[Knowledge and implementation of the S3 guideline on delirium management in Germany]

Forecasting Postoperative Delirium in Older Adult Patients with Fast-and-Frugal Decision Trees

Postoperative delirium (POD) is associated with increased complication and mortality rates, particularly among older adult patients. However, guideline recommendations for POD detection and management are poorly implemented. Fast-and-frugal trees (FFTrees), which are simple prediction algorithms, may be useful in this context. We compared the capacity of simple FFTrees with two more complex models—namely, unconstrained classification trees (UDTs) and logistic regression (LogReg)—for the prediction of POD among older surgical patients in the perioperative setting. Models were trained and tested on the European BioCog project clinical dataset. Based on the entire dataset, two different FFTrees were developed for the pre-operative and postoperative settings. Within the pre-operative setting, FFTrees outperformed the more complex UDT algorithm with respect to predictive balanced accuracy, nearing the prediction level of the logistic regression. Within the postoperative setting, FFTrees outperformed both complex models. Applying the best-performing algorithms to the full datasets, we proposed an FFTree using four cues (Charlson Comorbidity Index (CCI), site of surgery, physical status and frailty status) for the pre-operative setting and an FFTree containing only three cues (duration of anesthesia, age and CCI) for the postoperative setting. Given that both FFTrees contained considerably fewer criteria, which can be easily memorized and applied by health professionals in daily routine, FFTrees could help identify patients requiring intensified POD screening.

Delirium on stroke units: a prospective, multicentric quality-improvement project

Background

Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management.

Methods

Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others.

Results

Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved.

Conclusions

Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke.

Registry

DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11000-6.

[Disorientation and delirium assessment : A secondary analysis of a prospective, observational study]

Disorientation may present as a warning sign of developing delirium. The most commonly used delirium assessment tool in Germany, the Confusion Assessment Method for Intensive Care Unit (CAM-ICU), does not rate "disorientation", since intubated patients cannot communicate verbally. However, the majority of German ICU patients are not orally intubated, so they could be examined for their orientation. This study was carried out to investigate whether the delirium feature "disorientation" in extubated patients yields diverging findings in comparison to the CAM-ICU and whether the sensitivity of the CAM-ICU may be improved when combined with the feature "disorientation" (CAM-IMC). A total of 86 paired assessments were completed in 50 extubated patients. Delirium was found in 19.8% (N = 17). The CAM-ICU had a sensitivity of 71% (95% confidence interval [CI] 44-90%) and a specificity of 100% (95-100%). Disorientation, if taken as the only delirium feature, had a sensitivity of 77% (50-93%) and a specificity of 93% (89-100%). The CAM-IMC reached a sensitivity of 88% (64-99%) and a specificity of 100% (95-100%). The receiver operating characteristics (ROC) analyses found an area under the curve (AUC) of 0.941 (95%CI 0.851-1.000) for the CAM-IMC, which was the highest compared to the other delirium tests (CAM-ICU, AUC 0.853 [0.720-0.986]; disorientation, AUC 0.868 [0.745-0.991]). This research emphasizes the importance of the feature "disorientation" for delirium assessments in patients able to verbally communicate and explains some controversial delirium ratings in daily practice. The CAM-IMC appears to be an attractive tool for delirium assessment in nonintubated patients and deserves further research.

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study

BACKGROUND

Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients.

METHODS

This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group.

RESULTS

In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis.

CONCLUSION

Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis.

TRIAL REGISTRATION

clinicaltrials.gov NCT02265263, Registered 15 October 2014.

Implementation of strategies to prevent and treat postoperative delirium in the post-anesthesia caring unit : A German survey of current practice

Postoperative delirium is associated with worse outcome. The aim of this study was to understand present strategies for delirium screening and therapy in German Post-Anesthesia-Caring-Units (PACU). We designed a German-wide web-based questionnaire which was sent to 922 chairmen of anesthesiologic departments and to 726 anesthetists working in ambulatory surgery. The response rate was 30% for hospital anesthesiologists. 10% (95%-confidence interval: 8–12) of the anesthesiologists applied a standardised screening for delirium. Even though not on a regular basis, in 44% (41–47) of the hospitals, a recommended and validated screening was used, the Nursing Delirium Screening Scale (NuDesc) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). If delirium was likely to occur, 46% (43–50) of the patients were examined using a delirium tool. 20% (17–23) of the patients were screened in intensive care units. For the treatment of delirium, alpha-2-agonists (83%, 80–85) were used most frequently for vegetative symptoms, benzodiazepines for anxiety in 71% (68–74), typical neuroleptics in 77% (71–82%) of patients with psychotic symptoms and in 20% (15–25) in patients with hypoactive delirium. 45% (39–51) of the respondents suggested no therapy for this entity. Monitoring of delirium is not established as a standard procedure in German PACUs. However, symptom-oriented therapy for postoperative delirium corresponds with current guidelines.

[Study protocol to improve the quality of delirium management in intensive care]

BACKGROUND

Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far.

HYPOTHESIS

In cardiac surgery ICU patients, standardized delirium management will lead after a 4‑week introduction, compared to nonstandardized treatment, to a reduction of delirium duration.

METHODS

Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients.

INCLUSION CRITERIA

(a) ≥18 years, (b) consent for research with their data.

EXCLUSION CRITERIA

(a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics.

OBJECTIVES

The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.

Incidence, risk factors, and cumulative risk of delirium among ICU patients: A case-control study

Objectives

Delirium is a common acute cognitive impairment syndrome among intensive care unit (ICU) patients. This study was aimed to investigate the incidence, risk factors, and cumulative risk of delirium among ICU patients.

Methods

A case-control study including clinical records of 452 patients were retrospectively analyzed. Delirium was assessed using the Confusion Assessment Method for the ICU and Richmond Agitation–Sedation Scale.

Results

We found that 163 out of the 452 patients (36.1%) had delirium. Multivariate analysis showed that use of sedatives, length of ICU hospitalization, and physical restraint were independent risk factors for delirium. The additive effect of all three factors resulted to an odds ratio of 30.950.

Conclusion

The incidence of delirium remained high. Thus, nurses shall strengthen the monitoring of delirium, regularly access the patient's level of calmness, and limit the use of physical restraint.

[Delirium in geriatric urology patients]

BACKGROUND

Delirium is a common but often undiagnosed complication in geriatric patients following a major or minor operation. With 14-56% in patients over 70 years of age, it is one of the most frequent complications seen in hospitals. The link between the prescription of drugs with antimuscarinic effects and cognitive disturbance is also well known.

METHODS

Recognizing the presence of delirium and the criteria to establish the diagnosis of delirium will improve a clinician's ability to detect this complication. Treating delirium with non-pharmacologic, reduces the incidence and side effects of postoperative delirium. The purpose of this article is to describe the diagnosis and treatment of postoperative delirium.

RESULTS

A sudden rise following fluctuating symptoms with decreased attentiveness, awareness and thinking are typical symptoms of delirium. The organic origin is not focused and must be considered. Transurethral resection (TUR) of the prostate and the bladder can increase the risk of bleeding, delirium and TUR syndrome. As simple instruments to assess signs and symptoms, the Clinical Assessment Method (CAM) and the Nurses Delirium Screening Scale (Nu-DESC) in the clinical setting are well examined.

CONCLUSIONS

Preoperatively screening and execution of a geriatric assessment to detect vulnerable elderly could be a first step in reduction of complication. Regularly screening for delirium reduces the pre-, post-, and perioperative complications in patients with delirium.