Days Of Delirium Research Articles

Effect of ABCDE Bundle Implementation on Prevalence of Delirium in Intensive Care Unit Patients.

The ABCDE bundle incorporates multidisciplinary measures to improve and/or preserve patients' physical, functional, and neurocognitive status through awakening and breathing coordination, delirium prevention and management, and early physical mobility. To quantify the prevalence and duration of delirium in patients in the intensive care unit (ICU) before and after implementation of the ABCDE bundle. Delirium prevalence was defined as the percentage of patients who had at least 1 positive delirium score on the Intensive Care Delirium Screening Checklist (ICDSC) during the ICU stay; delirium duration was the number of days during the ICU stay that a positive ICDSC score was noted. Retrospective data were collected from before and after implementation of the ABCDE bundle. Of the 159 records reviewed (80 before and 79 after bundle implementation), most were for white men (mean age, 66.3 years). After implementation of the ABCDE bundle, the prevalence of delirium decreased significantly (from 38% to 23%, P = .01) and the mean number of days of delirium decreased significantly (from 3.8 to 1.72 days, P < .001). The number of patients with delirium-free stays increased after bundle implementation. Implementation of the ABCDE bundle led to significant decreases in the prevalence and duration of delirium in ICU patients.

Interprofessional Perspectives on ABCDE Bundle Implementation

The ABCDE bundle is a multifaceted, interprofessional intervention that is associated with reduced ventilator and delirium days as well as increased likelihood of mobility in intensive care. The aim of this study is to describe organizational domains that contribute to variation in ABCDE bundle implementation as reported by intensive care unit providers and to examine the capability of a conceptual framework for identifying variation in ABCDE bundle implementation. We conducted 2 separate focus groups that included nurses, respiratory therapists, occupational and physical therapists (N = 16) from the surgical and medical intensive care units at 1 academic medical center. All participants had experience performing ABCDE bundle activities. Variation in how the ABCDE bundle was interpreted and executed within and across disciplines was noted. Organizational facets, the physical environment, labor quantity and quality, task burden, provider attitudes, and patient characteristics were noted to influence ABCDE bundle execution. The difficulty coordinating and implementing early mobility was emphasized. The number of disciplines required to perform an activity and individual component complexity was reported to influence ABCDE bundle implementation. Nurses repeatedly described challenges with coordinating care across disciplines. Small tests of change, adequate staffing, interprofessional training and protocol development efforts, and role modeling may be effective methods for successful ABCDE bundle implementation.

Long-Term Mental Health Problems After Delirium in the ICU*

To determine whether delirium during ICU stay is associated with long-term mental health problems defined as symptoms of anxiety, depression, and posttraumatic stress disorder. Prospective cohort study. Survey study, 1 year after discharge from a medical-surgical ICU in the Netherlands. One-year ICU survivors of an ICU admission lasting more than 48 hours, without a neurologic disorder or other condition that would impede delirium assessment during ICU stay. None. One year after discharge, ICU survivors received a survey containing the Hospital Anxiety and Depression Scale with a subscale for symptoms of depression and a subscale for symptoms of anxiety, and the Impact of Event Scale 15 item measuring symptoms of posttraumatic stress disorder. Participants were classified as having experienced no delirium (n = 270; 48%), a single day of delirium (n = 86; 15%), or multiple days of delirium (n = 211; 37%) during ICU stay. Log-binomial regression was used to assess the association between delirium and symptoms of anxiety, depression, and posttraumatic stress disorder. The study population consisted of 567 subjects; of whom 246 subjects (43%) reported symptoms of anxiety (Hospital Anxiety and Depression Scale with a subscale for anxiety, ≥ 8), and 254 (45%) symptoms of depression (Hospital Anxiety and Depression Scale with a subscale for depression, ≥ 8). In 220 patients (39%), the Impact of Event Scale 15 item was greater than or equal to 35, indicating a high probability of posttraumatic stress disorder. There was substantial overlap between these mental health problems-63% of the subjects who scored positive for the presence of any three of the mental health problems, scored positive for all three. No association was observed between either a single day or multiple days of delirium and symptoms of anxiety, depression, or posttraumatic stress disorder. Although symptoms of anxiety, depression, and posttraumatic stress disorder were found to be common 1 year after critical illness, the occurrence of delirium during ICU stay did not increase the risk of these long-term mental health problems.

Use of a Structured Mirrors Intervention Does Not Reduce Delirium Incidence But May Improve Factual Memory Encoding in Cardiac Surgical ICU Patients Aged Over 70 Years: A Pilot Time-Cluster Randomized Controlled Trial.

Introduction: Post-operative delirium remains a significant problem, particularly in the older surgical patient. Previous evidence suggests that the provision of supplementary visual feedback about ones environment via the use of a mirror may positively impact on mental status and attention (core delirium diagnostic domains). We aimed to explore whether use of an evidence-based mirrors intervention could be effective in reducing delirium and improving post-operative outcomes such as factual memory encoding of the Intensive Care Unit (ICU) environment in older cardiac surgical patients.Methods: This was a pilot time-cluster randomized controlled trial at a 32-bed ICU, enrolling 223 patients aged 70 years and over, admitted to ICU after elective or urgent cardiac surgery from October 29, 2012 to June 23, 2013. The Mirrors Group received a structured mirrors intervention at set times (e.g., following change in mental status). The Usual Care Group received the standard care without mirrors. Primary outcome was ICU delirium incidence; secondary outcomes were ICU delirium days, ICU days with altered mental status or inattention, total length of ICU stay, physical mobilization (balance confidence) at ICU discharge, recall of factual and delusional ICU memories at 12 weeks, Health-Related Quality of Life at 12 weeks, and acceptability of the intervention.Results: The intervention was not associated with a significant reduction in ICU delirium incidence [Mirrors: 20/115 (17%); Usual Care: 17/108 (16%)] or duration [Mirrors: 1 (1–3); Usual Care: 2 (1–8)]. Use of the intervention on ICU was predictive of significantly higher recall of factual (but not delusional) items at 12 weeks after surgery (p = 0.003) and acceptability was high, with clinicians using mirrors at 86% of all recorded hourly observations. The intervention did not significantly impact on other secondary outcomes.Conclusion: Use of a structured mirrors intervention on the post-operative ICU does not reduce delirium, but may result in improved factual memory encoding in older cardiac surgical patients. This effect may occur via mechanisms unrelated to delirium, altered mental status, or inattention. The intervention may provide a new means of improving outcomes in patients at risk of post-ICU anxiety and/or Post-Traumatic Stress Disorder.Trial Registration: Clinicaltrials.gov identifier NCT01599689.

Delirium in Survivors of Cardiac Arrest Treated With Mild Therapeutic Hypothermia.

Mild therapeutic hypothermia is recommended for comatose patients resuscitated from cardiac arrest. However, the prevalence of delirium and its associated risk factors have not been assessed in survivors of cardiac arrest treated with therapeutic hypothermia. To determine the prevalence of and risk factors for delirium among survivors of cardiac arrest who were treated with therapeutic hypothermia. A retrospective observational study of patients treated with therapeutic hypothermia after cardiac arrest from 2007 through 2014. Baseline demographic data and daily delirium assessments throughout the intensive care unit stay were obtained. The association between duration of delirium and various risk factors was assessed. Of 251 patients, 107 (43%) awoke from coma. Among the 107 survivors, all had at least 1 day of delirium during their intensive care unit stay. Median number of days of delirium was 4.0 (interquartile range, 2.0-7.5). Multivariable analysis revealed that age (odds ratio, 1.72; 95% CI, 1.0-2.95; P = .05), time from cardiopulmonary resuscitation to return of spontaneous circulation (odds ratio 1.52; 95% CI, 1.11-2.07; P = .01), and total dose of prewarming propofol (odds ratio, 0.02; 95% CI, 0.00-0.48; P = .02) were associated with duration of delirium. All survivors of cardiac arrest treated with mild therapeutic hypothermia had at least 1 day of delirium. Age and time from initiation of cardiopulmonary resuscitation to return of spontaneous circulation were associated with prolonged delirium, whereas exposure to propofol was protective against delirium. These findings are limited to this unique cohort and may not be generalizable to different populations.

Quantifying the Severity of a Delirium Episode Throughout Hospitalization: the Combined Importance of Intensity and Duration.

The ability to determine which episodes of delirium are likely to lead to poor clinical outcomes has remained a major area of challenge. To quantify delirium severity and course over an entire hospitalization using several measures, and to evaluate their predictive validity for 30- and 90-day outcomes post-discharge. Two prospective cohort studies. Analysis was conducted in two independent cohorts of adult patients aged ≥70. Nine delirium episode severity measures were examined: (1) measures reflecting delirium intensity (peak Confusion Assessment Method-Severity [CAM-S] and mean CAM-S score), (2) a measure reflecting delirium intensity and duration (sum of all CAM-S scores, sum of all CAM-S scores on delirium days only, peak CAM-S score x days with delirium), (3) measures requiring information on delirium duration and delirium at discharge (total number of delirium days, percentage of delirium days, delirium at discharge), and (4) a measure of cognitive change. Associations of the delirium episode severity measures with 30- and 90-day post-hospital outcomes (death, nursing home placement, and readmission) relevant to delirium were examined. The delirium episode severity measure that required information on both delirium intensity and duration (sum of all CAM-S scores) was the most strongly associated with 30- and 90-day post-hospital outcomes. Using this measure, the relative risk [95% confidence interval] for death at 30-days increased across levels of sum of all CAM-S scores from 1.0 (referent) to 2.1 [0.8, 5.4] for 'low,' to 2.9 [1.2, 7.1] for 'moderate,' to 6.4 [2.9, 14.0] for 'high' (p for trend <.01). The delirium episode severity measure that included both intensity and duration had the strongest association with important post-hospital outcomes.

Influence of Granulocyte-Macrophage Colony-Stimulating Factor or Influenza Vaccination on HLA-DR, Infection and Delirium Days in Immunosuppressed Surgical Patients: Double Blind, Randomised Controlled Trial.

PurposeSurgical patients are at high risk for developing infectious complications and postoperative delirium. Prolonged infections and delirium result in worse outcome. Granulocyte-macrophage colony-stimulating factor (GM-CSF) and influenza vaccination are known to increase HLA-DR on monocytes and improve immune reactivity. This study aimed to investigate whether GM-CSF or vaccination reverses monocyte deactivation. Secondary aims were whether it decreases infection and delirium days after esophageal or pancreatic resection over time.MethodsIn this prospective, randomized, placebo-controlled, double-blind, double dummy trial setting on an interdisciplinary ICU of a university hospital 61 patients with immunosuppression (monocytic HLA-DR [mHLA-DR] <10,000 monoclonal antibodies [mAb] per cell) on the first day after esophageal or pancreatic resection were treated with either GM-CSF (250 μg/m2/d), influenza vaccination (Mutagrip 0.5 ml/d) or placebo for a maximum of 3 consecutive days if mHLA-DR remained below 10,000 mAb per cell. HLA-DR on monocytes was measured daily until day 5 after surgery. Infections and delirium were followed up for 9 days after surgery. Primary outcome was HLA-DR on monocytes, and secondary outcomes were duration of infection and delirium.ResultsmHLA-DR was significantly increased compared to placebo (p < 0.001) and influenza vaccination (p < 0.001) on the second postoperative day. Compared with placebo, GM-CSF-treated patients revealed shorter duration of infection (p < 0.001); the duration of delirium was increased after vaccination (p = 0.003).ConclusionTreatment with GM-CSF in patients with postoperative immune suppression was safe and effective in restoring monocytic immune competence. Furthermore, therapy with GM-CSF reduced duration of infection in immune compromised patients. However, influenza vaccination increased duration of delirium after major surgery.Trial Registration www.controlled-trials.com ISRCTN27114642

Original Research: Implementation of an Early Mobility Program in an ICU.

Research is needed to determine the feasibility of implementing a dedicated ICU mobility team in community hospital settings. The purpose of this study was to assess, in one such hospital, four nurse-sensitive quality-of-care outcomes (falls, ventilator-associated events, pressure ulcers, and catheter-associated urinary tract infections [CAUTIs]), as well as hospital costs, sedation and delirium measures, and functional outcomes by comparing ICU patients who received physical therapy from a dedicated mobility team with ICU patients who received routine care. We conducted a retrospective longitudinal study at a community acute care hospital; patients were randomly assigned to intervention or routine care groups. The mobility team screened patients Monday through Friday using a mobility algorithm to determine eligibility for participation in each early mobility session. Based on their strength, balance, hemodynamic stability, and ability to participate in early mobility activities, patients advanced through four progressively difficult phases of mobility. Data were collected and analyzed after patients were discharged from the hospital. The 66 patients who received the mobility intervention had significantly fewer falls, ventilator-associated events, pressure ulcers, and CAUTIs than the 66 patients in the routine care group. The mobility group also had lower hospital costs, fewer delirium days, lower sedation levels, and improved functional independence compared with the routine care group. Patients in the mobility group got out of bed on 2.5 more days than patients in the routine care group. There were also no adverse events in the mobility group. It is feasible for a community hospital to create and implement a dedicated ICU mobility team. Early mobilization of ICU patients contributed to fewer delirium days and improved patient outcomes, sedation levels, and functional status.

Delirium in critically ill military patients following trauma: A cohort analysis.

Critically ill military trauma patients have been found to have a high incidence of psychological morbidity following their Intensive Care Unit (ICU) experience, including recall of significant auditory and visual hallucinations. It follows that this may be attributable to delirium, which has not been previously described in a young, previously fit population following trauma. The case-notes of 85 male patients (mean age 26 years), admitted to a single UK ICU following military trauma, were retrospectively assessed for delirium using DSM-IV criteria. Of the 993 ICU days assessed, 13.4% were delirium-positive, with just over half of patients (51.8%) experiencing at least one day of delirium. On delirium-positive days, 69.2% received a documented intervention, with the majority of interventions (66.4%) being pharmacological, commonly with a sedative or anti-psychotic. Presence of delirium was significantly associated with severity of injury, assessed by Injury Severity Score (OR 1.037, 95% CI 1.003-1.072, p = 0.031). Duration of ICU stay was significantly increased, from 4 to 8 days (p < 0.005), as was the duration of mechanical ventilation (for the 84.7% of patients who were ventilated) from 7 to 13 days (p < 0.005). Delirium is common in military trauma patients, despite their young age and premorbid fitness. A review of longer-term psychological outcomes should be considered.

Does Apolipoprotein E Genotype Increase Risk of Postoperative Delirium?

To determine whether apolipoprotein E (ApoE) is associated with postoperative delirium incidence, severity, and duration in older patients free of dementia at baseline. The authors examined 557 nondemented patients aged 70 years or older undergoing major noncardiac surgery enrolled in the Successful Aging after Elective Surgery Study. Three ApoE measures were considered: ε2, ε4 carriers versus noncarriers, and a three-category ApoE measure. Delirium was determined using the Confusion Assessment Method (CAM) and chart review. We used generalized linear models to estimate the association between ApoE and delirium incidence, severity (peak CAM Severity [CAM-S] score), and days. ApoE ε2 and ε4 was present in 15% and 19%, respectively, and postoperative delirium occurred in 24%. Among patients with delirium, the mean peak CAM-S score was 8.0 (standard deviation: 4), with most patients experiencing 1 or 2 delirium days (51% or 28%, respectively). After adjusting for age, sex, surgical procedure, and preoperative cognitive function, ApoE ε4 and ε2 carrier status were not associated with postoperative delirium: RR for ε4=1.0, 95% CI: 0.7-1.5 and RR for ε2=0.9, 95% CI: 0.6-1.4. No association between ApoE and delirium severity or number of delirium days was observed. In older surgery patients free of dementia, our findings do not support the hypothesis that the ApoE genotype does not confer either risk or protection in postoperative delirium incidence, severity, or duration. Thus, an important genetic risk factor for Alzheimer disease does not affect risk of delirium.

What is Recovery From Delirium? Defining Recovery in Delirium.

Introduction Delirium is a common neuropsychiatric disorder. The natural course is of an acute, fluctuating and often transient condition; however, accumulating evidence suggests delirium can be associated with incomplete recovery. Despite the growing body of relevant research, a lack of clarity exists regarding definition and outcomes. Objectives To clarify the definition of recovery of delirium used in the literature. Methods A Medline search was performed using relevant keywords. Studies were included if they were in English, provided any definition of recovery, and were longitudinal. Excluded articles were duplicated studies, case studies, review articles or articles related to alcohol, children, subsyndromal delirium only or those investigating core symptoms such as function. Results Fifty-six studies met the inclusion criteria. Only 2 studies used clinical criteria alone for the diagnosis of delirium, most studies used at least one validated scale, either categorical or continuous severity scales. A variety of 16 different terms were used to define the 'recovery of delirium”. The definitions of each term also varied. Studies using severity scales used either cut-off points or percentage reduction between assessments while others using dichotomous scales (yes/ no) defined as recovery one or more days of negative delirium as the end point. Conclusions An agreed terminology to define recovery in delirium is required. A distinction should also be made between symptomatic and overall recovery as well as between long and short term outcomes. It is proposed that cognition recovery may be used as outcome to identify recovery of delirium.

Preoperative education on postoperative delirium, anxiety, and knowledge in pulmonary thromboendarterectomy patients.

Delirium is the most common postoperative psychiatric condition in intensive care settings and can lead to increased complications and costs. To evaluate the impact of multifaceted preoperative patient education on postoperative delirium, anxiety, and knowledge and to explore predictors of postoperative delirium, days of mechanical ventilation, and days in the intensive care unit (ICU) in patients undergoing pulmonary thromboendarterectomy. A prospective, randomized controlled trial was conducted on consented patients from October 2011 to April 2013. Patients were randomized in a 1 to 1 ratio to receive either an individualized 45-minute multifaceted preoperative education (experimental group, n = 63) or standard education (control group, n = 66). Participants completed the State-Trait Anxiety Inventory and Knowledge Test before and after the education. Data on incidence of delirium, days of mechanical ventilation, ICU days, and cardiopulmonary parameters were collected. The experimental group had significantly more knowledge about postoperative care (P< .001) and fewer days of mechanical ventilation (P = .04) than the control group. The 2 groups did not differ significantly in anxiety, incidence of delirium, or ICU days. In exploratory multivariate analyses, hearing impairment was a positive predictor for days of delirium (P = .009), days of mechanical ventilation (P< .001), and ICU days (P= .049), whereas the posttest knowledge was a negative predictor for days of mechanical ventilation (P = .02). The patient education appeared to be effective in improving knowledge and reducing days of mechanical ventilation. Hearing impairment was an unexpected predictor of adverse outcomes for patients but may be amenable to nursing intervention.

Evaluation of the PRE-DELIRIC delirium prediction tool on a general ICU

Delirium is a frequently occurring complication of critical care, occurring in approximately 45% of unplanned UK ICU admissions [1]. The presence of delirium in critical care is an independent risk factor for mortality; for every day of delirium, there is an additional 10% relative risk of death at 1 year [2]. A delirium prediction tool PREDELIRIC has been recently developed and calibrated in a multinational project [3]. This study aimed to determine the utility of PRE-DELIRIC on our ICU.

Defining 'recovery' for delirium research: a systematic review.

Delirium is a common neuropsychiatric disorder. The natural course is of an acute, fluctuating and often transient condition; however, accumulating evidence suggests that delirium can be associated with incomplete recovery. Despite a growing body of research, a lack of clarity exists regarding definition and outcomes. To clarify the definition of recovery of delirium used in the literature. A Medline search was performed using relevant keywords. Studies were included if they were in English, provided any definition of recovery and were longitudinal. Excluded articles were duplicated studies, case studies, review articles or articles related to alcohol, children, subsyndromal delirium only or those investigating core symptoms such as function. Fifty-six studies met the inclusion criteria. Only two studies used clinical criteria alone for the diagnosis of delirium; most studies used at least one validated scale-either categorical or continuous severity scales. A variety of 16 different terms were used to define the 'recovery of delirium'. The definitions of each term also varied. Studies using severity scales used either cut-off points or percentage reduction between assessments, while others using dichotomous scales (yes/no) defined recovery as one or more days of negative delirium. An agreed terminology to define recovery in delirium is required. A distinction should also be made between symptomatic and overall recovery, as well as between long- and short-term outcomes. It is proposed that cognitive recovery should be central to defining recovery in delirium.

Classification of daily mental status in critically ill patients for research purposes

PurposeThe purpose of this study is to develop a reliable tool for daily mental status classification in intensive care unit (ICU) patients for research purposes. Secondly, to identify patients with single, 1-day episodes of delirium and to compare them with patients having more delirium days or episodes. Patients and methodsA 5-step algorithm was designed, which includes Richmond Agitation Sedation Scale and Confusion Assessment Method for the ICU scores from bedside nurses, initiation of delirium treatment, chart review, and the Confusion Assessment Method for the ICU administered by researchers. This algorithm was validated against a reference standard of delirium experts. Subsequently, a cohort study was performed in patients admitted to a mixed ICU. ResultsIn 65 paired observations, the algorithm had 0.75 sensitivity and 0.85 specificity. Applying the algorithm, interobserver agreement was high with mean Fleiss κ of 0.94 (5 raters) and 0.97 (4 raters). In the cohort study, 1112 patients were included of whom 535 (48%) became delirious. Single, 1-day episodes occurred in 43% of the delirious patients, whom were characterized by lower age compared with those with more delirium days. ConclusionsThe algorithm for daily mental status classification seems to be a valid tool. In a substantial proportion of patients, delirium occurs only once during ICU admission lasting only 1 day.

SS4.03: ‘Crossing the last border as good as possible …’ A multidisciplinary session around palliative care, especially spiritual care, dementia, delirium and last days of life

SS4.03: ‘Crossing the last border as good as possible …’ A multidisciplinary session around palliative care, especially spiritual care, dementia, delirium and last days of life

The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients.

Sleep deprivation is common among intensive care patients and may be associated with delirium. We investigated whether the implementation of a bundle of non-pharmacological interventions, consisting of environmental noise and light reduction designed to reduce disturbing patients during the night, was associated with improved sleep and a reduced incidence of delirium. The study was divided into two parts, before and after changing our practice. One hundred and sixty-seven and 171 patients were screened for delirium pre- and post-intervention, respectively. Compliance with the interventions was > 90%. The bundle of interventions led to an increased mean (SD) sleep efficiency index (60.8 (3.5) before vs 75.9 (2.2) after, p = 0.031); reduced mean sound (68.8 (4.2) dB before vs 61.8 (9.1) dB after, p = 0.002) and light levels (594 (88.2) lux before vs 301 (53.5) lux after, p = 0.003); and reduced number of awakenings caused by care activities overnight (11.0 (1.1) before vs 9.0 (1.2) after, p = 0.003). In addition, the introduction of the care bundle led to a reduced incidence of delirium (55/167 (33%) before vs 24/171 (14%) after, p < 0.001), and less time spent in delirium (3.4 (1.4) days before vs 1.2 (0.9) days after, p = 0.021). Increases in sleep efficiency index were associated with a lower odds ratio of developing delirium (OR 0.90, 95% CI 0.84-0.97). The introduction of an environmental noise and light reduction programme as a bundle of non-pharmacological interventions in the intensive care unit was effective in reducing sleep deprivation and delirium, and we propose a similar programme should be implemented more widely.

Association Between Endothelial Dysfunction and Acute Brain Dysfunction During Critical Illness

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.

Improved Analgesia, Sedation, and Delirium Protocol Associated with Decreased Duration of Delirium and Mechanical Ventilation

Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and (3) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P < 0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P < 0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P < 0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

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Introduction: Early identification and modification are key strategies for preventing and decreasing delirium duration. Delirium costs an estimated $38 to $152 billion per year per health care systems. Delirium development is associated with negative outcomes in ICU patients, often manifesting as prolonged ICU and hospital lengths of stay (LOS), loss of adaptive function, development of post-ICU cognitive impairment, and increased mortality in ICU population. Many patient environment and iatrogenic factors that contribute to the development of delirium in acute and critically ill patients are modifiable. The overall purpose of the study was to evaluate the effectiveness of a delirium prevention bundle in reducing the incidence and duration of delirium in adult ICU patients. Methods: This cohort intervention study was conducted in two medical-surgical ICUs at a large tertiary care hospital in the Texas Medical Center in Houston, Texas. Data Collection involved the use of three instruments: Richmond Agitation Sedation Scale (RASS); Confusion Assessment Method-ICU (CAM-ICU); and a researcher-generated data collection tool. Results: Data collected January 2012 through August 2012 resulted in a heterogeneous sample in both the control and intervention units. Sample size was 782 patients with over 23,430 observations. Data was analyzed for patients who had <30 days of observation. Delirium incidence was 43% in all 15 ICUs, which coincides with the national rate. Patients requiring mechanical ventilation or restraint demonstrated statistically significant odds of developing at least one day of delirium (p<0.0001). Patients who stayed in the ICU >3 days demonstrated statistically significant odds of developing at least one day of delirium (p<0.001). Patients with >3 lines, tubes or drains were more likely to develop delirium (p=0.017). Patients who experienced significant events or complications (i.e.. active bleeding requiring blood replacement, hemodynamic instability, cardiac arrest, new episode of documented sepsis, etc…) were more likely to develop delirium (OR = 3.86, p<0.001). The odds of developing delirium increased by 2.5% (p=0.13) for every day in the control unit, while the odds decreased by 4.8% (p=0.08) per day for every day in the intervention unit. The overall effect of implementing the bundle reduced the odds of delirium by 7.1% (p=0.02). Early and progressive mobilization significantly decreased the odds of developing delirium by 37% (OR = 0.37, p=0.004), while a small sample size of those on the sedation protocol failed to demonstrate a significant finding. Conclusions: It is feasible for staff nurses to effectively use the CAM-ICU at the bedside to assess patients for delirium. Use of a delirium prevention bundle in the ICU setting is an effective and feasible method to decrease the incidence of delirium in ICU patients. Hospitals should consider implementing a core model of delirium prevention care that combines evidence-based strategies with nursing interventions that are integrated into routine ICU care.