Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review

Performance and validation of two ICU delirium assessment and severity tools; a prospective observational study

BACKGROUND

The clinical statistical performance of the Confusion Assessment Method Intensive Care Unit (CAM-ICU, including CAM-ICU-7) and Intensive Care Delirium Screening Checklist (ICDSC) have rarely been studied. Additionally, delirium severity is often not measured due to a lack of validation of delirium assessment tools.

OBJECTIVE

The aim was to determine the statistical performance of both delirium assessment tools in daily practice, and the correlation with the gold standard Delirium Rating Scale (DRS)-R98, for delirium severity.

RESEARCH METHOD

CAM-ICU-7 and ICDSC, performed by nurses were compared with the DRS-R98 assessed by delirium experts, twice weekly. Within a time-window of one hour all assessments were independently performed.

DESIGN

A prospective observational study performed between October and December 2020.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive value of both tools was determined. The correlation between DRS-R98 and CAM-ICU-7 and ICDSC was used for validation of delirium severity.

RESULTS

In total, 104 CAM-ICU-7 and 105 ICDSC assessments in 86 patients were compared with the DRS-R98. For the CAM-ICU-7 and ICDSC, respectively, the sensitivity was 90% and 95%, the specificity was 92.4% and 92.3%. The positive predictive value was 0.76 and 0.80, and negative predictive value was 0.77 and 0.97. Correlation of the CAM-ICU-7 score and ICDSC score with the DRS-R98 score was 0.74 (95% CI 0.64-0.81) and 0.70 (95%CI 0.59-0.79; both p < 0.001), respectively.

CONCLUSION

Both CAM-ICU-7 and ICDSC demonstrated good statistical performance and correlated well with the delirium severity tool DRS-R98.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses can either use the CAM-ICU(-7) or the ICDSC in their practice, both are accurate in delirium diagnosis. Total CAM-ICU-7 and ICDSC score reflects delirium severity well; the higher the score, the more severe the delirium. This enables nurses to gauge the impact of their interventions and enhance the well-being of patients experiencing delirium by minimizing distressing occurrences.

From Traditional Typing to Intelligent Insights: A Narrative Review of Directions Toward Targeted Therapies in Delirium

Delirium is a heterogeneous syndrome characterized by an acute change in level of consciousness that is associated with inattention and disorganized thinking. Delirium affects most critically ill patients and is associated with poor patient-oriented outcomes such as increased mortality, longer ICU and hospital length of stay, and worse long-term cognitive outcomes. The concept of delirium and its subtypes has existed since nearly the beginning of recorded medical literature, yet robust therapies have yet to be identified. Analogous to other critical illness syndromes, we suspect the lack of identified therapies stems from patient heterogeneity and prior subtyping efforts that do not capture the underlying etiology of delirium. The time has come to leverage machine learning approaches, such as supervised and unsupervised clustering, to identify clinical and pathophysiological distinct clusters of delirium that will likely respond differently to various interventions. We use sedation in the ICU as an example of how precision therapies can be applied to critically ill patients, highlighting the fact that while for some patients a sedative drug may cause delirium, in another cohort sedation is the specific treatment. Finally, we conclude with a proposition to move away from the term delirium, and rather focus on the treatable traits that may allow precision therapies to be tested.

A Case Report and Review of the Literature of ICU Delirium

This case report focuses on what patients and family members may experience when a neurological trauma transpires and resultant intensive care (ICU) delirium occurs. It is the personal account of the patient (A.B.) and spouse's (R.G.B.) perspectives when the patient (A.B) suffered a vertebral artery aneurysm and hemorrhage and experienced intensive care unit (ICU) delirium after being in the ICU for 22 days. This case report provides the patient's and spouse's perspectives regarding delirium, i.e., A.B.'s inability to discern reality, loss of memory, paranoia and hallucinations, agency and recovery, post-ICU syndrome, and post-traumatic stress disorder (PTSD). Clinical diagnosis by the neurosurgeon indicated delirium, with treatment consisting of sleep sedation and uninterrupted sleep. A.B. was able to regain consciousness yet experienced post-traumatic stress disorder up to one year afterward. Consistent family participation in the patient's delirium care is crucial. Family member care and family-centered strategies are provided with implications for future research and health care.

Cognitive impairment in critically ill patients and former critically ill patients: A concept analysis

OBJECTIVES

This concept analysis aimed to clarify the meaning of the concept of cognitive impairment in critically ill patients throughout the trajectory of their rehabilitation during and after an intensive care unit admission.

REVIEW METHODS USED

This study used concept analysis based on Rodgers' evolutionary method.

DATA SOURCES

A systematic search was conducted in Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, and American Psychological Associations PsycINFO. The web was searched for grey literature.

REVIEW METHODS

Overall search terms used were "patients with cognitive impairments" AND "intensive care unit". Literature published between 2008 and 2022 was included and screened by title and abstract using systematic review software. The descriptive analysis focussed on surrogate terms/related concepts, attributes, and contextual basis.

RESULTS

Thirty studies were included, representing variability in study design and country of origin. The analysis uncovered descriptions of the general terminology and the temporal trajectory of the concept, spanning from the acute phase to a long-term perspective. Attributes of the concept were described as delirium and domains of cognition. Antecedents were juxtaposed to risk factors, which were multifactorial. Consequences of cognitive impairment related to patients' quality of life, such as a decline in their ability to function independently, return to work, and manage everyday life. Also, cognitive impairment was identified as a significant public health problem.

CONCLUSION

Cognitive impairment is a complex concept with many surrogate and related terms. Furthermore, the concept is inextricably intertwined with the concepts of delirium and post-intensive care syndrome. Cognitive impairment may manifest as symptoms that can be challenging to identify and assess due to limitations in current screening tools and the absence of a consensus on timing. In relation to assessment and preventive strategies, the findings underline the need to distinguish between acute and long-term cognitive impairment.

REGISTRATION

There is no study registration number.

The impact of perioperative enhanced recovery nursing model on postoperative delirium and rehabilitation quality in elderly patients with femoral neck fractures

BACKGROUND

The aim of this study was to investigate the effects of introducing the Enhanced Recovery After Surgery (ERAS) nursing model on postoperative delirium occurrence and rehabilitation quality in elderly patients with femoral neck fractures.

METHODS

A total of 160 elderly patients with femoral neck fractures, who met the inclusion criteria and were admitted between March 2021 to March 2023, were divided into two groups: the traditional care group and the ERAS nursing model group. In addition to traditional care measures, the ERAS nursing model group received interventions based on the principles of the ERAS nursing model. The occurrence of delirium and sleep quality were observed at 24, 48, and 72 h postoperatively, as well as during the overall hospital stay. The duration of hospitalization, time to first mobilization, and post-discharge follow-up on quality of life were compared between the two groups.

RESULTS

The ERAS nursing model group exhibited a significant difference in the occurrence of delirium at 48 and 72 h postoperatively, as well as during the overall hospital stay (P < 0.05). However, there was no significant difference in the occurrence of delirium at 24 h postoperatively (P > 0.05). The sleep quality of the two groups showed a statistically significant difference (P < 0.05). The ERAS nursing model group had shorter time to first mobilization, reduced hospitalization duration, and higher Harris and SF-36 scores during post-discharge follow-up, compared to the traditional care group (P < 0.05).

CONCLUSIONS

The implementation of the ERAS nursing model in elderly patients with femoral neck fractures improved postoperative sleep quality, reduced delirium occurrence, shortened average hospitalization duration, and enhanced patients' quality of life.

Nurses' experiences of managing cognitive problems in intensive care unit patients: A qualitative study

OBJECTIVES

Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses' perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit. The objective of this study was to explore nurses' experiences of cognitive problems in patients admitted to an intensive care unit.

RESEARCH METHODOLOGY

A phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation.

FINDINGS

Three themes related to nurses' experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment.

CONCLUSIONS

The interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives' knowledge to assess patients' cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients' cognition, which involved "shielding" patients from the noisy and disruptive intensive care unit environment.

IMPLICATIONS FOR CLINICAL PRACTICE

Effective communication methods, coupled with family involvement may aid nurses in identifying patients' cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients' cognition. Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.

The use of checklists in the intensive care unit: a scoping review

BACKGROUND

Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within the intensive care unit, their implementation and validation, and the recommended clinical context for their use. Accordingly, a scoping review was necessary to map the current literature and to guide future research on intensive care checklists. This review focuses on what checklists are currently used, how they are used, process of checklist development and implementation, and outcomes associated with checklist use.

METHODS

A systematic search of MEDLINE (Ovid), Embase, Scopus, and Google Scholar databases was conducted, followed by a grey literature search. The abstracts of the identified studies were screened. Full texts of relevant articles were reviewed, and the references of included studies were subsequently screened for additional relevant articles. Details of the study characteristics, study design, checklist intervention, and outcomes were extracted.

RESULTS

Our search yielded 2046 studies, of which 167 were selected for further analysis. Checklists identified in these studies were categorised into the following types: rounding checklists; delirium screening checklists; transfer and handover checklists; central line-associated bloodstream infection (CLABSI) prevention checklists; airway management checklists; and other. Of 72 significant clinical outcomes reported, 65 were positive, five were negative, and two were mixed. Of 122 significant process of care outcomes reported, 114 were positive and eight were negative.

CONCLUSIONS

Checklists are commonly used in the intensive care unit and appear in many clinical guidelines. Delirium screening checklists and rounding checklists are well implemented and validated in the literature. Clinical and process of care outcomes associated with checklist use are predominantly positive. Future research on checklists in the intensive care unit should focus on establishing clinical guidelines for checklist types and processes for ongoing modification and improvements using post-intervention data.

Accuracy of Delirium Screening Tools in Older People with Cancer-A Systematic Review

BACKGROUND

The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages.

OBJECTIVE

To determine which delirium screening instrument is the most accurate in older people with cancer.

METHODS

A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded.

RESULTS

From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group.

CONCLUSIONS

Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.

Measures for the Core Outcome Set for Research Evaluating Interventions to Prevent and/or Treat Delirium in Critically Ill Adults: An International Consensus Study (Del-COrS)

To gain consensus on measurement methods for outcomes (delirium occurrence, severity, time to resolution, mortality, health-related quality of life [HrQoL], emotional distress including anxiety, depression, acute stress, and post-traumatic stress disorder, and cognition) of our Core Outcome Set (COS) for trials of interventions to prevent and/or treat delirium in critically ill adults.

New onset delirium prediction using machine learning and long short-term memory (LSTM) in electronic health record

OBJECTIVE

To develop and test an accurate deep learning model for predicting new onset delirium in hospitalized adult patients.

METHODS

Using electronic health record (EHR) data extracted from a large academic medical center, we developed a model combining long short-term memory (LSTM) and machine learning to predict new onset delirium and compared its performance with machine-learning-only models (logistic regression, random forest, support vector machine, neural network, and LightGBM). The labels of models were confusion assessment method (CAM) assessments. We evaluated models on a hold-out dataset. We calculated Shapley additive explanations (SHAP) measures to gauge the feature impact on the model.

RESULTS

A total of 331 489 CAM assessments with 896 features from 34 035 patients were included. The LightGBM model achieved the best performance (AUC 0.927 [0.924, 0.929] and F1 0.626 [0.618, 0.634]) among the machine learning models. When combined with the LSTM model, the final model's performance improved significantly (P = .001) with AUC 0.952 [0.950, 0.955] and F1 0.759 [0.755, 0.765]. The precision value of the combined model improved from 0.497 to 0.751 with a fixed recall of 0.8. Using the mean absolute SHAP values, we identified the top 20 features, including age, heart rate, Richmond Agitation-Sedation Scale score, Morse fall risk score, pulse, respiratory rate, and level of care.

CONCLUSION

Leveraging LSTM to capture temporal trends and combining it with the LightGBM model can significantly improve the prediction of new onset delirium, providing an algorithmic basis for the subsequent development of clinical decision support tools for proactive delirium interventions.

Incidence, Associated Factors, and Outcome of Delirium among Patients Admitted to ICUs in Oman

Background

The incidence of delirium is high up to 46.3% among patients admitted to ICU. Delirium is linked to negative patient outcomes like increased duration of mechanical ventilation use, prolonged ICU stay, increased mortality rate, and healthcare costs. Despite the importance of delirium and its consequences that are significant, there is a scarcity of studies which explored delirium in Oman.

Objectives

This study was conducted to assess the incidence of delirium, the association between the selected predisposing factors and precipitating factors with delirium, determine the predicators of delirium, and evaluate its impacts on ICU mortality and ICU length of stay among ICU patients in Oman.

Methods

A multicenter prospective observational design was used. A total of 153 patients were assessed two-times a day by bedside ICU nurses through the Intensive Care Delirium Screening Checklist (ICDSC).

Results

The results revealed that the delirium incidence was 26.1%. Regression analysis showed that sepsis, metabolic acidosis, nasogastric tube use, and APACHE II score were independent predictors for delirium among ICU patients in Oman and delirium had significant impacts on ICU length of stay and mortality rate.

Conclusion

Delirium is common among ICU patients and it is associated with negative consequences. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Delirium diagnosis without a gold standard: Evaluating diagnostic accuracy of combined delirium assessment tools

Background

Fluctuating course of delirium and complexities of ICU care mean delirium symptoms are hard to identify or commonly confused with other disorders. Delirium is difficult to diagnose, and clinicians and researchers may combine assessments from multiple tools. We evaluated diagnostic accuracy of different combinations of delirium assessments performed in each enrolled patient.

Methods

Data were obtained from a previously conducted cross-sectional study. Eligible adult patients who remained admitted to ICU for >24 hours with at least one family member present were consecutively enrolled as patient-family dyads. Clinical delirium assessments (Intensive Care Delirium Screening Checklist [ICSDC] and Confusion Assessment Method-ICU [CAM-ICU]) were completed twice daily by bedside nurse or trained research assistant, respectively. Family delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily by family members. We pooled all delirium assessment tools in a single two-class latent model and pairwise (i.e., combined, clinical or family assessments) Bayesian analyses.

Results

Seventy-three patient-family dyads were included. Among clinical delirium assessments, the ICDSC had lower sensitivity (0.72; 95% Bayesian Credible [BC] interval 0.54–0.92) and higher specificity (0.90; 95%BC, 0.82–0.97) using Bayesian analyses compared to pooled latent class analysis and CAM-ICU had higher sensitivity (0.90; 95%BC, 0.70–1.00) and higher specificity (0.94; 95%BC, 0.80–1.00). Among family delirium assessments, the Family Confusion Assessment Method had higher sensitivity (0.83; 95%BC, 0.71–0.92) and higher specificity (0.93; 95%BC, 0.84–0.98) using Bayesian analyses compared to pooled latent class analysis and the Sour Seven had higher specificity (0.85; 95%BC, 0.67–0.99) but lower sensitivity (0.64; 95%BC 0.47–0.82).

Conclusions

Results from delirium assessment tools are often combined owing to imperfect reference standards for delirium measurement. Pairwise Bayesian analyses that explicitly accounted for each tool’s (performed within same patient) prior sensitivity and specificity indicate that two combined clinical or two combined family delirium assessment tools have fair diagnostic accuracy.

Advantages of score-based delirium detection compared to a clinical delirium assessment-a retrospective, monocentric cohort study

Purpose

Delirium is an underdiagnosed complication on intensive care units (ICU). We hypothesized that a score-based delirium detection using the Nudesc score identifies more patients compared to a traditional diagnosis of delirium by ICU physicians.

Methods

In this retrospective study, all patients treated on a general medical ICU with 30 beds in a university hospital in 2019 were analyzed. Primary outcome was a documented physician diagnosis of delirium, or a delirium score ≥2 using the Nudesc.

Results

In 205/943 included patients (21.7%), delirium was diagnosed by ICU physicians compared to 438/943 (46.4%; ratio 2.1) by Nudesc≥2. Both assessments were independent predictors of ICU stay (p<0.01). The physician diagnosis however was no independent predictor of mortality (OR 0.98 (0.57–1.72); p = 0.989), in contrast to the score-based diagnosis (OR 2.31 (1.30–4.10); p = 0.004). Subgroup analysis showed that physicians underdiagnosed delirium in case of hypoactive delirium and delirium in patients with female gender and in patients with an age below 60 years.

Conclusion

Delirium in patients with hypoactive delirium, female patients and those below 60 years was underdiagnosed by physicians. The score-based delirium diagnosis detected delirium more frequently and correlated with ICU mortality and stay.

Family Caregivers' Experience of Patients With Delirium in Critical Care Units: A State-of-the-Science Integrative Review

BACKGROUND

Delirium as a sudden cognitive and behavioral change can be traumatic for family caregivers. An understanding of family caregivers' experiences with delirium in their loved one in an intensive care unit (ICU) will help clinicians provide family-centered care.

OBJECTIVE

To explore the impact of delirium on, and the needs of, family caregivers of ICU patients with delirium.

METHODS

A comprehensive search was done of literature in the PubMed, CINAHL, and Scopus databases published from 2000 to 2020. Primary studies written in English and done in critical care settings were included. Studies that did not focus on the family experience of delirium were excluded. Additional studies were identified by reviewing the reference lists of selected articles. Evidence was synthesized, and common themes were identified.

RESULTS

Among 210 studies, 7 were included after irrelevant and duplicate studies had been removed. Findings were categorized as (1) psychological impacts of a patient's delirium on family caregivers and (2) family caregivers' needs. Common psychological impacts included anxiety, depression, concern, fear, anger, uncertainty, shock, insecurity, and disappointment. Family caregivers reported needing informational and emotional support from, and effective communication with, health care professionals.

CONCLUSIONS

Family caregivers' health is crucial to ensuring the effectiveness of family engagement in delirium management. Future studies should consider family caregiver characteristics that could be used to predict psychological symptoms when caregivers are exposed to a patient's delirium and explore whether specific types of delirium cause more psychological impacts and needs among family caregivers than other types of delirium cause.

Patients' Self-Reported Recovery After an Environmental Intervention Aimed to Support Patient's Circadian Rhythm in Intensive Care

BACKGROUND

Patients in intensive care units (ICUs) are among the most vulnerable, and they require support to start their recovery. The design of the patient area in the ICU can play a prominent role in both the quality of care and patients' recovery. The lighting environment has the opportunity to restore and strengthen the natural human circadian rhythm and health.

AIM

To evaluate patients' self-reported recovery after being cared for in an ICU room rebuilt according to evidence-based design principles that promote recovery.

METHOD

An intervention was set up in a two-bed patient room including a cycled lighting system. Self-reported recovery was reported at 6 and 12 months after discharge. Data were analyzed using a 2(mechanically ventilated, nonmechanically ventilated) × 2(intervention room, ordinary room) analysis of covariance (ANCOVA) and 2(male, women) × 2(intervention room, ordinary room) ANCOVA.

RESULTS

Data from the different rooms showed no significant main effects for recovery after 6 months, p = .21; however, after 12 months, it become significant, p. < .05. This indicated that patient recovery was positively influenced for patients cared for in the intervention room (M = 8.88, SD = 4.07) compared to the ordinary room (M = 10.90, SD = 4.26). There were no interaction effects for gender or if the patients had been mechanically ventilated either at 6 or 12 months' postdischarge.

CONCLUSIONS

A cycled lighting system may improve patient self-reported recovery after ICU care; however, more research on the topic is needed.

Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III

OBJECTIVES

Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators.

DESIGN

A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process.

PARTICIPANTS

Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process.

MEASUREMENTS AND MAIN RESULTS

The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization.

CONCLUSIONS

These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.

Delirium in Intensive Care

Purpose of Review

Delirium in the intensive care unit (ICU) has become increasingly acknowledged as a significant problem for critically ill patients affecting both the actual course of illness as well as outcomes. In this review, we focus on the current evidence and the gaps in knowledge.

Recent Findings

This review highlights several areas in which the evidence is weak and further research is needed in both pharmacological and non-pharmacological treatment. A better understanding of subtypes and their different response to therapy is needed and further studies in aetiology are warranted. Larger studies are needed to explore risk factors for developing delirium and for examining long-term consequences. Finally, a stronger focus on experienced delirium and considering the perspectives of both patients and their families is encouraged.

Summary

With the growing number of studies and a better framework for research leading to stronger evidence, the outcomes for patients suffering from delirium will most definitely improve in the years to come.

The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation

Post-operative delirium after lung transplantation is common. Its associations with health-related quality of life (HRQL), depression, and mortality remains unknown. In 236 lung transplant recipients, HRQL and depressive symptoms were assessed as part of a structured survey battery before and after transplantation. Surveys included the Geriatric Depressive Scale (GDS) and Short Form 12 (SF12). Delirium was assessed throughout the post-operative intensive care unit (ICU) stay with Confusion Assessment Method for ICU. Delirium and mortality data were extracted from electronic medical records. We examined associations between delirium and changes in depressive symptoms and HRQL using linear mixed effects models and association between delirium and mortality with Cox-proportional hazard models. Post-operative delirium occurred in 34 participants (14%). Delirium was associated with attenuated improvements in SF12-PCS (difference ₋4.0; 95%CI: -7.4, -0.7) but not SF12-MCS (difference 2.2; 95%CI: -0.7,5.7) or GDS (difference ₋0.4; 95%CI: -1.5,0.7). Thirty-two participants died during the study period. Delirium was associated with increased adjusted hazard risk of mortality (HR 17.9, 95%CI: 4.4,72.5). Delirium after lung transplantation identifies a group at increased risk for poorer HRQL and death within the first post-operative year. Further studies should investigate potential causal links between delirium, and poorer HRQL and mortality risk after lung transplantation.

Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study

Background

Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients.

Methods

A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15).

Results

Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69.

Conclusions

The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03561-1.

A qualitative analysis of clinicians' communication strategies with family members of patients experiencing hospital-acquired delirium

OBJECTIVE

Identify doctors' and nurses' perceptions of effective communication strategies when talking with family members of patients with hospital-acquired delirium.

METHODS

We conducted focus groups and interviews of hospitalists, anesthesiologists, and nurses using a semi-structured approach. We rigorously analyzed transcribed data using a constant comparative method.

RESULTS

We conducted six focus groups and 14 interviews. Participants included 20 hospitalists, 9 anesthesiologists, and 21 nurses. Clinicians identified three communication approaches as effective when communicating with family of delirium patients: Provide reassurance, educate families, and engage in family-centered communication.

CONCLUSION

In communicating with families of patients with post-operative delirium, clinicians work to reassure and educate families using family-centered communication. Different approaches are used by different types of clinicians to accomplish this goal. Clinicians recognized the importance of involving family members in the patients' recovery.

PRACTICE IMPLICATIONS

Though clinically common and familiar to clinicians, delirium may be a new diagnosis for family members and thus compassion and education are vital. Due to the different clinical roles, education may be different for each discipline.

Evaluation of an Educational Intervention Utilizing Nurse "Champions" and Nurses' Documentation of Intensive Care Unit Delirium

BACKGROUND

Delirium is a common, underdetected problem that has short- and long-term negative sequelae for critically ill patients. Prompt and accurate delirium identification by nurses can ensure early intervention and treatment to help minimize adverse outcomes.

OBJECTIVES

To evaluate the relationship between an educational program and the accuracy of registered nurses' (RNs') documentation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a delirium screening tool.

METHODS

In a medical ICU at a tertiary academic medical center from September 2015 to March 2016, RNs were reinstructed on use of the CAM-ICU. Registered nurse assessment data were collected retrospectively for 12 months before and after intervention and were compared against the CAM-ICU algorithm using χ analysis.

RESULTS

A total of 10 736 RN assessments in 1020 patients preintervention and 11 068 in 951 patients postintervention were evaluated. Overall RN accuracy improved from 78% to 80% (P = .054). The algorithm determined delirium to be present in 32% versus 30% of all patients preintervention and postintervention, respectively; there was no difference in rate of nurse detection of delirium preintervention and postintervention (54% vs 55%, not statistically significant). The percentage of "inappropriate unable to assess" ratings by nurses decreased from 42% to 37% postintervention (P < .05).

CONCLUSIONS

After a comprehensive training initiative, there was no significant improvement in CAM-ICU documentation and no improvements in patient delirium identification. Future quality improvement efforts should target reducing the number of assessments that RNs judge to be "unable to assess." Clinical practice must evolve to routinely incorporate RN delirium assessments into the patient's plan of care.

Enfermería en la monitorización del delirium en cuidado intensivo adulto: una revisión de alcance

Introducción. El delirium es una alteración cognitiva secundaria a una situación clínica aguda que puede estar presente en el paciente crítico, y la enfermería juega un rol protagónico en la prevención, monitoreo y tratamiento no farmacológico del delirium en el paciente en unidad de cuidado intensivo. Objetivo. Identificar las investigaciones actuales que describen las estrategias que utilizan las enfermeras para la monitorización del delirium en la unidad de cuidado intensivo adulto. Método. Revisión de alcance, utilizando la pregunta orientadora ¿qué estrategias utiliza enfermería en la monitorización del delirium en la unidad de cuidado intensivo?, estudios obtenidos en las bases de datos PubMed, Biblioteca Virtual en Salud, Science Direct y Cochrane. Se realizó una revisión crítica con el instrumento CASPe, los datos se extrajeron, y se llevaron a cabo registros en tablas de gráficos elaboradas para condensar la información. Resultados. Trece estudios se consideraron relevantes y fueron analizados. Las estrategias de monitorización del delirium empleadas por enfermería son, principalmente, el juicio clínico, la observación de la agitación y, en menor medida, el empleo de instrumentos validados para la detección. Conclusión. La enfermería requiere comprender mejor el delirium, y para esto la educación es vital para mejorar su conocimiento, y aumentar la autoconfianza y competencia en la evaluación a través del uso correcto de instrumentos.

Delirium in Emergency Departments: Is it Recognized?

BACKGROUND

Delirium is a complex neurocognitive manifestation of an underlying medical or surgical abnormality such as substance abuse, infection, sepsis, or organ failure. A recognized risk factor for delirium is advanced age (age >65 years). The projected demographic changes over the next 2 decades suggest that the number of aging adults will grow dramatically, and emergency nurses will see an increasing number of older patients manifesting the wide range of neuropsychiatric symptoms associated with delirium.

METHOD

An examination of 5 commonly used delirium assessment tools was undertaken specific to clinical features, use, scoring, findings, advantages, and disadvantages.

FINDINGS

Numerous factors contribute to the lack of effective delirium recognition. However, emergency nurses, with educational support, can successfully use the delirium assessment tools to recognize delirium.

CONCLUSION

Emergency nurses face challenges in recognizing delirium. One key challenge for many of these nurses is the appropriate use of assessment tools suitable for the ED setting.

Delirium screening for patients in the intensive care unit: A prospective validation study of the iCAM-ICU by nurse researchers and bedside nurses in routine practice

BACKGROUND

Daily delirium assessment using the Confusion Assessment Method for the Intensive Care Unit was recommended for patients in the intensive care unit, yet implementation may be difficult because of lack of simple and standardized data collection schemes which may result in low sensitivities when used by bedside nurses.

OBJECTIVE

This study was to validate the diagnostic accuracy of the intelligent Confusion Assessment Method for the Intensive Care Unit (iCAM-ICU) used by both nurse investigators and bedside nurses in Chinese patients in the intensive care unit.

DESIGN

Prospective cohort study.

SETTING

A university affiliated tertiary hospital in China.

PARTICIPANTS

A total of 373 hospitalized patients (181 in phase I and 192 in phase II) in the intensive care units met the inclusion criteria and participated in the study. There were two nursing researchers (phase I) and 24 bedside nurses (phase II) used the iCAM-ICU to assess delirium among patients.

METHODS

Two prospective cohort studies were conducted to validate the diagnostic accuracy of iCAM-ICU on delirium screening when it was used by nurse investigators and bedside nurses in the intensive care unit. Using the Diagnostic and Statistical Manual of Mental Disorders as the gold standard, the sensitivity, specificity, predictive values along with the likelihood ratios were determined to estimate the performance of the iCAM-ICU in patients in the intensive care setting. The Kappa consistency test was examined to determine the inter-rater consistency. Subgroup analysis in terms of different age, level of education, severity of illness and cognitive status were also conducted to evaluate potential variations of the iCAM-ICU performance in different patient groups.

RESULTS

A total of 373 patients were included in the validation studies. In comparing with the gold standard, the sensitivities of the iCAM-ICU demonstrated by the two nurse investigators were 95.2 % and 93.7%, while the specificities of the iCAM-ICU were 93.3% and 93.2%. The Kappa consistency between two nurse investigators was 0.96. The sensitivity and specificity of the iCAM-ICU demonstrated by bedside nurses in intensive care patients were 86.7% and 97.7%, respectively. Subgroup analysis also revealed that the sensitivities and specificities in those different subgroups were acceptable, with all statistics being above 80%.

CONCLUSIONS

The iCAM-ICU, an information technology enabled delirium screening tool, showed highly acceptable accuracy in detecting delirium in the intensive care units. It can assist bedside nurses to detect delirium reliably and identify potential patients with delirium accurately.

REGISTRATION NUMBER

ChiCTR-OCH-13003050.

Early Identification of Delirium in Intensive Care Unit Patients: Improving the Quality of Care

BACKGROUND

Delirium has long-term consequences for intensive care unit patients. The project site, an urban academic hospital, did not previously use a validated delirium screening tool, and patients commonly received sedative medications to treat agitation.

OBJECTIVE

To minimize the risk of delirium by implementing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) as the standard-of-care delirium assessment tool in the intensive care unit and by decreasing use of high-risk medications (ie, opioids and benzodiazepines).

METHODS

An observational pretest-posttest design was used to analyze deidentified patient data from electronic health records. The evidence-based practice intervention focused on educating nurses on high-risk medications and CAM-ICU implementation. Control charts, χ2 tests, and mixed regression models were used to evaluate the effectiveness of the intervention in reducing delirium risk by decreasing use of high-risk medications.

RESULTS

High-risk medication use significantly decreased after intervention among patients at low risk for delirium (before intervention, 7.37%; after intervention, 3.92%; P < .001) and at high risk for delirium (before intervention, 4.73%; after intervention, 2.99%; P < .001). Hospital stays were significantly shorter in patients at low risk than at high risk for delirium (P < .001) but increased by a mean of 0.13 days with each additional high-risk medication used (P < .001).

CONCLUSIONS

The variation of high-risk medication use was significantly controlled with the implementation of CAM-ICU and education. Nurses felt that hands-on training with the CAM-ICU increased their comfort in identifying patients at risk for delirium. Future work will focus on assessment accuracy.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement

BACKGROUND

Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions.

METHODS

GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci.

RESULTS

In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research.

CONCLUSIONS

Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

Delirium in the acute hospital setting: the role of psychiatry

In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU)

OBJECTIVE

To adapt and validate a chart-based delirium detection tool for use in critically ill adults.

DESIGN

Validation study.

SETTING

Medical-surgical intensive care unit (ICU) in an academic hospital.

MEASUREMENTS

A chart-based delirium detection tool (CHART-DEL) was adapted for use in critically ill adults (CHART-DEL-ICU) and compared with prospective delirium assessments (i.e., clinical assessments (reference standard) by a research nurse trained by a neuropsychiatrist and routine delirium screening tools Confusion Assessment Method (CAM-ICU)) and (Intensive Care Delirium Screening Checklist (ICDSC)). The original CHART-DEL tool was adapted to include physician-reported ICDSC score (for probable delirium) and Richmond-Agitation Sedation Scale score (for altered level of consciousness and agitation). Two trained chart abstractors blinded to all delirium assessments manually abstracted delirium-related information from medical charts and electronic medical records and rated if delirium was present (four levels: uncertain, possible, probable, definite) or absent (no evidence).

RESULTS

Charts were manually abstracted for delirium-related information for 213 patients who were included in a prospective cohort study that included prospective delirium assessments. The CHART-DEL-ICU tool had excellent interrater reliability (kappa = 0.90). Compared to the reference standard, the sensitivity was 66.0% (95% CI = 59.3-72.3%) and specificity was 82.1% (95% CI = 78.0-85.7%), with a cut-point that included definite, probable, possible, and uncertain delirium. The AUC of the CHART-DEL-ICU alone is 74.1% (95% CI = 70.4-77.8%) compared with the addition of the CAM-ICU and ICDSC (CAM-ICU/CHART-DEL-ICU: 80.9% (95% CI = 77.8-83.9%), P = .01; ICDSC/CHART-DEL-ICU: 79.2% (95% CI = 75.9-82.6%), P = .03).

CONCLUSION

A chart-based delirium detection tool has improved diagnostic accuracy when combined with routine delirium screening tools (CAM-ICU and ICDSC), compared to a chart-based method on its own. This presents a potential for retrospective detection of delirium from medical charts for research or to augment routine delirium screening methods to find missed cases of delirium.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings

BACKGROUND/OBJECTIVES

Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research.

DESIGN

We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments.

MEASUREMENTS

Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework.

RESULTS

Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale.

CONCLUSION

Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.

Impact of Therapeutic Music Listening on Intensive Care Unit Patients: A Pilot Study

This pilot study investigated the association between patient-specific, therapeutic music listening as a nursing intervention for mechanically ventilated patients, and the proportion of time those patients were considered to have intensive care unit delirium. The pilot study used the person-centered nursing framework as its theoretic foundation. Findings from an intimate prospective cohort design encourage an expanded look at potential benefits of therapeutic music listening in large, multisite, randomized clinical trials. Research and practice implications are discussed.

Delirium risk prediction models for intensive care unit patients: A systematic review

OBJECTIVE

To systematically review the delirium risk prediction models for intensive care unit (ICU) patients.

METHODS

A systematic review was conducted. The Cochrane Library, PubMed, Ovid and Web of Science were searched to collect studies on delirium risk prediction models for ICU patients from database establishment to 31 March 2019. Two reviewers independently screened the literature according to the pre-determined inclusion and exclusion criteria, extracted the data and evaluated the risk of bias of the included studies using the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) checklist. A descriptive analysis was used to describe and summarise the data.

RESULTS

A total of six models were included. All studies reported the area under the receiver operating characteristic curve (AUROC) of the prediction models in the derivation and (or) validation datasets as over 0.7 (from 0.75 to 0.9). Five models reported calibration metrics. Decreased cognitive reserve and the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score were the most commonly reported predisposing and precipitating factors, respectively, of ICU delirium among all models. The small sample size, lack of external validation and the absence of or unreported blinding method increased the risk of bias.

CONCLUSION

According to the discrimination and calibration statistics reported in the original studies, six prediction models may have moderate power in predicting ICU delirium. However, this finding should be interpreted with caution due to the risk of bias in the included studies. More clinical studies should be carried out to validate whether these tools have satisfactory predictive performance in delirium risk prediction for ICU patients.

Role of Family Members in Pain Management in Adult Critical Care

This review describes family member involvement in intensive care unit pain assessment and management and generates implications for clinical practice, education, and future research. A literature review was performed in MEDLINE, PubMed, EMBASE, Cochrane, and CINAHL databases from their inception until April 30, 2019. Only 11 studies addressing the topic were identified, and the current quality of evidence is low. Family members can be involved in pain assessment by describing patients' pain behaviors and in pain management by selecting and delivering nonpharmacological interventions tailored to patients' needs, if the family members feel comfortable with this role. More-rigorous research is required to describe the role of family members in patients' pain assessment and management. Advancing knowledge in this field could improve patients' and family members' experiences with pain assessment and management in the intensive care unit.

A Tunisian version of the confusion assessment method for the intensive care unit (CAM-ICU): translation and validation

BACKGROUND

Delirium is common in critically ill patients and it is associated with poor outcomes. In Tunisia, however, it is still underdiagnosed as there is no validated screening tool. The aim of this study was to translate and to validate a Tunisian version of the CAM-ICU.

METHODS

For the validation and inter-rater reliability assessment of the Tunisian CAM-ICU, two trained intensivists independently evaluated delirium in the patients admitted to the ICU between October 2017 and June 2018. All the patients consecutively admitted to the ICU for more than 24 h and having a Richmond Agitation-Sedation Scale greater than or equal to "-3" were assessed for delirium excluding those with stroke, dementia, psychosis or persistent coma. The results were compared with the reference evaluation carried out by a psychiatrist using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. The inter-rater reliability was calculated using the kappa (κ) statistic. The CAM-ICU concurrent validity was assessed using Cronbach's α coefficient, sensitivity, specificity as well as positive and negative predictive values (PPV and NPV, respectively) for the two Tunisian CAM-ICU raters.

RESULTS

The study involved 137 patients [median (IQR) age: 60 [49-68] years, male sex (n = 102), invasive mechanical ventilation (n = 49)]. Using the DSM-V criteria evaluations, 46 patients were diagnosed with delirium. When applying the Tunisian version of the CAM-ICU, 38(27.7%) patients were diagnosed with delirium for the first rater and 45(32.6%) patients for the second one. The Tunisian CAM-ICU showed a very-high inter-rater reliability for both intensivists (κ = 0.844, p < 0.001). Using the DSM-V rater as the reference standard, the sensitivity of the two intensivists' evaluations was 80.4 vs. 95.7%. Specificity was 98.9% for both. The Cronbach's α of the first and second raters' evaluations using the Tunisian version of the CAM-ICU were 0.886 and 0.887, respectively.

CONCLUSIONS

The Tunisian version of the CAM-ICU showed almost perfect validity and reliability in detecting delirium in critically ill patients. It could therefore be used in Tunisian ICUs or where Tunisian translators are available following appropriate training.

TRIAL REGISTRATION

Not applicable.

Psychometric properties of the intensive care delirium screening checklist when used by bedside nurses in clinical practice: a prospective descriptive study

Background

The Intensive Care Delirium Screening Checklist (ICDSC) demonstrates good psychometric characteristics in research settings. However, evidence about these characteristics in pragmatic ICU settings is inconsistent. This study evaluated psychometric properties and user-friendliness of the ICDSC when administered by ICU nurses in daily practice.

Methods

This prospective study included 77 patients from a surgical intensive care unit. To examine the psychometric characteristics, the scores on the ICDSC (performed by bedside nurses) were compared with the scores on the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (performed by researchers as gold standard). The user-friendliness was evaluated by 34 ICU nurses with a 20-item questionnaire.

Results

The ICDSC had an area under the curve of 0.843. It showed a good diagnostic accuracy with a sensitivity of 81.0%, a specificity of 87.7%, and a 53.1% positive and 96.4% negative predictive value. The overall Cronbach’s alpha coefficient for all ICDSC scores was high (0.839). Overall, ICU nurses experienced the ICDSC as easy-to-use. The scale was usable in most surgical ICU patients. Yet, some nurses (11.8%) had problems to score the items ‘inappropriate speech’ and ‘symptom fluctuation’ in intubated patients.

Conclusions

The ICDSC is a valid and user-friendly tool for delirium screening in daily ICU nursing practice. Yet, some problems were reported in intubated patients. Therefore, validation studies with specific focus on intubated patients are needed.

Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study

BACKGROUND

Guidelines advocate intensive care unit (ICU) patients be regularly assessed for delirium using either the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC). Single-centre studies, primarily with the CAM-ICU, suggest level of sedation may influence delirium screening results.

OBJECTIVE

The objective of this study was to determine the association between level of sedation and delirium occurrence in critically ill patients assessed with either the CAM-ICU or the ICDSC.

METHODS

This was a secondary analysis of a multinational, prospective cohort study performed in nine ICUs from seven countries. Consecutive ICU patients with a Richmond Agitation-Sedation Scale (RASS) of -3 to 0 at the time of delirium assessment where a RASS ≤ 0 was secondary to a sedating medication. Patients were assessed with either the CAM-ICU or the ICDSC. Logistic regression analysis was used to account for factors with the potential to influence level of sedation or delirium occurrence.

RESULTS

Among 1660 patients, 1203 patients underwent 5741 CAM-ICU assessments [9.6% were delirium positive; at RASS = 0 (3.3% were delirium positive), RASS = -1 (19.3%), RASS = -2 (35.1%); RASS = -3 (39.0%)]. The other 457 patients underwent 3210 ICDSC assessments [11.6% delirium positive; at RASS = 0 (4.9% were delirium positive), RASS = -1 (15.8%), RASS = -2 (26.6%); RASS = -3 (20.6%)]. A RASS of -3 was associated with more positive delirium evaluations (odds ratio: 2.31; 95% confidence interval: 1.34-3.98) in the CAM-ICU-assessed patients (vs. the ICDSC-assessed patients). At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations (odds ratio: 0.58; 95% confidence interval: 0.43-0.78). At a RASS of -1 or -2, no association was found between the delirium assessment method used (i.e., CAM-ICU or ICDSC) and a positive delirium evaluation.

CONCLUSIONS

The influence of level of sedation on a delirium assessment result depends on whether the CAM-ICU or ICDSC is used. Bedside ICU nurses should consider these results when evaluating their sedated patients for delirium. Future research is necessary to compare the CAM-ICU and the ICDSC simultaneously in sedated and nonsedated ICU patients.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02518646.

Delirium in hospitalized older adults

Delirium is a common and underdiagnosed problem in hospitalized older adults. It is associated with an increased risk of poor cognitive and functional outcomes, institutionalization, and death. Timely diagnosis of delirium and non-pharmacological prevention and management strategies can improve patient outcomes. The Confusion Assessment Method (CAM) is the most widely used clinical assessment tool for the diagnosis of delirium. Multiple variations of the CAM have been developed for ease of administration and for the unique needs of specific patient populations, including the 3-min diagnostic CAM (3D CAM), CAM-Intensive Care Unit (CAM-ICU), Delirium Triage Screen (DTS)/Brief CAM (b-CAM), 4AT tool, and ultrabrief delirium assessment. Strong evidence supports the effectiveness of nonpharmacologic strategies as the primary intervention for the prevention of delirium. Multicomponent delirium prevention strategies can reduce the incidence of delirium by 40%. Investigation of underlying medical precipitants and optimization of non-pharmacological interventions are first line in the management of delirium. Despite a lack of evidence supporting use of antipsychotics, low dose antipsychotics remain second line for off-label treatment of distressing psychoses and/or agitated behaviors that are refractory to non-pharmacological behavioral interventions and pose an imminent risk of harm to self or others. Any antipsychotic prescription for delirium should be accompanied by an appropriate taper plan. Follow up with primary care providers on discharge from hospital for ongoing screening of cognitive impairment is important.

Vital signs fluctuations and their relationship with pain in the brain-injured adult critically ill - A repeated-measures descriptive-correlational study

OBJECTIVES

To evaluate the use of vital signs for pain detection in brain-injured patients in the intensive care unit.

DESIGN

A repeated-measures descriptive-correlational study.

SETTING

Two neurological intensive care units in Montréal, Canada. A total of 101 brain-injured patients were included.

MAIN OUTCOME MEASURES

This study examined the fluctuations in systolic and diastolic blood pressure, heart and respiratory rates, and oxygen saturation in brain-injured critically ill patients before, during, and 15 minutes after turning and soft touch using a data collection computer. When possible, patients' pain self-reports were obtained using a 0-10 Faces Pain Thermometer.

RESULTS

The heart and respiratory rates were higher during turning than soft touch and higher during the procedure compared to prior (p < 0.05), but their fluctuation was modest. The systolic blood pressure increased during both turning and soft touch by 2 mmHg, but was 26.6 mmHg higher for those who reported pain versus no pain (Mann-Whitney = 25.00, p = 0.008, n = 28). A moderate correlation was observed between the systolic blood pressure (Spearman's rho = 0.617, p = 0.004, n = 24) and self-reported pain intensity during turning. No significant effects were observed for diastolic blood pressure and oxygen saturation.

CONCLUSION

Only increases in systolic blood pressure were positively associated with pain in this sample and replication studies with larger samples is needed.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Clinical Education to Decrease Perceived Barriers to Delirium Screening in Adult Intensive Care Units

Despite current advances in critical care medicine, delirium remains a frequent complication of an intensive care unit stay. The consequences can be severe and far reaching, including an increase in mortality, length of stay, and long-term cognitive sequelae. Frequently, delirium can be missed by clinicians who fail to complete a standardized delirium screening tool and, therefore, many cases go unrecognized and untreated. A multidimensional education program is one of the most effective methods to increase awareness of the condition and increase compliance in utilizing standardized delirium screening tools at the bedside.

Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients

BACKGROUND

The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings.

METHODS

A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

RESULTS

A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients.

CONCLUSION

The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.