practice. Involving nurses would give a complete picture about this issue. Furthermore, the data collection tool was not validated through Cronbach test of reliability. 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 bigger and more populated hospitals. 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 Benzodiazepines 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). 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Publisher Full Text Comments on this article Comments (0) Version 4 VERSION 4 PUBLISHED 07 May 2024 ADD YOUR COMMENT Comment 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 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 https://doi.org/10.12688/f1000research.142233.3 version 2 Revised Published: 31 Oct 2024, 13:456 https://doi.org/10.12688/f1000research.142233.2 version 1 Published: 07 May 2024, 13:456 https://doi.org/10.12688/f1000research.142233.1 Copyright © 2025 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. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article 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 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.12688/f1000research.142233.4 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE 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 Version 4 VERSION 4 PUBLISHED 19 Feb 2025 Revised Views 0 Cite How to cite this report: Takeuchi H. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.178238.r367580 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v4#referee-response-367580 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 20 Feb 2025 Hiroyoshi Takeuchi , Keio University, Tokyo, Japan Approved VIEWS 0 https://doi.org/10.5256/f1000research.178238.r367580 As the authors adequately revised the manuscript according ... Continue reading READ ALL 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Takeuchi H. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.178238.r367580 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v4#referee-response-367580 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 3 VERSION 3 PUBLISHED 21 Nov 2024 Revised Views 0 Cite How to cite this report: Takeuchi H. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.174773.r361960 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v3#referee-response-361960 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Feb 2025 Hiroyoshi Takeuchi , Keio University, Tokyo, Japan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.174773.r361960 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. ... Continue reading READ ALL 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Takeuchi H. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.174773.r361960 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v3#referee-response-361960 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 19 Feb 2025 Ghada Abd El-Raheem , Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan 19 Feb 2025 Author Response Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed ... Continue reading Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed as mean and SD. 2. Specified sedatives as benzodiazepines. 3. Corrected the spelling of Risperidone in the text and figure. Thank you again Best regards, Corresponding Author Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed as mean and SD. 2. Specified sedatives as benzodiazepines. 3. Corrected the spelling of Risperidone in the text and figure. Thank you again Best regards, Corresponding Author Competing Interests: No competing interests. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 19 Feb 2025 Ghada Abd El-Raheem , Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan 19 Feb 2025 Author Response Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed ... Continue reading Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed as mean and SD. 2. Specified sedatives as benzodiazepines. 3. Corrected the spelling of Risperidone in the text and figure. Thank you again Best regards, Corresponding Author Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed as mean and SD. 2. Specified sedatives as benzodiazepines. 3. Corrected the spelling of Risperidone in the text and figure. Thank you again Best regards, Corresponding Author Competing Interests: No competing interests. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Frohnhofen H. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.174773.r354246 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v3#referee-response-354246 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Jan 2025 Helmut Frohnhofen , University Hospital Düsseldorf, Düsseldorf, Germany Approved VIEWS 0 https://doi.org/10.5256/f1000research.174773.r354246 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. ... Continue reading READ ALL 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Frohnhofen H. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.174773.r354246 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v3#referee-response-354246 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 31 Oct 2024 Revised Views 0 Cite How to cite this report: Kennedy RE. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.172723.r336635 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v2#referee-response-336635 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Nov 2024 Richard E Kennedy , University of Alabama at Birmingham, Birmingham, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.172723.r336635 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 ... Continue reading READ ALL 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 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kennedy RE. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.172723.r336635 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v2#referee-response-336635 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 21 Nov 2024 Ghada Abd El-Raheem , Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan 21 Nov 2024 Author Response Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. Competing Interests: No competing interests Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. Competing Interests: No competing interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 21 Nov 2024 Ghada Abd El-Raheem , Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan 21 Nov 2024 Author Response Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. Competing Interests: No competing interests Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. Competing Interests: No competing interests Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 07 May 2024 Views 0 Cite How to cite this report: Kennedy RE. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.155756.r295363 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v1#referee-response-295363 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jul 2024 Richard E Kennedy , University of Alabama at Birmingham, Birmingham, USA Not Approved VIEWS 0 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 ... Continue reading READ ALL 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kennedy RE. Reviewer Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.155756.r295363 ) The direct URL for this report is: https://f1000research.com/articles/13-456/v1#referee-response-295363 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern 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 Respond or Comment 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 COMMENT ON THIS REPORT Comments on this article Comments (0) Version 4 VERSION 4 PUBLISHED 07 May 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline 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 Reviewer Reports Invited Reviewers 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 Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Takeuchi H. This is an open access peer review report 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. 20 Feb 2025 | for Version 4 Hiroyoshi Takeuchi , Keio University, Tokyo, Japan 0 Views copyright © 2025 Takeuchi H. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (0) Approved info_outline 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 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. reply Respond to this report Responses (0) Takeuchi H. Peer Review Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.178238.r367580) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-456/v4#referee-response-367580 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Takeuchi H. This is an open access peer review report 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. 06 Feb 2025 | for Version 3 Hiroyoshi Takeuchi , Keio University, Tokyo, Japan 0 Views copyright © 2025 Takeuchi H. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline 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 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. reply Respond to this report Responses (1) Author Response 19 Feb 2025 Ghada Abd El-Raheem, Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan Dear Prof. Hiroyoshi Takeuchi, Thank you for devoting your time for reviewing our paper. All your amendments were fulfilled as follows: 1. Age and years of experience were expressed as mean and SD. 2. Specified sedatives as benzodiazepines. 3. Corrected the spelling of Risperidone in the text and figure. Thank you again Best regards, Corresponding Author View more View less Competing Interests No competing interests. reply Respond Report a concern Takeuchi H. Peer Review Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.174773.r361960) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-456/v3#referee-response-361960 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Frohnhofen H. This is an open access peer review report 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. 24 Jan 2025 | for Version 3 Helmut Frohnhofen , University Hospital Düsseldorf, Düsseldorf, Germany 0 Views copyright © 2025 Frohnhofen H. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (0) Approved info_outline 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 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. reply Respond to this report Responses (0) Frohnhofen H. Peer Review Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.174773.r354246) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-456/v3#referee-response-354246 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Kennedy R. This is an open access peer review report 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. 12 Nov 2024 | for Version 2 Richard E Kennedy , University of Alabama at Birmingham, Birmingham, USA 0 Views copyright © 2024 Kennedy R. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline 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 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 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. reply Respond to this report Responses (1) Author Response 21 Nov 2024 Ghada Abd El-Raheem, Clinical pharmacy, Soba University Hospital, Khartoum, 11111, Sudan Dear reviewer, Thank you for your valuable time and comments. We revised the references and corrected the reference 18. Thank you again. View more View less Competing Interests No competing interests reply Respond Report a concern Kennedy RE. Peer Review Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.172723.r336635) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-456/v2#referee-response-336635 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Kennedy R. This is an open access peer review report 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. 29 Jul 2024 | for Version 1 Richard E Kennedy , University of Alabama at Birmingham, Birmingham, USA 0 Views copyright © 2024 Kennedy R. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline 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 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. reply 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. reply Respond Report a concern Kennedy RE. Peer Review Report For: Delirium management and current practice among Intensive Care Units Doctors, Khartoum [version 4; peer review: 2 approved, 1 approved with reservations] . F1000Research 2025, 13 :456 ( https://doi.org/10.5256/f1000research.155756.r295363) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-456/v1#referee-response-295363 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. 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });