Abstract
Delirium is associated with poor outcomes among critically ill patients. However, it is not well characterized among patients with ischemic or hemorrhagic stroke (IS and HS). We provide the population-level frequency of in-hospital delirium and assess its association with in-hospital outcomes and with 30-day readmission among IS and HS patients. We analyzed Nationwide in-hospital and readmission data for years 2010-2015 and identified stroke patients using ICD-9 codes. Delirium was identified using validated algorithms. Outcomes were in-hospital mortality, length of stay, unfavorable discharge disposition, and 30-day readmission. We used survey design logistic regression methods to provide national estimates of proportions and 95% confidence intervals (CI) for delirium, and odds ratios (OR) for association between delirium and poor outcomes. We identified 3,107,437 stroke discharges of whom 7.45% were coded to have delirium. This proportion significantly increased between 2010 (6.3%) and 2015 (8.7%) (aOR, 95% CI: 1.04, 1.03-1.05). Delirium proportion was higher among HS patients (ICH: 10.0%, SAH: 9.8%) as compared to IS patients (7.0%). Delirious stroke patients had higher in-hospital mortality (12.3% vs. 7.8%), longer in-hospital stay (11.6 days vs. 7.3 days) and a significantly greater adjusted risk of 30-day-readmission (16.7%) as compared to those without delirium (12.2%) (aRR, 95% CI: 1.13, 1.11-1.15). Upon readmission, patients with delirium at initial admission continued to have a longer length of stay (7.7 days vs. 6.6 days) and a higher in-hospital mortality (9.3% vs. 6.4%). Delirium identified through claims data in stroke patients is independently associated with poor in-hospital outcomes both at index admission and readmission. Identification and management of delirium among stroke patients provides an opportunity to improve outcomes.
Highlights
Delirium is characterized by an acute disturbance of attention and awareness.[1]
We provide the population-level frequency of in-hospital delirium and assess its association with in-hospital outcomes and with 30-day readmission among IS and HS patients
Delirium proportion was higher among HS patients (ICH: 10.0%, sub-arachnoid hemorrhage (SAH): 9.8%) as compared to IS patients (7.0%)
Summary
The majority of the literature on ICU delirium comprises studies that exclude neuro-critical care populations. This is understandable given the difficulties in implementing commonly used delirium screening tools in patients with neurologic catastrophes such as ischemic or hemorrhagic stroke (IS and HS). The frequency of delirium among IS and HS patients reported from single center studies ranges between 12% and 43%.[9, 10] the current literature neither provides a comprehensive view of population-based delirium frequency among various types of stroke patients, nor does it shed light on the relationship between delirium and other relevant outcomes such as mortality, length of stay, discharge disposition and early hospital readmissions in neuro-critically ill patients
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