Prevalence and management of delirium in intensive care units in the Netherlands: An observational multicentre study

Prevalence, risk factors and impact of delirium in adult inpatients in a tertiary care hospital: A point prevalence study

AIMS

To describe the point prevalence, risk factors and possible outcomes of delirium in inpatients.

DESIGN

A cross-sectional point prevalence study.

BACKGROUND

Delirium is an acute brain syndrome that negatively affects patients, healthcare professionals and institutions alike; it is common in inpatient settings and is preventable in about one third of cases. Although guidelines recommend systematic screening and assessment, delirium is often unrecognised, undiagnosed and uncoded. There is a lack of valid data on this patient safety indicator in German-speaking countries.

METHODS

The study was conducted in a tertiary care hospital in Switzerland on 5 July 2022. Specially trained registered nurses collected data from all patients meeting the inclusion criteria using CAM, ICDSC or mCAM-ED. Data were analysed descriptively with stratification by delirium status, setting and surgery.

RESULTS

The point prevalence across all settings was 6.9% (27/390), with large variation between settings: ICU 28.6% (4/14), IMC 28.0% (7/25), wards 4.6% (15/326) and ED 4% (1/25). Surgical patients were almost twice as likely to be affected as medical patients (8.9% vs. 4.8%). Patients with delirium differed most clearly from those without by having a larger number of ICD-10 F-diagnoses, a larger number of medications and higher age, which are known risk factors. Moreover, those with delirium had more missed diagnoses, increased mortality, more adverse events and higher costs.

CONCLUSIONS

A significant number of patients experienced delirium and adverse clinical outcomes. Missed delirium diagnoses may further jeopardise patient safety and result in lost revenue. It remains unclear to what extent the risk factors and effects of delirium are causal and what determinants underlie missed diagnoses.

RELEVANCE TO CLINICAL PRACTICE

Consistent identification of high-risk patients and treatment settings with elevated risk, accompanied by the implementation of effective preventive and management strategies, is critical to addressing delirium.

Effects of Sensory-Based Interventions on Delirium Prevention in Critically Ill Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To identify, appraise and synthesize current evidence on different sensory-based interventions on delirium prevention in critically ill patients.

DATA SOURCES

A comprehensive electronic literature search was performed in the PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, China Biology Medicine, China National Knowledge Infrastructure, Wanfang and WeiPu databases from inception to 2 June 2022. The data were updated on 24 December 2022. The study was registered on PROSPERO (CRD 42021254328).

REVIEW METHODS

Randomized controlled trials were included. Participants in the included studies were critically ill patients aged 18 years or older, and the interventions involved care by sensory-based intervention. And the outcome was the incidence of delirium rated by the Confusion Assessment Method for the ICU Tool.

RESULTS

The 14 studies included in the systematic review indicated a reduction in the effectiveness of sensory-based intervention on the incidence of delirium. Subgroup analyses showed significant effects for auditory stimulation (OR, 0.46; 95% confidence interval [CI], 0.27-0.79; p = 0.005) and tactile stimulation (OR, 0.53; 95% CI, 0.33-0.87; p = 0.01) but not for the effectiveness of visual intervention on the incidence of delirium (OR, 0.71; 95% CI, 0.38-1.30; p = 0.27).

CONCLUSIONS

Sensory-based interventions significantly reduce the incidence of delirium in critical patients. It is suggested that when choosing sensory-based interventions, auditory intervention should be preferred.

A world-wide study on delirium assessments and presence of protocols

BACKGROUND

Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities.

OBJECTIVE

To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols.

DESIGN

Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023.

SETTING

Cross-sectional online survey including hospitals, rehabilitation and long-term facilities.

METHODS

Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers.

RESULTS

Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions.

CONCLUSION

Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.

Monitoring delirium in the intensive care unit: Diagnostic accuracy of the CAM-ICU tool when performed by certified nursing assistants - A prospective multicenter study

BACKGROUND

Monitoring delirium in critically ill patients is recognized as a major challenge. Although involving certified nursing assistants could be a valuable help in this field, such strategy has never been formally investigated.

OBJECTIVES

Following theoretical training, we conducted a prospective multicenter study assessing the diagnostic accuracy of a CAM-ICU delirium screening strategy performed by CNAs in clinical settings, compared to parallel blinded evaluations conducted by nurses and physicians.

METHODS

From October 2020 to June 2022, adult intensive care patients admitted in three French University teaching hospitals with Richmond Agitation Sedation Scale ≥-2 were independently assessed for delirium by the three members of the care team (clinical nursing assistant, nurse and physician) using CAM-ICU in a random order. Physician's assessment served as the reference standard for comparisons.

RESULTS

We analyzed results from 268 triplets of CAM-ICU assessments performed sequentially on 203 patients. Prevalence of delirium was 22%. Compared to physician's assessments, clinical nursing assistants demonstrated a sensitivity (Se) of 88% CI95% [80-96] and a specificity (Sp) of 95% [92-98] in detecting delirium. There was no significant difference in the performance of clinical nursing assistants and nurses (Se = 90 % [82-97] p = 0.77, Sp = 98 % [95-100] p = 0.19). We observed high agreement between results obtained by physicians and clinical nursing assistants (ĸ = 0.82) and clinical nursing assistants performance remained consistent in the subgroups at higher risk of delirium.

CONCLUSION

Evaluation of the CAM-ICU by clinical nursing assistants is feasible and should be seen as an opportunity to increase routine monitoring of delirium in intensive care patients.

IMPLICATION FOR CLINICAL PRACTICE

Delirium is a severe and underestimated complication of intensive care unit stay. This study results demonstrate the great performance of trained clinical nursing assistants in detecting delirium using the CAM-ICU. Further research is needed to define the most effective role for clinical nursing assistants in the routine management of delirium in intensive care patients.

A protocol of an international validation study to assess the clinical accuracy of the eDIS-ICU delirium screening tool

BACKGROUND

Delirium is a common, yet underdiagnosed neuropsychiatric complication of intensive care unit (ICU) admission, associated with significant mortality and morbidity. Delirium can be difficult to diagnose, with gold standard assessments by a trained specialist being impractical and rarely performed. To address this, various tools have been developed, enabling bedside clinicians to assess for delirium efficiently and accurately. However, the performance of these tools varies depending on factors including the assessor's training. To address the shortcomings of current tools, electronic tools have been developed.

AIMS AND OBJECTIVES

The aims of this validation study are to assess the feasibility, acceptability, and generalisability of a recently developed and pilot-tested electronic delirium screening tool (eDIS-ICU) and compare diagnostic concordance, sensitivity, and specificity between eDIS-ICU, Confusion Assessment Method for the ICU (CAM-ICU), and the Diagnostic and Statistical Manual of Mental Disorders - 5th edition (DSM-V) gold standard in diverse ICU settings.

METHODS

Seven hundred participants will be recruited across five sites in three countries. Participants will complete three assessments (eDIS-ICU, CAM-ICU, and DSM-V) twice within one 24-h period. At each time point, assessments will be completed within one hour. Assessments will be administered by three different people at any given time point, with the assessment order and assessor for eDIS-ICU and CAM-ICU randomly allocated. Assessors will be blinded to previous and concurrent assessment results.

RESULTS

The primary outcome is comparing diagnostic sensitivity of eDIS-ICU and CAM-ICU against the DSM-V.

RELEVANCE TO CLINICAL PRACTICE

This protocol describes a definitive validation study of an electronic diagnostic tool to assess for delirium in the ICU. Delirium remains a common and difficult challenge in the ICU and is linked with multiple neurocognitive sequelae. Various challenges to routine assessment mean many cases are still unrecognised or misdiagnosed. An improved ability for bedside clinicians to screen for delirium accurately and efficiently will support earlier diagnosis, identification of underlying cause(s) and timely treatments, and ultimately improved patient outcomes.

CLINICAL TRIAL REGISTRATION NUMBER

This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (ANZCTR) on 8th February 2022 (ACTRN12622000220763).

Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors

BACKGROUND

Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium.

OBJECTIVES

To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later.

METHODS

A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests.

RESULTS

Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04).

CONCLUSIONS

The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.

Sustained adherence to a delirium guideline five years after implementation in an intensive care setting: A retrospective cohort study

OBJECTIVE

To explore the level of sustained adherence to a delirium guideline in a university intensive care unit setting five years after cessation of a multifaceted implementation program conducted between April 2012 and February 2015.

RESEARCH METHODOLOGY/DESIGN

A quantitative retrospective cohort study was conducted using the medical records of all eligible patients admitted to the intensive care unit from November 2019 to February 2020.

SETTING

Four adult intensive care units in a university hospital.

MAIN OUTCOME MEASURES

Primary outcome is adherence to seven performance indicators indicated in the guideline being: light sedation days, mobilisation, physical therapy, analgesics use, delirium and sedation screening and avoiding benzodiazepines. Clinical patient outcomes such as Intensive care unit stay and prevalence of delirium were also collected. Data were compared with the results of the original implementation study's using descriptive statistics and Kruskal-wallis and Chi-square tests.

RESULTS

Data of 236 patients were included. The most notable decrease in adherence concerned 'number of light sedation days' (-28 %). Adherence to three indicators had increased: 'number of days receiving out-of-bed mobilisation' (+11 %); 'number of days receiving physical therapy' (+9%); and 'use of analgesics' (+12 %). Comparison of clinical outcomes showed an increased intensive care unit length-of-stay from 3 to 5 days (P < 0.001). Prevalence of delirium increased over five years from 41 % to 43 % of patients while delirium duration decreased from a median of 3 days to a median of 2 days.

CONCLUSION

Five years after ceasing of implementation efforts regarding the delirium guideline, partial sustainability has been achieved. The decrease in adherence to 'number of light sedation days' could have contributed to the increased length-of-stay on the intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

After implementation, routine monitoring of performance indicators is required to evaluate the level of sustainment. Further, revisiting reasons for decrease in guideline adherence when contextual changes occur. Reassessment of the perceived barriers and facilitators can guide adaptations to sustain, or even improve, adherence.

Incidence, Associated Factors, and Outcome of Delirium among Patients Admitted to ICUs in Oman

Background

The incidence of delirium is high up to 46.3% among patients admitted to ICU. Delirium is linked to negative patient outcomes like increased duration of mechanical ventilation use, prolonged ICU stay, increased mortality rate, and healthcare costs. Despite the importance of delirium and its consequences that are significant, there is a scarcity of studies which explored delirium in Oman.

Objectives

This study was conducted to assess the incidence of delirium, the association between the selected predisposing factors and precipitating factors with delirium, determine the predicators of delirium, and evaluate its impacts on ICU mortality and ICU length of stay among ICU patients in Oman.

Methods

A multicenter prospective observational design was used. A total of 153 patients were assessed two-times a day by bedside ICU nurses through the Intensive Care Delirium Screening Checklist (ICDSC).

Results

The results revealed that the delirium incidence was 26.1%. Regression analysis showed that sepsis, metabolic acidosis, nasogastric tube use, and APACHE II score were independent predictors for delirium among ICU patients in Oman and delirium had significant impacts on ICU length of stay and mortality rate.

Conclusion

Delirium is common among ICU patients and it is associated with negative consequences. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Screening for delirium in the intensive care unit using eDIS-ICU - A purpose-designed app: A pilot study

INTRODUCTION

Delirium, a common complication of an intensive care unit (ICU) admission, is inconsistently diagnosed by clinicians. Current screening tools require specialist expertise and/or training. Some are time-consuming to administer, and reliability in routine clinical practice is questionable. An innovative app designed to enable efficient and sensitive screening for delirium without specialist training (eDIS-ICU) has recently been described. This pilot study compared the eDIS-ICU against the reference standard expert assessment using DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria and the Confusion Assessment Method for the ICU (CAM-ICU).

METHODS

In this prospective, single-centre pilot study, a convenience sample of 29 ICU patients were recruited at a tertiary referral hospital between November 2018 and August 2019. After obtaining written consent, demographic and clinical data were collected, and the patients were screened for delirium using eDIS-ICU and CAM-ICU by two clinician researchers in random order. The patients were also assessed for presence of delirium independently by an expert clinician using a structured interview to diagnose as per DSM-V criteria. The results of screening and diagnosis were tabulated to allow comparison of screening tools against diagnosis; sensitivity and specificity of the tools were calculated.

RESULTS

Seven participants were diagnosed with delirium as per DSM-V criteria. The eDIS-ICU tool correctly identified six of these participants compared with two identified by CAM-ICU. The sensitivity of the eDIS-ICU tool was 86% (95% confidence interval [CI] = 81.5-100.0) compared with 29% (95% CI = 5.1-69.7) for CAM-ICU (p < 0.05), and the specificity was 73% (95% CI = 81.5-100.0) versus 96% (95% CI = 75.1-99.8), respectively.

CONCLUSION

The simple and novel eDIS-ICU delirium screening tool was noninferior to the CAM-ICU in detecting delirium as per DSM-V criteria. A definitive validation study is warranted.