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Mart MF, Boehm LM, Kiehl AL, Gong MN, Malhotra A, Owens RL, Khan BA, Pisani MA, Schmidt GA, Hite RD, Exline MC, Carson SS, Hough CL, Rock P, Douglas IS, Feinstein DJ, Hyzy RC, Schweickert WD, Bowton DL, Masica A, Orun OM, Raman R, Pun BT, Strength C, Rolfsen ML, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Ely EW, Jackson JC, Girard TD. Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial. Lancet Respir Med 2024:S2213-2600(24)00077-8. [PMID: 38701817 DOI: 10.1016/s2213-2600(24)00077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes. METHODS This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete. FINDINGS Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo. INTERPRETATION In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults. FUNDING National Institutes of Health and the US Department of Veterans Affairs.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Leanne M Boehm
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA; Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Amy L Kiehl
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Michelle N Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, New York, NY, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Margaret A Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory A Schmidt
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa, Iowa City, IA, USA
| | - R Duncan Hite
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew C Exline
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, OR, USA
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David L Bowton
- Department of Anesthesiology, Section on Critical Care, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Onur M Orun
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Rameela Raman
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Cayce Strength
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Mark L Rolfsen
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher G Hughes
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Mayur B Patel
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Pun BT, Jun J, Tan A, Byrum D, Mion L, Vasilevskis EE, Ely EW, Balas M. Interprofessional Team Collaboration and Work Environment Health in 68 US Intensive Care Units. Am J Crit Care 2022; 31:443-451. [PMID: 36316176 DOI: 10.4037/ajcc2022546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Safe, reliable, high-quality critical care delivery depends upon interprofessional teamwork. OBJECTIVE To describe perceptions of intensive care unit (ICU) teamwork and healthy work environments and evaluate whether perceptions vary by profession. METHODS In August 2015, Assessment of Interprofessional Team Collaboration Scale (AITCS) and the American Association of Critical-Care Nurses Healthy Work Environment Assessment Tool (HWEAT) surveys were distributed to all interprofessional members at the 68 ICUs participating in the ICU Liberation Collaborative. Overall scores range from 1 (needs improvement) to 5 (excellent). RESULTS Most of the 3586 surveys completed were from registered nurses (51.2%), followed by respiratory therapists (17.8%), attending physicians (10.5%), rehabilitation therapists (8.3%), pharmacists (4.9%), nursing assistants (3.1%), and physician trainees (4.1%). Overall, respondents rated teamwork and work environment health favorably (mean [SD] scores: AITCS, 3.92 [0.64]; HWEAT, 3.45 [0.79]). The highest-rated AITCS domain was "partnership/shared decision-making" (mean [SD], 4.00 [0.63); lowest, "coordination" (3.67 [0.80]). The highest-scoring HWEAT standard was "effective decision-making" (mean [SD], 3.60 [0.79]); lowest, "meaningful recognition" (3.30 [0.92]). Compared with attending physicians (mean [SD] scores: AITCS, 3.99 [0.54]; HWEAT, 3.48 [0.70]), AITCS scores were lower for registered nurses (3.91 [0.62]), respiratory therapists (3.86 [0.76]), rehabilitation therapists (3.84 [0.65]), and pharmacists (3.83 [0.55]), and HWEAT scores were lower for respiratory therapists (3.38 [0.86]) (all P ≤ .05). CONCLUSIONS Teamwork and work environment health were rated by ICU team members as good but not excellent. Care coordination and meaningful recognition can be improved.
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Affiliation(s)
- Brenda T Pun
- Brenda T. Pun is director of data quality at the Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jin Jun
- Jin Jun is an assistant professor, Center for Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing, Columbus
| | - Alai Tan
- Alai Tan is a research professor, Center for Research and Health Analytics, The Ohio State University College of Nursing, Columbus
| | - Diane Byrum
- Diane Byrum is a quality implementation consultant at Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Lorraine Mion
- Lorraine Mion is a research professor, Center for Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing, Columbus
| | - Eduard E Vasilevskis
- Eduard E. Vasilevskis is an associate professor, Division of General Internal Medicine and Public Health, Section of Hospital Medicine; the Center for Health Services Research; the Center for Quality Aging; and the Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, and staff physician at the Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - E Wesley Ely
- E. Wesley Ely is a professor at the Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, and at the Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - Michele Balas
- Michele Balas is associate dean of research and Dorothy Hodges Olson Distinguished Professor of Nursing at the University of Nebraska Medical Center College of Nursing, Omaha
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Williams Roberson S, Azeez NA, Taneja R, Pun BT, Pandharipande PP, Jackson JC, Ely EW. Quantitative EEG During Critical Illness Correlates with Patterns of Long-Term Cognitive Impairment. Clin EEG Neurosci 2022; 53:435-442. [PMID: 33289394 PMCID: PMC8561666 DOI: 10.1177/1550059420978009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Many intensive care unit (ICU) survivors suffer disabling long-term cognitive impairment (LTCI) after critical illness. We compared EEG characteristics during critical illness with patients' 1-year neuropsychological outcomes. METHODS We performed a post hoc analysis of patients in the BRAIN-ICU study who had undergone EEG for clinical purposes during admission (n = 10). All survivors underwent formal cognitive assessments at 12-month follow-up. We evaluated EEGs by conventional visual inspection and computed 10 quantitative features. We explored associations between EEG and patterns of LTCI using Wilcoxon rank-sum tests and Spearman's rank correlations. RESULTS Of 521 Vanderbilt patients enrolled in the parent study, 24 had EEG recordings during admission. Ten survivors had EEG tracings available and completed follow-up cognitive testing. All but one inpatient EEG showed generalized background slowing. All patients demonstrated cognitive impairment in at least one domain at follow-up. The most common deficits occurred in delayed memory (DM-median index 62) and visuospatial/constructional (VC-median index 69) domains. Relative alpha power correlated with VC score (ρ = 0.78, P = .008). Peak interhemispheric coherence correlated negatively with DM (ρ = -0.81, P = .018). CONCLUSIONS Quantitative EEG features during critical illness correlated with domain-specific cognitive performance in our small cohort of ICU survivors. Further study in larger prospective cohorts is required to determine whether these relationships hold. SIGNIFICANCE EEG may serve as a prognostic biomarker predicting patterns of long-term cognitive impairment.
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Affiliation(s)
- Shawniqua Williams Roberson
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naureen Abdul Azeez
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Randip Taneja
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
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Balas MC, Tan A, Pun BT, Ely EW, Carson SS, Mion L, Barnes-Daly MA, Vasilevskis EE. Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation. Am J Crit Care 2022; 31:54-64. [PMID: 34972842 PMCID: PMC9972543 DOI: 10.4037/ajcc2022768] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor. OBJECTIVE To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance. METHODS This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation. RESULTS Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility. CONCLUSIONS Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.
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Affiliation(s)
- Michele C. Balas
- University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Alai Tan
- Center for Research and Health Analytics, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, and at the Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - Shannon S. Carson
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lorraine Mion
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing
| | | | - Eduard E. Vasilevskis
- Division of General Internal Medicine and Public Health, Section of Hospital Medicine; the Center for Health Services Research; the Center for Quality Aging; and the Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, and a staff physician, Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center
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Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 2021; 47:1089-1103. [PMID: 34401939 PMCID: PMC8366492 DOI: 10.1007/s00134-021-06503-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
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Affiliation(s)
- Joanna L Stollings
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA.
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Katarzyna Kotfis
- Department Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Gerald Chanques
- Department of Anaesthesia and Critical Care Medicine, Saint Eloi Hospital, Montpellier University Hospital Center, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Brenda T Pun
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
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Abstract
The advent of modern critical care medicine has revolutionized care of the critically ill patient in the last 50 years. The Society of Critical Care Medicine (was formed in recognition of the challenges and need for specialized treatment for these fragile patients. As the specialty has grown, it has achieved impressive scientific advances that have reduced mortality and saved lives. With those advances, however, came growing recognition that the burden of critical illness did not end at the doorstep of the hospital. Delirium, once thought to be a mere by-product of critical illness, was found to be an independent predictor of mortality, prolonged mechanical ventilation, and long-lasting cognitive impairment. Similarly, deep sedation and immobility, so often used to keep patients "comfortable" and to facilitate mechanical ventilation and recovery, worsen mortality and lead to the development of ICU-acquired weakness. The realization that these outcomes are inextricably linked to one another and how we manage our patients has helped us recognize the need for culture change. We, as a specialty, now understand that although celebrating the successes of survival, we now also have a duty to focus on those who survive their diseases. Led by initiatives such as the ICU Liberation Campaign of the Society of Critical Care Medicine, the natural progression of the field is now focused on getting patients back to their homes and lives unencumbered by disability and impairment. Much work remains to be done, but the futures of our most critically ill patients will continue to benefit if we leverage and build on the history of our first 50 years.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - Brenda T Pun
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
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Hughes CG, Mailloux PT, Devlin JW, Swan JT, Sanders RD, Anzueto A, Jackson JC, Hoskins AS, Pun BT, Orun OM, Raman R, Stollings JL, Kiehl AL, Duprey MS, Bui LN, O'Neal HR, Snyder A, Gropper MA, Guntupalli KK, Stashenko GJ, Patel MB, Brummel NE, Girard TD, Dittus RS, Bernard GR, Ely EW, Pandharipande PP. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med 2021; 384:1424-1436. [PMID: 33528922 PMCID: PMC8162695 DOI: 10.1056/nejmoa2024922] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).
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Affiliation(s)
- Christopher G Hughes
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Patrick T Mailloux
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - John W Devlin
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Joshua T Swan
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Robert D Sanders
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Antonio Anzueto
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - James C Jackson
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Aimee S Hoskins
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Brenda T Pun
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Onur M Orun
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Rameela Raman
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Joanna L Stollings
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Amy L Kiehl
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Matthew S Duprey
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Lan N Bui
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Hollis R O'Neal
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Allison Snyder
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Michael A Gropper
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Kalpalatha K Guntupalli
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Gregg J Stashenko
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Mayur B Patel
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Nathan E Brummel
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Timothy D Girard
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Robert S Dittus
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Gordon R Bernard
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - E Wesley Ely
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Pratik P Pandharipande
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
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Pun BT, Badenes R, Heras La Calle G, Orun OM, Chen W, Raman R, Simpson BGK, Wilson-Linville S, Hinojal Olmedillo B, Vallejo de la Cueva A, van der Jagt M, Navarro Casado R, Leal Sanz P, Orhun G, Ferrer Gómez C, Núñez Vázquez K, Piñeiro Otero P, Taccone FS, Gallego Curto E, Caricato A, Woien H, Lacave G, O'Neal HR, Peterson SJ, Brummel NE, Girard TD, Ely EW, Pandharipande PP. Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study. Lancet Respir Med 2021; 9:239-250. [PMID: 33428871 PMCID: PMC7832119 DOI: 10.1016/s2213-2600(20)30552-x] [Citation(s) in RCA: 275] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 12/21/2022]
Abstract
Background To date, 750 000 patients with COVID-19 worldwide have required mechanical ventilation and thus are at high risk of acute brain dysfunction (coma and delirium). We aimed to investigate the prevalence of delirium and coma, and risk factors for delirium in critically ill patients with COVID-19, to aid the development of strategies to mitigate delirium and associated sequelae. Methods This multicentre cohort study included 69 adult intensive care units (ICUs), across 14 countries. We included all patients (aged ≥18 years) admitted to participating ICUs with severe acute respiratory syndrome coronavirus 2 infection before April 28, 2020. Patients who were moribund or had life-support measures withdrawn within 24 h of ICU admission, prisoners, patients with pre-existing mental illness, neurodegenerative disorders, congenital or acquired brain damage, hepatic coma, drug overdose, suicide attempt, or those who were blind or deaf were excluded. We collected de-identified data from electronic health records on patient demographics, delirium and coma assessments, and management strategies for a 21-day period. Additional data on ventilator support, ICU length of stay, and vital status was collected for a 28-day period. The primary outcome was to determine the prevalence of delirium and coma and to investigate any associated risk factors associated with development of delirium the next day. We also investigated predictors of number of days alive without delirium or coma. These outcomes were investigated using multivariable regression. Findings Between Jan 20 and April 28, 2020, 4530 patients with COVID-19 were admitted to 69 ICUs, of whom 2088 patients were included in the study cohort. The median age of patients was 64 years (IQR 54 to 71) with a median Simplified Acute Physiology Score (SAPS) II of 40·0 (30·0 to 53·0). 1397 (66·9%) of 2088 patients were invasively mechanically ventilated on the day of ICU admission and 1827 (87·5%) were invasively mechanical ventilated at some point during hospitalisation. Infusion with sedatives while on mechanical ventilation was common: 1337 (64·0%) of 2088 patients were given benzodiazepines for a median of 7·0 days (4·0 to 12·0) and 1481 (70·9%) were given propofol for a median of 7·0 days (4·0 to 11·0). Median Richmond Agitation–Sedation Scale score while on invasive mechanical ventilation was –4 (–5 to –3). 1704 (81·6%) of 2088 patients were comatose for a median of 10·0 days (6·0 to 15·0) and 1147 (54·9%) were delirious for a median of 3·0 days (2·0 to 6·0). Mechanical ventilation, use of restraints, and benzodiazepine, opioid, and vasopressor infusions, and antipsychotics were each associated with a higher risk of delirium the next day (all p≤0·04), whereas family visitation (in person or virtual) was associated with a lower risk of delirium (p<0·0001). During the 21-day study period, patients were alive without delirium or coma for a median of 5·0 days (0·0 to 14·0). At baseline, older age, higher SAPS II scores, male sex, smoking or alcohol abuse, use of vasopressors on day 1, and invasive mechanical ventilation on day 1 were independently associated with fewer days alive and free of delirium and coma (all p<0·01). 601 (28·8%) of 2088 patients died within 28 days of admission, with most of those deaths occurring in the ICU. Interpretation Acute brain dysfunction was highly prevalent and prolonged in critically ill patients with COVID-19. Benzodiazepine use and lack of family visitation were identified as modifiable risk factors for delirium, and thus these data present an opportunity to reduce acute brain dysfunction in patients with COVID-19. Funding None. Translations For the French and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Surgery, University of Valencia, Valencia, Spain; INCLIVA Health Research Institute, Valencia, Spain.
| | - Gabriel Heras La Calle
- Proyecto HU-CI, Hospital Comarcal Santa Ana, Motril, Spain; Universidad Francisco de Vitoria, Madrid, Spain
| | - Onur M Orun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wencong Chen
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Beata-Gabriela K Simpson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie Wilson-Linville
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Borja Hinojal Olmedillo
- Department of Anesthesiology and Surgical Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Rosalía Navarro Casado
- Department of Anesthesiology and Surgical Critical Care, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Leal Sanz
- Department of Intensive Care Complejo Hospitalario de Toledo -Virgen de la Salud Hospital, Toledo, Spain
| | - Günseli Orhun
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Carolina Ferrer Gómez
- Department of Anesthesiology and Critical Care, Consorcio Hospital General Universitario, Valencia, Spain
| | | | - Patricia Piñeiro Otero
- Department of Anesthesiology and Intensive Care Medicine, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Elena Gallego Curto
- Department of Intensive Care, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain
| | - Anselmo Caricato
- Neuro Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hilde Woien
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Guillaume Lacave
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Hollis R O'Neal
- Pulmonary and Critical Care Medicine, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Sarah J Peterson
- Department of Clinical Nutrition and Department of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Critical Care Medicine, Clinical Research, Investigations, and Systems Modeling of Acute illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Boehm LM, Pun BT, Stollings JL, Girard TD, Rock P, Hough CL, Hsieh SJ, Khan BA, Owens RL, Schmidt GA, Smith S, Ely EW. A multisite study of nurse-reported perceptions and practice of ABCDEF bundle components. Intensive Crit Care Nurs 2020; 60:102872. [PMID: 32389395 DOI: 10.1016/j.iccn.2020.102872] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 02/25/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES ABCDEF bundle implementation in the Intensive Care Unit (ICU) is associated with dose dependent improvements in patient outcomes. The objective was to compare nurse attitudes about the ABCDEF bundle to self-reported adherence to bundle components. RESEARCH METHODOLOGY/DESIGN Cross-sectional study. SETTING Nurses providing direct patient care in 28 ICUs within 18 hospitals across the United States. MAIN OUTCOME MEASURES 53-item survey of attitudes and practice of the ABCDEF bundle components was administered between November 2011 and August 2015 (n = 1661). RESULTS We did not find clinically significant correlations between nurse attitudes and adherence to Awakening trials, Breathing trials, and sedation protocol adherence (rs = 0.05-0.28) or sedation plan discussion during rounds and Awakening and Breathing trial Coordination (rs = 0.19). Delirium is more likely to be discussed during rounds when ICU physicians and nurse managers facilitate delirium reduction (rs = 0.27-0.36). Early mobilization is more likely to occur when ICU physicians, nurse managers, staffing, equipment, and the ICU environment facilitate early mobility (rs = 0.36-0.47). Physician leadership had the strongest correlation with reporting an ICU environment that facilitates ABCDEF bundle implementation (rs = 0.63-0.74). CONCLUSIONS Nurse attitudes about bundle implementation did not predict bundle adherence. Nurse manager and physician leadership played a large role in creating a supportive ICU environment.
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Affiliation(s)
- Leanne M Boehm
- Vanderbilt University School of Nursing, Nashville, TN, United States; VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States.
| | - Brenda T Pun
- Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States.
| | - Joanna L Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States; Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States; University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, United States.
| | - Peter Rock
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, United States.
| | - Catherine L Hough
- University of Washington and Harborview Medical Center, Seattle, WA, United States.
| | - S Jean Hsieh
- Mount Sinai School of Medicine, New York, NY, United States.
| | - Babar A Khan
- Indiana University School of Medicine, Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, United States.
| | - Robert L Owens
- UC San Diego School of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, San Diego, CA, United States.
| | - Gregory A Schmidt
- University of Iowa, College of Medicine, Department of Internal Medicine, Iowa City, IA, United States.
| | - Susan Smith
- Baylor University Medical Center, Critical Care, Dallas, TX, United States.
| | - E Wesley Ely
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States; Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States.
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10
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Kotfis K, Williams Roberson S, Wilson JE, Dabrowski W, Pun BT, Ely EW. COVID-19: ICU delirium management during SARS-CoV-2 pandemic. Crit Care 2020; 24:176. [PMID: 32345343 PMCID: PMC7186945 DOI: 10.1186/s13054-020-02882-x] [Citation(s) in RCA: 298] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/08/2020] [Indexed: 12/20/2022] Open
Abstract
The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 (COVID-19), emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic.
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Affiliation(s)
- Katarzyna Kotfis
- Department Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Al. Powstańców Wielkopolskich 72, 70-111, Szczecin, Poland.
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Bioengineering, Vanderbilt University, Nashville, TN, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN, USA
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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11
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Stollings JL, Devlin JW, Lin JC, Pun BT, Byrum D, Barr J. Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle. Crit Care Med 2020; 48:562-570. [PMID: 32205603 DOI: 10.1097/ccm.0000000000004197] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance. DESIGN Best practice synthesis. METHODS The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence. RESULTS Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making. CONCLUSIONS Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.
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Affiliation(s)
- Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - John C Lin
- Division of Pediatrics and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Diane Byrum
- Innovative Solutions for Healthcare Education, LLC, Charlotte, NC
| | - Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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12
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Chandrasekhar R, Hughes CG, Pun BT, Orun OM, Ely EW, Pandharipande PP. Statistical analysis plan for the Maximizing the Efficacy of Sedation and Reducing Neurological Dysfunction and Mortality in Septic Patients with Acute Respiratory Failure trial. CRIT CARE RESUSC 2020. [DOI: 10.51893/2020.1.oa7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The best sedative medication to reduce delirium, mortality and long term brain dysfunction in mechanically ventilated septic patients is unclear. This multicentre, double-blind, randomised trial investigates the short term and long term effects of dexmedetomidine versus propofol for sedation in mechanically ventilated severely septic patients. OBJECTIVES: To describe the statistical analysis plan for this randomised clinical trial comprehensively and place it in the public domain before unblinding. METHODS: To ensure that analyses are not selectively reported, we developed a comprehensive statistical analysis plan before unblinding. This trial has an enrolment target of 420 severely septic and mechanically ventilated adult patients, randomly assigned to dexmedetomidine or propofol in a 1:1 ratio. Enrolment was completed in January 2019, and the study was estimated to be completed in September 2019. The primary endpoint is days alive without delirium or coma during first 14 study days. Secondary outcomes include 28-day ventilator-free days, 90-day all-cause mortality and cognitive function at 180 days. Time frames all begin on the day of randomisation. All analyses will be conducted on an intention-to-treat basis. CONCLUSION: This study will compare the effects of two sedatives in mechanically ventilated severely septic patients. In keeping with the guidance on statistical principles for clinical trials, we have developed a comprehensive statistical analysis plan by which we will adhere, as this will avoid bias and support transparency and reproducibility. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01739933).
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13
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Chandrasekhar R, Hughes CG, Pun BT, Orun OM, Ely EW, Pandharipande PP. Statistical analysis plan for the Maximizing the Efficacy of Sedation and Reducing Neurological Dysfunction and Mortality in Septic Patients with Acute Respiratory Failure trial. CRIT CARE RESUSC 2020; 22:63-71. [PMID: 32102644 PMCID: PMC10692449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The best sedative medication to reduce delirium, mortality and long term brain dysfunction in mechanically ventilated septic patients is unclear. This multicentre, double-blind, randomised trial investigates the short term and long term effects of dexmedetomidine versus propofol for sedation in mechanically ventilated severely septic patients. OBJECTIVES To describe the statistical analysis plan for this randomised clinical trial comprehensively and place it in the public domain before unblinding. METHODS To ensure that analyses are not selectively reported, we developed a comprehensive statistical analysis plan before unblinding. This trial has an enrolment target of 420 severely septic and mechanically ventilated adult patients, randomly assigned to dexmedetomidine or propofol in a 1:1 ratio. Enrolment was completed in January 2019, and the study was estimated to be completed in September 2019. The primary endpoint is days alive without delirium or coma during first 14 study days. Secondary outcomes include 28-day ventilator-free days, 90-day all-cause mortality and cognitive function at 180 days. Time frames all begin on the day of randomisation. All analyses will be conducted on an intention-to-treat basis. CONCLUSION This study will compare the effects of two sedatives in mechanically ventilated severely septic patients. In keeping with the guidance on statistical principles for clinical trials, we have developed a comprehensive statistical analysis plan by which we will adhere, as this will avoid bias and support transparency and reproducibility. TRIAL REGISTRATION ClinicalTrials.gov (NCT01739933).
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Affiliation(s)
- Rameela Chandrasekhar
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Onur M Orun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Kotfis K, Roberson SW, Wilson JE, Pun BT, Ely EW, Jeżowska I, Jezierska M, Dabrowski W. COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic? Anaesthesiol Intensive Ther 2020; 52:132-138. [PMID: 32419438 PMCID: PMC7667988 DOI: 10.5114/ait.2020.95164] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 01/15/2023] Open
Abstract
In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy, and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Bioengineering, Vanderbilt University, Nashville, TN, United States
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN, United States
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN, United States
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ilona Jeżowska
- Integrative Counselling and Psychotherapy, The Minster Centre, Department of Psychology, Middlesex University, London, UK
| | - Maja Jezierska
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Poland
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Poland
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15
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Stollings JL, Devlin JW, Pun BT, Puntillo KA, Kelly T, Hargett KD, Morse A, Esbrook CL, Engel HJ, Perme C, Barnes-Daly MA, Posa PJ, Aldrich JM, Barr J, Carson SS, Schweickert WD, Byrum DG, Harmon L, Ely EW, Balas MC. Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative. Crit Care Nurse 2019; 39:36-45. [PMID: 30710035 DOI: 10.4037/ccn2019981] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.
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Affiliation(s)
- Joanna L Stollings
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - John W Devlin
- John Devlin is Professor of Pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Brenda T Pun
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathleen A Puntillo
- Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - Tamra Kelly
- Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California
| | - Ken D Hargett
- Ken Hargett is a respiratory therapist, Houston Methodist Hospital, Houston, Texas
| | | | - Cheryl L Esbrook
- Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois
| | - Heidi J Engel
- Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco
| | - Christiane Perme
- Christiane Perme is a physical therapist, Houston Methodist Hospital
| | - Mary Ann Barnes-Daly
- Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health
| | - Patricia J Posa
- Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - J Matthew Aldrich
- J. Matthew Aldrich is the Medical Director of Critical Care Medicine and an associate clinical professor, University of San Francisco, San Francisco
| | - Juliana Barr
- Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Shannon S Carson
- Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill
| | - William D Schweickert
- William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Diane G Byrum
- Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Lori Harmon
- Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois
| | - E Wesley Ely
- E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Michele C Balas
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus
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Balas MC, Pun BT, Pasero C, Engel HJ, Perme C, Esbrook CL, Kelly T, Hargett KD, Posa PJ, Barr J, Devlin JW, Morse A, Barnes-Daly MA, Puntillo KA, Aldrich JM, Schweickert WD, Harmon L, Byrum DG, Carson SS, Ely EW, Stollings JL. Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience. Crit Care Nurse 2019; 39:46-60. [PMID: 30710036 DOI: 10.4037/ccn2019927] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.
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Affiliation(s)
- Michele C Balas
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus.
| | - Brenda T Pun
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus
| | - Chris Pasero
- Chris Pasero is a pain management clinical consultant, El Dorado Hills, California
| | - Heidi J Engel
- Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco
| | - Christiane Perme
- Christiane Perme is a physical therapist, Houston Methodist Hospital, Houston, Texas
| | - Cheryl L Esbrook
- Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois
| | - Tamra Kelly
- Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California
| | - Ken D Hargett
- Ken Hargett is a respiratory therapist, Houston Methodist Hospital
| | - Patricia J Posa
- Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - Juliana Barr
- Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - John W Devlin
- John Devlin is a professor of pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Mary Ann Barnes-Daly
- Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health
| | - Kathleen A Puntillo
- Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - J Matthew Aldrich
- J. Matthew Aldrich is medical director, critical care medicine, and an associate clinical professor, University of California, San Francisco Medical Center, San Francisco
| | - William D Schweickert
- William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lori Harmon
- Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois
| | - Diane G Byrum
- Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Shannon S Carson
- Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill
| | - E Wesley Ely
- E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Joanna L Stollings
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center
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Kruser JM, Aaby DA, Stevenson DG, Pun BT, Balas MC, Barnes-Daly MA, Harmon L, Ely EW. Assessment of Variability in End-of-Life Care Delivery in Intensive Care Units in the United States. JAMA Netw Open 2019; 2:e1917344. [PMID: 31825508 PMCID: PMC6991207 DOI: 10.1001/jamanetworkopen.2019.17344] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death. OBJECTIVE To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States. DESIGN, SETTING, AND PARTICIPANTS This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019. MAIN OUTCOMES AND MEASURES Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU. RESULTS Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events. CONCLUSIONS AND RELEVANCE In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.
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Affiliation(s)
- Jacqueline M. Kruser
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University, Chicago, Illinois
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - David A. Aaby
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - David G. Stevenson
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Lori Harmon
- Society of Critical Care Medicine, Mount Prospect, Illinois
| | - E. Wesley Ely
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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Balas MC, Barnes-Daly MA, Byrum DG, Posa PJ, Pun BT, Puntillo KA. The Authors Respond. Crit Care Nurse 2019; 39:14-15. [PMID: 31154325 DOI: 10.4037/ccn2019690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Abstract
Delirium, one of the most common manifestations of acute brain dysfunction, is a serious complication in patients receiving care throughout the hospital and a strong predictor of worse outcome. Although delirium monitoring is advocated in numerous evidence-based guidelines as part of routine clinical care, it is still not widely and consistently performed at the bedside in different patient care settings. In a debate on delirium monitoring in hospitalized patients at the 7th American Delirium Society meeting in Nashville, Tennessee, June 2017, areas related to the feasibility, acceptability, and effectiveness of routine delirium monitoring of hospitalized patients were identified, and arguments both for (pro) and against (con) the practice were presented. These arguments and others arising in the discussion were subsequently expanded. The goals were to present a conversation among clinicians and researchers from different settings and to identify the evidence-practice gaps for delirium monitoring for future research and organizational quality improvement programs. Further research is needed to determine whether or not delirium monitoring should become routine clinical care for every patient in every hospital setting.
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Affiliation(s)
- Annachiara Marra
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center.
| | - Katarzyna Kotfis
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Annmarie Hosie
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Alasdair M J MacLullich
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Pratik P Pandharipande
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - E Wesley Ely
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
| | - Brenda T Pun
- Annachiara Marra is an anesthesiologist, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, and Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy. Katarzyna Kotfis is an assistant professor, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland. Annmarie Hosie is a postdoctoral research fellow, IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia. Alasdair M. J. MacLullich is a professor, Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, Scotland. Pratik P. Pandharipande is a professor, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, and Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center. E. Wesley Ely is a professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Center for Health Services Research, Department of Medicine, and Center for Quality Aging, Vanderbilt University Medical Center, and associate director for research, Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, and CIBS Center, Vanderbilt University Medical Center. Brenda T. Pun is an advanced practice nurse, CIBS Center, Vanderbilt University Medical Center
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Girard TD, Exline MC, Carson SS, Hough CL, Rock P, Gong MN, Douglas IS, Malhotra A, Owens RL, Feinstein DJ, Khan B, Pisani MA, Hyzy RC, Schmidt GA, Schweickert WD, Hite RD, Bowton DL, Masica AL, Thompson JL, Chandrasekhar R, Pun BT, Strength C, Boehm LM, Jackson JC, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Bernard GR, Dittus RS, Ely EW. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med 2018; 379:2506-2516. [PMID: 30346242 PMCID: PMC6364999 DOI: 10.1056/nejmoa1808217] [Citation(s) in RCA: 309] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are conflicting data on the effects of antipsychotic medications on delirium in patients in the intensive care unit (ICU). METHODS In a randomized, double-blind, placebo-controlled trial, we assigned patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol (maximum dose, 20 mg daily), ziprasidone (maximum dose, 40 mg daily), or placebo. The volume and dose of a trial drug or placebo was halved or doubled at 12-hour intervals on the basis of the presence or absence of delirium, as detected with the use of the Confusion Assessment Method for the ICU, and of side effects of the intervention. The primary end point was the number of days alive without delirium or coma during the 14-day intervention period. Secondary end points included 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge. Safety end points included extrapyramidal symptoms and excessive sedation. RESULTS Written informed consent was obtained from 1183 patients or their authorized representatives. Delirium developed in 566 patients (48%), of whom 89% had hypoactive delirium and 11% had hyperactive delirium. Of the 566 patients, 184 were randomly assigned to receive placebo, 192 to receive haloperidol, and 190 to receive ziprasidone. The median duration of exposure to a trial drug or placebo was 4 days (interquartile range, 3 to 7). The median number of days alive without delirium or coma was 8.5 (95% confidence interval [CI], 5.6 to 9.9) in the placebo group, 7.9 (95% CI, 4.4 to 9.6) in the haloperidol group, and 8.7 (95% CI, 5.9 to 10.0) in the ziprasidone group (P=0.26 for overall effect across trial groups). The use of haloperidol or ziprasidone, as compared with placebo, had no significant effect on the primary end point (odds ratios, 0.88 [95% CI, 0.64 to 1.21] and 1.04 [95% CI, 0.73 to 1.48], respectively). There were no significant between-group differences with respect to the secondary end points or the frequency of extrapyramidal symptoms. CONCLUSIONS The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium. (Funded by the National Institutes of Health and the VA Geriatric Research Education and Clinical Center; MIND-USA ClinicalTrials.gov number, NCT01211522 .).
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Affiliation(s)
- Timothy D Girard
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Matthew C Exline
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Shannon S Carson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Catherine L Hough
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Peter Rock
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Michelle N Gong
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Ivor S Douglas
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Atul Malhotra
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert L Owens
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Daniel J Feinstein
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Babar Khan
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Margaret A Pisani
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert C Hyzy
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Gregory A Schmidt
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - William D Schweickert
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - R Duncan Hite
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - David L Bowton
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Andrew L Masica
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Jennifer L Thompson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Rameela Chandrasekhar
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Brenda T Pun
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Cayce Strength
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Leanne M Boehm
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - James C Jackson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Pratik P Pandharipande
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Nathan E Brummel
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Christopher G Hughes
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Mayur B Patel
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Joanna L Stollings
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Gordon R Bernard
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert S Dittus
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - E Wesley Ely
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
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Girard TD, Thompson JL, Pandharipande PP, Brummel NE, Jackson JC, Patel MB, Hughes CG, Chandrasekhar R, Pun BT, Boehm LM, Elstad MR, Goodman RB, Bernard GR, Dittus RS, Ely EW. Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med 2018; 6:213-222. [PMID: 29508705 DOI: 10.1016/s2213-2600(18)30062-6] [Citation(s) in RCA: 230] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/17/2018] [Accepted: 01/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Delirium during critical illness results from numerous insults, which might be interconnected and yet individually contribute to long-term cognitive impairment. We sought to describe the prevalence and duration of clinical phenotypes of delirium (ie, phenotypes defined by clinical risk factors) and to understand associations between these clinical phenotypes and severity of subsequent long-term cognitive impairment. METHODS In this multicentre, prospective cohort study, we included adult (≥18 years) medical or surgical ICU patients with respiratory failure, shock, or both as part of two parallel studies: the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study, and the Delirium and Dementia in Veterans Surviving ICU Care (MIND-ICU) study. We assessed patients at least once a day for delirium using the Confusion Assessment Method-ICU and identified a priori-defined, non-mutually exclusive phenotypes of delirium per the presence of hypoxia, sepsis, sedative exposure, or metabolic (eg, renal or hepatic) dysfunction. We considered delirium in the absence of hypoxia, sepsis, sedation, and metabolic dysfunction to be unclassified. 3 and 12 months after discharge, we assessed cognition with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We used multiple linear regression to separately analyse associations between the duration of each phenotype of delirium and RBANS global cognition scores at 3-month and 12-month follow-up, adjusting for potential confounders. FINDINGS Between March 14, 2007, and May 27, 2010, 1048 participants were enrolled, eight of whom could not be analysed. Of 1040 participants, 708 survived to 3 months of follow-up and 628 to 12 months. Delirium was common, affecting 740 (71%) of 1040 participants at some point during the study and occurring on 4187 (31%) of all 13 434 participant-days. A single delirium phenotype was present on only 1355 (32%) of all 4187 participant-delirium days, whereas two or more phenotypes were present during 2832 (68%) delirium days. Sedative-associated delirium was most common (present during 2634 [63%] delirium days), and a longer duration of sedative-associated delirium predicted a worse RBANS global cognition score 12 months later, after adjusting for covariates (difference in score comparing 3 days vs 0 days: -4·03, 95% CI -7·80 to -0·26). Similarly, longer durations of hypoxic delirium (-3·76, 95% CI -7·16 to -0·37), septic delirium (-3·67, -7·13 to -0·22), and unclassified delirium (-4·70, -7·16 to -2·25) also predicted worse cognitive function at 12 months, whereas duration of metabolic delirium did not (1·14, -0·12 to 3·01). INTERPRETATION Our findings suggest that clinicians should consider sedative-associated, hypoxic, and septic delirium, which often co-occur, as distinct indicators of acute brain injury and seek to identify all potential risk factors that may impact on long-term cognitive impairment, especially those that are iatrogenic and potentially modifiable such as sedation. FUNDING National Institutes of Health and the Department of Veterans Affairs.
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Affiliation(s)
- Timothy D Girard
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jennifer L Thompson
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Pratik P Pandharipande
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Nathan E Brummel
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James C Jackson
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA; Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Mayur B Patel
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Trauma and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, TN, USA; Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN, USA; Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Christopher G Hughes
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Rameela Chandrasekhar
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Brenda T Pun
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Leanne M Boehm
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Mark R Elstad
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine in the Department of Internal Medicine at the University of Utah School of Medicine, Salt Lake City, UT, USA; George E Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Richard B Goodman
- Division of Pulmonary, Critical Care, and Sleep Medicine in the Department of Internal Medicine at the University of Washington School of Medicine, Seattle, WA, USA; Department of Veterans Affairs Medical Center, Seattle Division, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Gordon R Bernard
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert S Dittus
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of General Internal Medicine and Public Health in the Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E W Ely
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Barnes‐Daly MA, Pun BT, Harmon LA, Byrum DG, Kumar VK, Devlin JW, Stollings JL, Puntillo KA, Engel HJ, Posa PJ, Barr J, Schweickert WD, Esbrook CL, Hargett KD, Carson SS, Aldrich JM, Ely EW, Balas MC. Improving Health Care for Critically Ill Patients Using an Evidence‐Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation. Worldviews Evid Based Nurs 2018; 15:206-216. [DOI: 10.1111/wvn.12290] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Brenda T. Pun
- Clinical Program ManagerVanderbilt University Medical Center Nashville TN USA
| | - Lori A. Harmon
- Director QualitySociety of Critical Care Medicine Mount Prospect IL USA
| | - Diane G. Byrum
- Quality Implementation ConsultantInnovative Solutions for HealthCare Education LLC Chicago IL USA
| | - Vishakha K. Kumar
- Senior Manager, ResearchSociety of Critical Care Medicine Mount Prospect IL USA
| | - John W. Devlin
- Professor of Pharmacy, School of Pharmacy, Northeastern University, and Scientific Staff, Division of Pulmonary and Critical Care MedicineTufts Medical Center Boston MA USA
| | - Joanna L. Stollings
- Medical Intensive Care Unit Clinical Pharmacy Specialist and Pharmacist ICU Recovery Center, Department of Pharmaceutical ServicesVanderbilt University Medical Center Nashville TN USA
| | - Kathleen A. Puntillo
- Professor EmeritaSchool of Nursing, University of California San Francisco San Francisco, CA USA
| | - Heidi J. Engel
- Clinical Specialist, Department of Rehabilitative ServicesUniversity of California San Francisco CA USA
| | - Patricia J. Posa
- Quality Excellence LeaderSaint Joseph Mercy Health System Ann Arbor MI USA
| | - Juliana Barr
- Associate Professor, Department of Anesthesiology, Perioperative, and Pain MedicineStanford University School of Medicine Stanford CA USA
- Staff Anesthesiologist and Intensivist at the VA, Anesthesiology ServiceVA Palo Alto Health Care System Palo Alto CA USA
| | - William D. Schweickert
- Director, Medical Critical Care Operations, Division of Pulmonary, Allergy and Critical CarePerelman School of Medicine at the University of Pennsylvania Philadelphia PA USA
| | - Cheryl L. Esbrook
- Program Coordinator of Occupational Therapy Professional DevelopmentUniversity of Chicago Medicine Chicago IL USA
| | - Ken D. Hargett
- Director, Respiratory Care ServicesHouston Methodist Hospital Houston TX USA
| | - Shannon S. Carson
- Professor of Medicine and Division Chief, Pulmonary Diseases & Critical Care MedicineUniversity of North Carolina‐Chapel Hill Chapel Hill NC USA
| | - J. Matthew Aldrich
- Medical Director, Critical Care Medicine, Associate Clinical Professor, Anesthesia and Perioperative CareUniversity of San Francisco‐California Medical Center San Francisco CA USA
| | - E. Wesley Ely
- Professor of Medicine, Department of Medicine, Pulmonary and Critical Care and Health Services Research CenterVanderbilt University School of Medicine and The Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC) Nashville TN USA
| | - Michele C. Balas
- Associate Professor, College of Nursing, Center of Excellence in Critical and Complex CareThe Ohio State University and Nurse Scientist, The Ohio State University Wexner Medical Center Columbus OH USA
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Gélinas C, Bérubé M, Chevrier A, Pun BT, Ely EW, Skrobik Y, Barr J. Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review. Crit Care Nurse 2018; 38:38-49. [PMID: 29437077 DOI: 10.4037/ccn2018633] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is highly prevalent in critically ill patients. Its detection with valid tools is crucial. OBJECTIVE To analyze the development and psychometric properties of delirium assessment tools for critically ill adults. METHODS Databases were searched to identify relevant studies. Inclusion criteria were English language, publication before January 2015, 30 or more patients, and patient population of critically ill adults (>18 years old). Search terms were delirium, scales, critically ill patients, adult, validity, and reliability. Thirty-six manuscripts were identified, encompassing 5 delirium assessment tools (Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Cognitive Test for Delirium, Delirium Detection Score, Intensive Care Delirium Screening Checklist (ICDSC), and Nursing Delirium Screening Scale). Two independent reviewers analyzed the psychometric properties of these tools by using a standardized scoring system (range, 0-20) to assess the tool development process, reliability, validity, feasibility, and implementation of each tool. RESULTS Psychometric properties were very good for the CAM-ICU (19.6) and the ICDSC (19.2), moderate for the Nursing Delirium Screening Scale (13.6), low for the Delirium Detection Score (11.2), and very low for the Cognitive Test for Delirium (8.2). CONCLUSIONS The results indicate that the CAM-ICU and the ICDSC are the most valid and reliable delirium assessment tools for critically ill adults. Additional studies are needed to further validate these tools in critically ill patients with neurological disorders and those at various levels of sedation or consciousness.
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Affiliation(s)
- Céline Gélinas
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada.
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University.
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre.
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System.
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC).
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada.
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California.
| | - Mélanie Bérubé
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC)
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California
| | - Annie Chevrier
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC)
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California
| | - Brenda T Pun
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC)
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California
| | - E Wesley Ely
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC)
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California
| | - Yoanna Skrobik
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC)
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California
| | - Juliana Barr
- Céline Gélinas is associate professor at Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, and is a researcher at the Centre for Nursing Research of the Jewish General Hospital, Montreal, Quebec, Canada
- Mélanie Bérubé is the trauma program coordinator and research coordinator for the Department of Nursing at the Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. She is pursuing doctorate studies at Ingram School of Nursing, McGill University
- Annie Chevrier is assistant director of the Bachelor of Nursing program and is a faculty lecturer in the undergraduate and graduate programs of Ingram School of Nursing, McGill University. She is a clinical associate for the medical mission and steering committee for diabetes care at the McGill University Health Centre
- Brenda T. Pun is an advanced practice nurse at Vanderbilt University Medical Center, Nashville, Tennessee. She is affiliated with the Geriatric Research Education and Clinical Center of the Veterans Affairs Tennessee Valley Healthcare System
- E. Wesley Ely is a professor of medicine at Vanderbilt University School of Medicine, Nashville, Tennessee, and Associate Director of Research for the Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC)
- Yoanna Skrobik is an intensive care specialist at McGill University, Montreal, Quebec, Canada
- Juliana Barr is an associate professor of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, and a staff anesthesiologist and intensivist, VA Palo Alto Health Care System, Palo Alto, California
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Jackson JC, Pandharipande PP, Girard TD, Brummel NE, Thompson JL, Hughes CG, Pun BT, Vasilevskis EE, Morandi A, Shintani AK, Hopkins RO, Bernard GR, Dittus RS, Ely EW. Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med 2014; 2:369-79. [PMID: 24815803 DOI: 10.1016/s2213-2600(14)70051-7] [Citation(s) in RCA: 401] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations of age and duration of delirium with mental health and functional disabilities in this group. METHODS In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist-Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795. FINDINGS We enrolled 821 patients with a median age of 61 years (IQR 51-71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive-affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes. INTERPRETATION Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care. FUNDING National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.
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Affiliation(s)
- James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA; Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Timothy D Girard
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Nathan E Brummel
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jennifer L Thompson
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA; Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Brenda T Pun
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Eduard E Vasilevskis
- Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Alessandro Morandi
- Rehabilitation and Aged Care Unit Hospital Ancelle, Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - Ayumi K Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ramona O Hopkins
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT, USA; Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Gordon R Bernard
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert S Dittus
- Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Brummel NE, Girard TD, Ely EW, Pandharipande PP, Morandi A, Hughes CG, Graves AJ, Shintani A, Murphy E, Work B, Pun BT, Boehm L, Gill TM, Dittus RS, Jackson JC. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014; 40:370-9. [PMID: 24257969 PMCID: PMC3943568 DOI: 10.1007/s00134-013-3136-0] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/07/2013] [Indexed: 12/21/2022]
Abstract
PURPOSE Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. METHODS We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%). RESULTS Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up. CONCLUSIONS This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.
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Affiliation(s)
- N E Brummel
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 350, Nashville, TN, 37203-1425, USA,
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Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306-16. [PMID: 24088092 PMCID: PMC3922401 DOI: 10.1056/nejmoa1301372] [Citation(s) in RCA: 1653] [Impact Index Per Article: 150.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized. METHODS We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders. RESULTS Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months. CONCLUSIONS Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.).
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Affiliation(s)
- P P Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, USA.
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Abstract
It has been 10 years since the last publication of the clinical practice guidelines for pain, agitation/sedation, and delirium (PAD). The results of new studies have directed significant changes in critical care practice. Using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology, the guidelines were revised, resulting in 32 recommendations and 22 summary statements. This article provides guidance toward guideline implementation strategies and outlines 10 key points to consider. Compared with its predecessor, the 2013 PAD guidelines are less prescriptive in that they recommend approaches to patient care rather than giving specific medication recommendations. This will help focus care teams on the process and structure of patient management and result in more flexibility when choosing specific medications. This article outlines approaches to guideline implementation that take into account the changes in philosophy surrounding medication selection. The manuscript focuses on the areas anticipated to generate the most change such as lighter sedation targets, avoidance of benzodiazepines, and early mobility. A gap analysis grid is provided. The release of any guideline should prompt reevaluation of current institutional practice standards. This manuscript uses the PAD guidelines as an example of how to approach the interprofessional work of guideline implementation.
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Affiliation(s)
- Brenda T Pun
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.
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Abstract
Delirium in the intensive care unit (ICU) is associated with many negative outcomes, including increased length of stay in both the ICU and the hospital, increased duration of mechanical ventilation, increased mortality, worse long-term cognitive impairment, and increased costs. The 2013 American College of Critical Care Medicine (ACCM)/Society of Critical Care Medicine (SCCM) clinical practice guidelines for pain, agitation, and delirium (PAD), based on available evidence, strongly recommend that critically ill patients be routinely monitored for delirium in the ICU using a validated tool. After conducting a thorough psychometric review of available delirium assessment tools, the 2013 PAD guideline group concluded that the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the ICU delirium screening tools with the strongest validity and reliability. This article discusses the importance and feasibility of delirium screening in the ICU and compares the most commonly used critical care delirium screening instruments. Strategies needed to implement and sustain delirium screening efforts in different critically ill populations are introduced and discussed. Accurate detection is the first step in managing ICU patients who develop delirium in an attempt to reduce the negative sequelae of delirium in this population.
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Affiliation(s)
- Brenda T Pun
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee, USA.
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Hughes CG, Morandi A, Girard TD, Riedel B, Thompson JL, Shintani AK, Pun BT, Ely EW, Pandharipande PP. Association between endothelial dysfunction and acute brain dysfunction during critical illness. Anesthesiology 2013; 118:631-9. [PMID: 23263016 DOI: 10.1097/aln.0b013e31827bd193] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Acute brain dysfunction (delirium and coma) during critical illness is prevalent and costly, but the pathophysiology remains unclear. The relationship of acute brain dysfunction with endothelial function, which is impaired in critical illness and may contribute to alterations in cerebral blood flow and blood-brain barrier permeability, has not been studied. This study sought to determine whether systemic endothelial dysfunction is associated with acute brain dysfunction during critical illness. METHODS In this prospective cohort study, adult medical/surgical intensive care unit patients in shock and/or respiratory failure were enrolled. Endothelial function was assessed at enrollment using peripheral artery tonometry to calculate the reactive hyperemia index, with lower reactive hyperemia index indicative of worse endothelial function. Patients were assessed for coma and delirium with the Richmond Agitation-Sedation Scale and Confusion Assessment Method for the Intensive Care Unit. Multivariable linear regression was used to analyze the association between reactive hyperemia index and (1) delirium/coma-free days among all patients and (2) delirium duration among survivors, both over a 14-day period. RESULTS One hundred forty-seven patients with median age of 57 yr and median Acute Physiology and Chronic Health Evaluation II score of 26 were enrolled. After adjusting for age, severity of illness, severe sepsis, preexisting cognitive function, medical versus surgical intensive care unit admission, and prehospital statin use, lower reactive hyperemia index (worse systemic endothelial function) was associated with fewer delirium/coma-free days (P = 0.02) and more delirium days (P = 0.05). CONCLUSIONS In this study, critically ill patients with lower vascular reactivity indicative of worse systemic endothelial function had increased duration of acute brain dysfunction.
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Affiliation(s)
- Christopher G Hughes
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, 1211 21st Ave. South, 526 MAB, Nashville, Tennessee 37212, USA.
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Balas MC, Vasilevskis EE, Burke WJ, Boehm L, Pun BT, Olsen KM, Peitz GJ, Ely EW. Critical care nurses' role in implementing the "ABCDE bundle" into practice. Crit Care Nurse 2012; 32:35-8, 40-7; quiz 48. [PMID: 22467611 DOI: 10.4037/ccn2012229] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Imagine working in an environment where all patients undergoing mechanical ventilation are alert, calm, and delirium free. Envision practicing in an environment where nonvocal patients can effectively express their need for better pain control, repositioning, or emotional reassurance. Picture an intensive care unit where a nurse-led, interprofessional team practices evidence-based, patient-centered care focused on preserving and/or restoring their clients' physical, functional, and neurocognitive abilities. A recently proposed bundle of practices for the intensive care unit could advance the current practice environment toward this idealized environment. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle incorporates the best available evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the intensive care unit for adoption into everyday clinical practice.
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Affiliation(s)
- Michele C Balas
- University of Nebraska Medical Center, College of Nursing, Omaha 68198-5330, USA.
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Vasilevskis EE, Morandi A, Boehm L, Pandharipande PP, Girard TD, Jackson JC, Thompson JL, Shintani A, Gordon SM, Pun BT, Ely EW. Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J Am Geriatr Soc 2012; 59 Suppl 2:S249-55. [PMID: 22091569 DOI: 10.1111/j.1532-5415.2011.03673.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the reliability and sustainability of delirium and sedation measurements of bedside intensive care unit (ICU) nurses. DESIGN Prospective cohort study. SETTING A tertiary care academic medical center. PARTICIPANTS Five hundred ten ICU patients from 2007 to 2010; 627 bedside nurses. MEASUREMENTS Bedside nurses and well-trained reference-rater research nurses independently measured delirium and sedation levels in routine care. Bedside nurses were instructed to use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) every 12 hours to measure delirium and the Richmond Agitation-Sedation Scale (RASS) every 4 hours to measure sedation. CAM-ICU and RASS assessment agreement were computed using weighted kappa statistics across the entire population and subgroups (e.g., ICU type). Sensitivity and specificity of bedside nurse identification of delirium were calculated to understand sources of discordance. RESULTS Six thousand one hundred ninety-eight CAM-ICU and 6,880 RASS measurement pairs obtained on 3,846 patient-days. For CAM-ICU measurements, agreement between bedside and research nurses was substantial (weighted kappa = 0.67, 95% confidence interval (CI) = 0.66-0.70) and stable over 3 years of data collection. RASS measures also demonstrated substantial agreement (weighted kappa = 0.66, 95% CI = 0.64-0.68), which was stable across all years of data collection. The sensitivity of delirium nurse assessments was 0.81 (95% CI = 0.78-0.83), and the specificity was 0.81 (95% CI = 0.78-0.85). CONCLUSION Bedside nurse measurements of delirium and sedation are sustainable and reliable sources of information. These measures can be used for clinical decision-making, quality improvement, and quality measurement activities.
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Affiliation(s)
- Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA.
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Abstract
A significant portion of critical care patients experience delirium. This form of acute brain dysfunction is associated with increased hospital stay, increased mortality, and greater long-term cognitive deficits. Critical care nurses are on the frontline with these patients and can make a significant impact on patient outcomes, including reducing the negative outcomes and experience of delirium. It is, therefore, imperative that nurses be equipped with a solid knowledge base of understanding delirium, which includes what has been reported specifically unique to delirium in the intensive care unit. This article will provide an overview of delirium and describe an interdisciplinary model of care combining multiple evidence-based practice strategies that nurses can and should use to help systematically reduce modifiable delirium risk factors. In addition, this article will provide an overview of recent reports concerning pharmacologic management of delirium in the intensive care unit.
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Affiliation(s)
- Brenda T Pun
- Vanderbilt University School of Nursing, Department of Medicine, Division of Allergy/Pulmonary/Critical Care Medicine, and Center for Health Services Research, 1215 21st Ave S, Nashville, TN 37232, USA.
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Pun BT, Boehm L. Delirium in the Intensive Care Unit. AACN Adv Crit Care 2011. [DOI: 10.4037/nci.0b013e318220c173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A significant portion of critical care patients experience delirium. This form of acute brain dysfunction is associated with increased hospital stay, increased mortality, and greater long-term cognitive deficits. Critical care nurses are on the frontline with these patients and can make a significant impact on patient outcomes, including reducing the negative outcomes and experience of delirium. It is, therefore, imperative that nurses be equipped with a solid knowledge base of understanding delirium, which includes what has been reported specifically unique to delirium in the intensive care unit. This article will provide an overview of delirium and describe an interdisciplinary model of care combining multiple evidence-based practice strategies that nurses can and should use to help systematically reduce modifiable delirium risk factors. In addition, this article will provide an overview of recent reports concerning pharmacologic management of delirium in the intensive care unit.
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Affiliation(s)
- Brenda T. Pun
- Brenda T. Pun is Clinical Assistant Professor of Nursing, Vanderbilt University School of Nursing, and Clinical Program Manager, Department of Medicine, Division of Allergy/Pulmonary/Critical Care Medicine, and Center for Health Services Research, 1215 21st Ave S, 6th Floor Medical Center East, Ste 6100, Nashville, TN 37232
| | - Leanne Boehm
- Leanne Boehm is Research Nurse Specialist, Department of Medicine, Division of Allergy/Pulmonary/Critical Care Medicine, and Center for Health Services Research, Nashville, Tennessee
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Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing iatrogenic risks: ICU-acquired delirium and weakness--crossing the quality chasm. Chest 2011; 138:1224-33. [PMID: 21051398 DOI: 10.1378/chest.10-0466] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
ICUs are experiencing an epidemic of patients with acute brain dysfunction (delirium) and weakness, both associated with increased mortality and long-term disability. These conditions are commonly acquired in the ICU and are often initiated or exacerbated by sedation and ventilation decisions and management. Despite > 10 years of evidence revealing the hazards of delirium, the quality chasm between current and ideal processes of care continues to exist. Monitoring of delirium and sedation levels remains inconsistent. In addition, sedation, ventilation, and physical therapy practices proven successful at reducing the frequency and severity of adverse outcomes are not routinely practiced. In this article, we advocate for the adoption and implementation of a standard bundle of ICU measures with great potential to reduce the burden of ICU-acquired delirium and weakness. Individual components of this bundle are evidence based and can help standardize communication, improve interdisciplinary care, reduce mortality, and improve cognitive and functional outcomes. We refer to this as the "ABCDE bundle," for awakening and breathing coordination, delirium monitoring, and exercise/early mobility. This evidence-based bundle of practices will build a bridge across the current quality chasm from the "front end" to the "back end" of critical care and toward improved cognitive and functional outcomes for ICU survivors.
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Affiliation(s)
- Eduard E Vasilevskis
- Division of Pulmonary Sciences and Critical Care Medicine, Veterans Affairs, Tennessee Valley Healthcare System, Vanderbilt University Medical Center, 1215 21st Ave, S, 6006 Medical Center East, NT, Nashville, TN 37232-8300, USA.
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Jackson JC, Girard TD, Gordon SM, Thompson JL, Shintani AK, Thomason JWW, Pun BT, Canonico AE, Dunn JG, Bernard GR, Dittus RS, Ely EW. Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial. Am J Respir Crit Care Med 2010; 182:183-91. [PMID: 20299535 DOI: 10.1164/rccm.200903-0442oc] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Studies have shown that reducing sedation of critically ill patients shortens time on the ventilator and in the intensive care unit (ICU). Little is known, however, of how such strategies affect long-term cognitive, psychological, and functional outcomes. OBJECTIVES To determine the long-term effects of a wake up and breathe protocol that interrupts and reduces sedative exposure in the ICU. METHODS In this a priori planned substudy conducted at one tertiary care hospital during the Awakening and Breathing Controlled Trial, a multicenter randomized controlled trial, we assessed cognitive, psychological, and functional/quality-of-life outcomes 3 and 12 months postdischarge among 180 medical ICU patients randomized to paired daily spontaneous awakening trials with spontaneous breathing trials (SBTs) or to sedation per usual care plus daily SBTs. MEASUREMENTS AND MAIN RESULTS Cognitive impairment was less common in the intervention group at 3-month follow-up (absolute risk reduction, 20.2%; 95% confidence interval, 1.5-36.1%; P = 0.03) but not at 12-month follow-up (absolute risk reduction, -1.9%; 95% CI, -21.3 to 27.1%; P = 0.89). Composite cognitive scores, alternatively, were similar in the two groups at 3-month and 12-month follow-up (P = 0.80 and 0.61, respectively), as were symptoms of depression (P = 0.59 and 0.82) and posttraumatic stress disorder (P = 0.59 and 0.97). Activities of daily living, functional status, and mental and physical quality of life were similar between groups throughout follow-up. CONCLUSIONS In this trial, management of mechanically ventilated medical ICU patients with a wake up and breathe protocol resulted in similar cognitive, psychological, and functional outcomes among patients tested 3 and 12 months post-ICU. The proven benefits of this protocol, including improved 1-year survival, were not offset by adverse long-term outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 00097630).
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Affiliation(s)
- James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA.
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Girard TD, Kress JP, Fuchs BD, Thomason JWW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371:126-34. [PMID: 18191684 DOI: 10.1016/s0140-6736(08)60105-1] [Citation(s) in RCA: 1212] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely. Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie, daily interruption of sedatives-with spontaneous breathing trials (SBTs). METHODS In four tertiary-care hospitals, we randomly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT (intervention group; n=168) or with sedation per usual care plus a daily SBT (control group; n=168). The primary endpoint was time breathing without assistance. Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00097630. FINDINGS One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up. Seven patients in the control group discontinued their assigned protocol, and two of these patients were lost to follow-up. Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group (14.7 days vs 11.6 days; mean difference 3.1 days, 95% CI 0.7 to 5.6; p=0.02) and were discharged from intensive care (median time in intensive care 9.1 days vs 12.9 days; p=0.01) and the hospital earlier (median time in the hospital 14.9 days vs 19.2 days; p=0.04). More patients in the intervention group self-extubated than in the control group (16 patients vs six patients; 6.0% difference, 95% CI 0.6% to 11.8%; p=0.03), but the number of patients who required reintubation after self-extubation was similar (five patients vs three patients; 1.2% difference, 95% CI -5.2% to 2.5%; p=0.47), as were total reintubation rates (13.8%vs 12.5%; 1.3% difference, 95% CI -8.6% to 6.1%; p=0.73). At any instant during the year after enrolment, patients in the intervention group were less likely to die than were patients in the control group (HR 0.68, 95% CI 0.50 to 0.92; p=0.01). For every seven patients treated with the intervention, one life was saved (number needed to treat was 7.4, 95% CI 4.2 to 35.5). INTERPRETATION Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials (ie, interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice.
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Affiliation(s)
- Timothy D Girard
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA.
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Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, Stiles RA, Dittus RS, Bernard GR, Ely EW. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007; 298:2644-53. [PMID: 18073360 DOI: 10.1001/jama.298.22.2644] [Citation(s) in RCA: 920] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Lorazepam is currently recommended for sustained sedation of mechanically ventilated intensive care unit (ICU) patients, but this and other benzodiazepine drugs may contribute to acute brain dysfunction, ie, delirium and coma, associated with prolonged hospital stays, costs, and increased mortality. Dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction. OBJECTIVE To determine whether dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients while providing adequate sedation as compared with lorazepam. DESIGN, SETTING, PATIENTS, AND INTERVENTION Double-blind, randomized controlled trial of 106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary care centers between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours. Study drugs were titrated to achieve the desired level of sedation, measured using the Richmond Agitation-Sedation Scale (RASS). Patients were monitored twice daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU). MAIN OUTCOME MEASURES Days alive without delirium or coma and percentage of days spent within 1 RASS point of the sedation goal. RESULTS Sedation with dexmedetomidine resulted in more days alive without delirium or coma (median days, 7.0 vs 3.0; P = .01) and a lower prevalence of coma (63% vs 92%; P < .001) than sedation with lorazepam. Patients sedated with dexmedetomidine spent more time within 1 RASS point of their sedation goal compared with patients sedated with lorazepam (median percentage of days, 80% vs 67%; P = .04). The 28-day mortality in the dexmedetomidine group was 17% vs 27% in the lorazepam group (P = .18) and cost of care was similar between groups. More patients in the dexmedetomidine group (42% vs 31%; P = .61) were able to complete post-ICU neuropsychological testing, with similar scores in the tests evaluating global cognitive, motor speed, and attention functions. The 12-month time to death was 363 days in the dexmedetomidine group vs 188 days in the lorazepam group (P = .48). CONCLUSION In mechanically ventilated ICU patients managed with individualized targeted sedation, use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00095251.
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Affiliation(s)
- Pratik P Pandharipande
- Department of Anesthesiology/Division of Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Abstract
ICU delirium represents a form of brain dysfunction that in many cohorts has been diagnosed in 60 to 85% of patients receiving mechanical ventilation. This organ dysfunction is grossly underrecognized because a majority of patients have hypoactive or "quiet" delirium characterized by "negative" symptoms (eg, inattention and a flat affect) not alarming the treating team. Hyperactive delirium, formerly called ICU psychosis, stands out because of symptoms such as agitation that may cause harm to self or staff, but is actually rare relative to hypoactive delirium and associated with a better prognosis. Delirium is often incorrectly thought to be transient and of little consequence. After adjusting for numerous covariates, delirium is a strong, independent predictor of prolonged length of stay, reintubation, higher mortality, and cost of care. Expanded work on patient safety and recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world. This evidence-based review for physicians, nurses, respiratory therapists, and pharmacists will outline why it is imperative that patients be routinely monitored for delirium. This review will discuss modifiable risk factors for delirium, such as metabolic disturbances or potent sedative and analgesic medications. Attention to mitigating risk factors, along with recommended pharmacologic approaches such as antipsychotic medications, may provide resolution of delirium in some patients, while others will persist with refractory brain dysfunction and long-term cognitive impairment following critical illness.
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Affiliation(s)
- Brenda T Pun
- RN, MSN, Center for Health Services Research, Vanderbilt Medical Center, Nashville, TN 37232-8300, USA.
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Abstract
The prevention and treatment of pain, anxiety, and delirium in the ICU are important goals. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry grave risks. Without having an agreed-upon end point for sedation, different providers will likely have disparate treatment goals, increasing the risk of iatrogenic complications and possibly impeding recovery. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations concerning sedation assessment and management, as well as the current literature. Last month, Part 1 reviewed pertinent recommendations concerning pain and delirium and discussed tools for assessing pain, delirium, and sedation. This month, Part 2 explores pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU. The second in a two-part series focuses on the pharmacologic and nonpharmacologic management of anxiety and agitation in the ICU.
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Affiliation(s)
- Brenda T Pun
- Vanderbilt University Medical Center in Nashville, TN, USA.
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Pun BT, Dunn J. The sedation of critically ill adults: Part 1: Assessment. The first in a two-part series focuses on assessing sedated patients in the ICU. Am J Nurs 2007; 107:40-8; quiz 49. [PMID: 17589228 DOI: 10.1097/01.naj.0000279265.66906.2f] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients. The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients.
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Affiliation(s)
- Brenda T Pun
- Vanderbilt University Medical Center, Nashville, TN, USA.
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Ely EW, Girard TD, Shintani AK, Jackson JC, Gordon SM, Thomason JWW, Pun BT, Canonico AE, Light RW, Pandharipande P, Laskowitz DT. Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients. Crit Care Med 2007; 35:112-7. [PMID: 17133176 DOI: 10.1097/01.ccm.0000251925.18961.ca] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test for an association between apolipoprotein E (APOE) genotypes and duration of intensive care unit delirium. DESIGN Prospective, observational cohort study. SETTING A 541-bed, community-based teaching hospital. PATIENTS Fifty-three mechanically ventilated intensive care unit patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients were managed with standardized sedation and ventilator weaning protocols as part of an ongoing clinical trial and were evaluated prospectively for delirium with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). DNA was extracted from whole blood samples obtained on enrollment, and APOE genotype was determined using polymerase chain reaction followed by restriction enzyme digestion by investigators blinded to the clinical information. Delirium occurred in 47 (89%) patients at some point during the intensive care unit stay. Of the 53 patients, 12 (23%) had an APOE4 allele (APOE4+) and 41 (77%) had only APOE2 or APOE3 alleles (APOE4-). APOE4+ patients were younger (53.2 +/- 21.9 vs. 65.4 +/- 13.4, p = .08) and less often admitted for pneumonia (0% vs. 29.3%, p = .05) compared with APOE4- patients, yet they had a duration of delirium that was twice as long: median (interquartile range), 4 (3, 4.5) vs. 2 (1, 4) days (p = .05). No other clinical outcomes were significantly different between the APOE4+ and APOE4- patients. Using multivariable regression analysis to adjust for age, admission diagnosis of sepsis or acute respiratory distress syndrome or pneumonia, severity of illness, and duration of coma, the presence of APOE4 allele was the strongest predictor of delirium duration (odds ratio, 7.32; 95% confidence interval, 1.82-29.51, p = .005). CONCLUSIONS APOE4 allele represents the first demonstrated genetic predisposition to longer duration of delirium in humans.
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Affiliation(s)
- E Wesley Ely
- Department of Medicine, Saint Thomas Hospital, and Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Girard TD, Shintani AK, Jackson JC, Gordon SM, Pun BT, Henderson MS, Dittus RS, Bernard GR, Ely EW. Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care 2007; 11:R28. [PMID: 17316452 PMCID: PMC2151865 DOI: 10.1186/cc5708] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 01/13/2007] [Accepted: 02/22/2007] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) has been identified in a significant portion of intensive care unit (ICU) survivors. We sought to identify factors associated with PTSD symptoms in patients following critical illness requiring mechanical ventilation. METHODS Forty-three patients who were mechanically ventilated in the medical and coronary ICUs of a university-based medical center were prospectively followed during their ICU admission for delirium with the Confusion Assessment Method for the ICU. Additionally, demographic data were obtained and severity of illness was measured with the APACHE II (Acute Physiology and Chronic Health Evaluation II) score. Six months after discharge, patients were screened for PTSD symptoms by means of the Post-Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10). Multiple linear regression was used to assess the association of potential risk factors with PTSS-10 scores. RESULTS At follow-up, six (14%) patients had high levels of PTSD symptoms. On multivariable analysis, women had higher PTSS-10 scores than men by a margin of 7.36 points (95% confidence interval [CI] 1.62 to 13.11; p = 0.02). Also, high levels of PTSD symptoms were less likely to occur in older patients, with symptoms declining after age 50 (p = 0.04). Finally, although causation cannot be assumed, the total dose of lorazepam received during the ICU stay was associated with PTSD symptoms; for every 10-mg increase in cumulative lorazepam dose, PTSS-10 score increased by 0.39 (95% CI 0.17 to 0.61; p = 0.04). No significant relationship was noted between severity of illness and PTSD symptoms or duration of delirium and PTSD symptoms. CONCLUSION High levels of PTSD symptoms occurred in 14% of patients six months following critical illness necessitating mechanical ventilation, and these symptoms were most likely to occur in female patients and those receiving high doses of lorazepam. High levels of PTSD symptoms were less likely to occur in older patients.
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Affiliation(s)
- Timothy D Girard
- Department of Medicine; Division of Allergy, Pulmonary, and Critical Care Medicine; Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
- Center for Health Services Research; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
| | - Ayumi K Shintani
- Department of Biostatistics; Vanderbilt University School of Medicine; S-2323 MCN, Nashville, TN 37232-2158, USA
| | - James C Jackson
- Department of Medicine; Division of Allergy, Pulmonary, and Critical Care Medicine; Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
- Center for Health Services Research; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
- Department of Psychiatry; Vanderbilt University School of Medicine; 1601 23rd Avenue South, Suite 3060, Nashville, TN, 37212, USA
| | - Sharon M Gordon
- Center for Health Services Research; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
- Department of Psychiatry; Vanderbilt University School of Medicine; 1601 23rd Avenue South, Suite 3060, Nashville, TN, 37212, USA
- Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center; 1310 24th Avenue South, Nashville, TN 37212-2637, USA
| | - Brenda T Pun
- Department of Medicine; Division of Allergy, Pulmonary, and Critical Care Medicine; Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
| | - Melinda S Henderson
- Division of General Internal Medicine; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6000; Nashville, TN, 37232-8300, USA
| | - Robert S Dittus
- Center for Health Services Research; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
- Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center; 1310 24th Avenue South, Nashville, TN 37212-2637, USA
- Division of General Internal Medicine; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6000; Nashville, TN, 37232-8300, USA
| | - Gordon R Bernard
- Department of Medicine; Division of Allergy, Pulmonary, and Critical Care Medicine; Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
| | - E Wesley Ely
- Department of Medicine; Division of Allergy, Pulmonary, and Critical Care Medicine; Vanderbilt University School of Medicine; T-1218 MCN, Nashville, TN 37232-2650, USA
- Center for Health Services Research; Vanderbilt University School of Medicine; 6th Floor MCE, Suite 6100, Nashville, TN 37232-8300, USA
- Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center; 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Abstract
OBJECTIVES To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort. DESIGN Prospective cohort study. SETTING The medical intensive care unit (MICU) of a tertiary care academic medical center. PARTICIPANTS Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium. MEASUREMENTS MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type. RESULTS Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status. CONCLUSION Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.
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Affiliation(s)
- Josh F Peterson
- Division of General Internal Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Thomason JWW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005; 9:R375-81. [PMID: 16137350 PMCID: PMC1269454 DOI: 10.1186/cc3729] [Citation(s) in RCA: 373] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Accepted: 05/04/2005] [Indexed: 02/08/2023]
Abstract
Introduction Delirium occurs in most ventilated patients and is independently associated with more deaths, longer stay, and higher cost. Guidelines recommend monitoring of delirium in all intensive care unit (ICU) patients, though few data exist in non-ventilated patients. The study objective was to determine the relationship between delirium and outcomes among non-ventilated ICU patients. Method A prospective cohort investigation of 261 consecutively admitted medical ICU patients not requiring invasive mechanical ventilation during hospitalization at a tertiary-care, university-based hospital between February 2002 and January 2003. ICU nursing staff assessed delirium and level of consciousness at least twice per day using the Confusion Assessment Method for the ICU (CAM-ICU) and Richmond Agitation-Sedation Scale (RASS). Cox regression with time-varying covariates was used to determine the independent relationship between delirium and clinical outcomes. Results Of 261 patients, 125 (48%) experienced at least one episode of delirium. Patients who experienced delirium were older (mean ± SD: 56 ± 18 versus 49 ± 17 years; p = 0.002) and more severely ill as measured by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (median 15, interquartile range (IQR) 10–21 versus 11, IQR 6–16; p < 0.001) compared to their non-delirious counterparts. Patients who experienced delirium had a 29% greater risk of remaining in the ICU on any given day (compared to patients who never developed delirium) even after adjusting for age, gender, race, Charlson co-morbidity score, APACHE II score, and coma (hazard ratio (HR) 1.29; 95% confidence interval (CI) 0.98–1.69, p = 0.07). Similarly, patients who experienced delirium had a 41% greater risk of remaining in the hospital after adjusting for the same covariates (HR 1.41; 95% CI 1.05–1.89, p = 0.023). Hospital mortality was higher among patients who developed delirium (24/125, 19%) versus patients who never developed delirium (8/135, 6%), p = 0.002; however, time to in-hospital death was not significant the adjusted (HR 1.27; 95% CI 0.55–2.98, p = 0.58). Conclusion Delirium occurred in nearly half of the non-ventilated ICU patients in this cohort. Even after adjustment for relevant covariates, delirium was found to be an independent predictor of longer hospital stay.
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Affiliation(s)
- Jason WW Thomason
- Attending Physician, Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ayumi Shintani
- Research Assistant Professor of Biostatistics and Medicine, Departments of Internal Medicine, Divisions of General Internal Medicine and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Josh F Peterson
- Assistant Professor of Medicine and Bioinformatics, Departments of Internal Medicine, Divisions of General Internal Medicine and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Brenda T Pun
- Clinical Assistant Professor of Nursing, Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James C Jackson
- Research Assistant Professor of Medicine and Psychiatry, Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - E Wesley Ely
- Associate Professor of Medicine, Division of Allergy/Pulmonary/Critical Care Medicine and Center of Health Services Research, Associate Director of Research, VA Tennessee Valley Geriatric Research, Education and Clinical Center (CRECC), Vanderbilt University School of Medicine, Nashville, TN, USA
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