Abstract
IntroductionDelirium is a serious and prevalent problem in intensive care units (ICUs). The purpose of this study was to develop a research algorithm to enhance detection of delirium in critically ill ICU patients using chart review to complement a validated clinical delirium instrument.MethodsA prospective cohort study was conducted in 178 patients aged 60 years and older who were admitted to the medical ICU. The Confusion Assessment Method for the ICU (CAM-ICU) and a validated chart review method for detecting delirium were performed daily. We assessed the diagnostic accuracy of the chart-based delirium method using the CAM-ICU as the 'gold standard'. We then used an algorithm to detect delirium first using the CAM-ICU ratings and then chart review when the CAM-ICU was unavailable.ResultsWhen using both the CAM-ICU and the chart-based review, the prevalence of delirium was found to be 80% of patients (143 out of 178) or 64% of patient-days (929 out of 1,457). Of these patient-days, 292 were classified as delirium by the CAM-ICU. The remainder (637 patient-days) were classified as delirium by the validated chart review method when CAM-ICU was missing because the assessment was conducted for weekends or holidays (404 patient-days), when CAM-ICU was not performed because of stupor or coma (205 patient-days), and when the CAM-ICU was negative (28 patient-days). Sensitivity of the chart-based method was 64% and specificity was 85%. Overall agreement between chart and the CAM-ICU was 72%.ConclusionEight out of 10 patients in this cohort study developed delirium in the ICU. Although use of a validated delirium instrument with frequent direct observations is recommended for clinical care, this approach may not always be feasible, especially in a research setting. The algorithm proposed here comprises a more comprehensive method for detecting delirium in a research setting, taking into account the fluctuation that occurs with delirium, which is a key component of accurate determination of delirium status. Improving detection of delirium is of paramount importance both to advance delirium research and to enhance clinical care and patient safety.
Highlights
Delirium is a serious and prevalent problem in intensive care units (ICUs)
The remainder (637 patient-days) were classified as delirium by the validated chart review method when Confusion Assessment Method for the ICU (CAM-ICU) was missing because the assessment was conducted for weekends or holidays (404 patient-days), when CAM-ICU was not performed because of stupor or coma (205 patient-days), and when the CAM-ICU was negative (28 patientdays)
Use of a validated delirium instrument with frequent direct observations is recommended for clinical care, this approach may not always be feasible, especially in a research setting
Summary
The purpose of this study was to develop a research algorithm to enhance detection of delirium in critically ill ICU patients using chart review to complement a validated clinical delirium instrument. Delirium is a common disorder among older intensive care unit (ICU) patients because of their advanced age, critical illness, and multiple medical procedures and interventions [1,2,3]. Ventilated patients are at risk for the development of delirium due to multi-system illnesses, co-morbidities, and medications. The Society for Critical Care Medicine sedation guidelines [8] recommend delirium assessment in all ICU patients using a validated assessment instrument. Recent studies have documented the usefulness of the Confusion Assessment Method for the ICU (CAM-ICU) in detecting delirium in critically ill patients [3,9,10]. In the absence of such assessments, delirium in the ICU is frequently missed because of its predominately hypoactive state [12,13]
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