Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med. 2009;37:825-832. [PMID: 19237884 DOI: 10.1097/ccm.0b013e31819b8608]

Daily Automated Prediction of Delirium Risk in Hospitalized Patients: Model Development and Validation

BACKGROUND

Delirium is common in hospitalized patients and is correlated with increased morbidity and mortality. Despite this, delirium is underdiagnosed, and many institutions do not have sufficient resources to consistently apply effective screening and prevention.

OBJECTIVE

This study aims to develop a machine learning algorithm to identify patients at the highest risk of delirium in the hospital each day in an automated fashion based on data available in the electronic medical record, reducing the barrier to large-scale delirium screening.

METHODS

We developed and compared multiple machine learning models on a retrospective dataset of all hospitalized adult patients with recorded Confusion Assessment Method (CAM) screens at a major academic medical center from April 2, 2016, to January 16, 2019, comprising 23,006 patients. The patient's age, gender, and all available laboratory values, vital signs, prior CAM screens, and medication administrations were used as potential predictors. Four machine learning approaches were investigated: logistic regression with L1-regularization, multilayer perceptrons, random forests, and boosted trees. Model development used 80% of the patients; the remaining 20% was reserved for testing the final models. Laboratory values, vital signs, medications, gender, and age were used to predict a positive CAM screen in the next 24 hours.

RESULTS

The boosted tree model achieved the greatest predictive power, with an area under the receiver operator characteristic curve (AUROC) of 0.92 (95% CI 0.913-9.22), followed by the random forest (AUROC 0.91, 95% CI 0.909-0.918), multilayer perceptron (AUROC 0.86, 95% CI 0.850-0.861), and logistic regression (AUROC 0.85, 95% CI 0.841-0.852). These AUROCs decreased to 0.78-0.82 and 0.74-0.80 when limited to patients who currently do not or never have had delirium, respectively.

CONCLUSIONS

A boosted tree machine learning model was able to identify hospitalized patients at elevated risk for delirium in the next 24 hours. This may allow for automated delirium risk screening and more precise targeting of proven and investigational interventions to prevent delirium.

A bibliometric analysis on delirium in intensive care unit from 2013-2023

Background

Delirium is a common manifestation of acute brain dysfunction among patients in the Intensive Care Unit (ICU), afflicting an estimated 30-35% of this vulnerable population. The prevalence of delirium in ICU settings has catalyzed a surge in academic interest, as evidenced by a growing body of literature on the subject. This study seeks to synthesize the progress in understanding ICU delirium through a bibliometric analysis.

Methods

We conducted a comprehensive search of the Web of Science Core (WOS) Collection database for literature on ICU delirium, focusing on studies published between 2013 and 2023. Our analysis utilized two bibliometric software tools, Citespace and VOSviewer, to scrutinize the data across various dimensions, including country contributions, authorship patterns, publishing journals, key thematic terms, and other pertinent metrics, with the aim of identifying emerging trends in the field.

Results

Our search yielded a total of 1,178 publications on ICU delirium within the WOS database from January 2013 to June 2023. The United States emerged as the leading contributor in terms of published articles, with Ely, E. Wesley being the most prolific author, having published 85 articles, and "Critical Care Medicine" as the journal with the highest number of publications, totaling 105. The application of literature clustering and keyword analysis revealed that future research is poised to delve deeper into areas such as pediatric delirium, risk factors, and the development of preventive and therapeutic strategies.

Conclusion

This study employs bibliometric analysis to provide a multifaceted overview of the ICU delirium research landscape over the past decade. By examining the topic from various perspectives, we have not only mapped the current state of ICU delirium research but also illuminated potential avenues for future inquiry and areas of emphasis.

Reinforcement learning model for optimizing dexmedetomidine dosing to prevent delirium in critically ill patients

Delirium can result in undesirable outcomes including increased length of stays and mortality in patients admitted to the intensive care unit (ICU). Dexmedetomidine has emerged for delirium prevention in these patients; however, optimal dosing is challenging. A reinforcement learning-based Artificial Intelligence model for Delirium prevention (AID) is proposed to optimize dexmedetomidine dosing. The model was developed and internally validated using 2416 patients (2531 ICU admissions) and externally validated on 270 patients (274 ICU admissions). The estimated performance return of the AID policy was higher than that of the clinicians' policy in both derivation (0.390 95% confidence interval [CI] 0.361 to 0.420 vs. -0.051 95% CI -0.077 to -0.025) and external validation (0.186 95% CI 0.139 to 0.236 vs. -0.436 95% CI -0.474 to -0.402) cohorts. Our finding indicates that AID might support clinicians' decision-making regarding dexmedetomidine dosing to prevent delirium in ICU patients, but further off-policy evaluation is required.

Adherence to optimal delirium management practices in intensive care units in Brazil: a nationwide survey

BACKGROUND

Effective delirium management is crucial, considering its association with adverse outcomes. Adherence to best practices has the potential to reduce the incidence and prevalence of delirium and improve health outcomes.

OBJECTIVES

The objectives of this project were to describe self-assessed adherence to best practices in delirium management by health care professionals in intensive care units (ICUs) in Brazil, assess the health care professionals' perception of the importance of adequate delirium prevention and treatment in ICUs, and compare the compliance rates with best practices between public and private ICUs.

METHOD

A cross-sectional study was conducted in Brazil using an online questionnaire consisting of three parts, namely, data about the health care professionals and the ICU in which they worked; statements about the 17 best practices; and questions related to perceptions of delirium prevention and management by ICU physicians and nurses. The survey was sent to email addresses registered with the Brazilian Association of Intensive Care Medicine.

RESULTS

The compliance rate exceeded 50% for only eight best practices. These included the identification and management of pressure sores and falls in delirium patients, with compliance rates of 77.8% and 74.1%, respectively.

CONCLUSION

Among ICU professionals in Brazil, adherence to best practices in delirium management is low, particularly for practices involving patient education and involvement of their relatives in their care. These results emphasize the importance of enhancing delirium management in Brazilian health care institutions, regardless of hospital classification.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A274.

AARC Clinical Practice Guideline: Spontaneous Breathing Trials for Liberation From Adult Mechanical Ventilation

Despite prior publications of clinical practice guidelines related to ventilator liberation, some questions remain unanswered. Many of these questions relate to the details of bedside implementation. We, therefore, formed a guidelines committee of individuals with experience and knowledge of ventilator liberation as well as a medical librarian. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we make the following recommendations: (1) We suggest that calculation of a rapid shallow breathing index is not needed to determine readiness for a spontaneous breathing trial (SBT) (conditional recommendation; moderate certainty); (2) We suggest that SBTs can be conducted with or without pressure support ventilation (conditional recommendation, moderate certainty); (3) We suggest a standardized approach to assessment and, if appropriate, completion of an SBT before noon each day (conditional recommendation, very low certainty); and (4) We suggest that FIO2 should not be increased during an SBT (conditional recommendation, very low certainty). These recommendations are intended to assist bedside clinicians to liberate adult critically ill patients more rapidly from mechanical ventilation.

Delirium Knowledge, Risk Factors, and Attitude Among the General Public in Saudi Arabia: A Cross-Sectional Study

Introduction Delirium is a common and serious neuropsychiatric disorder, of acute onset, present at any age, but more common in older adults, and very common in clinical practice. It combines mental and behavioral symptoms with a fluctuating course, with worsening of the condition in the afternoon and at night, with important repercussions on increased mortality, greater risk of cognitive impairment, and hospitalization costs. Delirium's impact extends to patients, families, and healthcare systems, emphasizing the need for public awareness and education in Saudi Arabia. Methodology It is a cross-sectional conducted in Saudi Arabia that aims to assess knowledge, risk factors, and attitudes regarding delirium among all Saudi and non-Saudi residents aged 18 and older. A 36 self-administered questionnaire, standardized Nordic, was used. Data were cleaned in Microsft Excel (Microsoft Corporation, USA) and analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY). This study was conducted in Saudi Arabia from May 2023 till March 2024. Results Our study involved 1,470 participants from Saudi Arabia, primarily females (79.1%), Saudi nationals (89.9%), and unmarried individuals (65.4%). Most participants were aged 18-24 (59.5%) and held bachelor's degrees (57.3%). Commonly recognized delirium risk factors included increasing age (63.3%), dementia (58.2%), and longer ICU stays (48.7%). The participants showed moderate knowledge of delirium symptoms and consequences. Attitudes varied, with many agreeing that delirium requires intervention (30.7%) but fewer considering it preventable (17.1%). Sociodemographic factors, including gender and age, significantly influenced knowledge and attitudes, while education levels did not. Conclusion Our study found that gender and age influenced knowledge and attitudes, highlighting the importance of targeted education. Future research should further investigate the effectiveness of such interventions in enhancing knowledge and awareness and promoting preventive actions.

Identification of risk factors for the onset of delirium associated with COVID-19 by mining nursing records

COVID-19 has a range of complications, from no symptoms to severe pneumonia. It can also affect multiple organs including the nervous system. COVID-19 affects the brain, leading to neurological symptoms such as delirium. Delirium, a sudden change in consciousness, can increase the risk of death and prolong the hospital stay. However, research on delirium prediction in patients with COVID-19 is insufficient. This study aimed to identify new risk factors that could predict the onset of delirium in patients with COVID-19 using machine learning (ML) applied to nursing records. This retrospective cohort study used natural language processing and ML to develop a model for classifying the nursing records of patients with delirium. We extracted the features of each word from the model and grouped similar words. To evaluate the usefulness of word groups in predicting the occurrence of delirium in patients with COVID-19, we analyzed the temporal changes in the frequency of occurrence of these word groups before and after the onset of delirium. Moreover, the sensitivity, specificity, and odds ratios were calculated. We identified (1) elimination-related behaviors and conditions and (2) abnormal patient behavior and conditions as risk factors for delirium. Group 1 had the highest sensitivity (0.603), whereas group 2 had the highest specificity and odds ratio (0.938 and 6.903, respectively). These results suggest that these parameters may be useful in predicting delirium in these patients. The risk factors for COVID-19-associated delirium identified in this study were more specific but less sensitive than the ICDSC (Intensive Care Delirium Screening Checklist) and CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). However, they are superior to the ICDSC and CAM-ICU because they can predict delirium without medical staff and at no cost.

Challenges of the Implementation of a Delirium Rate Scale in a Pediatric Intensive Care Unit: A Qualitative Approach

INTRODUCTION

Delirium in the pediatric population admitted to intensive care is a worrying reality due to its potential complications and the increase in associated costs. This study aims to explore the experiences of nursing staff of a Pediatric Intensive Care Unit after 15 months of starting a program to fight against childhood delirium in their unit.

METHODOLOGY

A qualitative study was conducted through semi-structured interviews with Pediatric Intensive Care Unit (PICU) Key Informants. The Standards for Reporting Qualitative Research (SRQR) and the consolidated criteria for Reporting Qualitative Research (COREQ) were followed as quality measures for the study. Seven nurses (33% of the eligible population) from the PICU of a referral hospital were interviewed. Text transcripts were analyzed using the Interpretative Description and Qualitative Content Analysis method.

RESULTS

The interviewees indicated not identifying delirium as an important reality; with great deficiencies observed in what is related to the identification of delirium; identifying CAPD as an unreliable tool in their unit; and not sharing therapeutic objectives in this respect with the medical staff.

CONCLUSIONS

The nursing staff presented a series of negative attitudes towards the phenomena of delirium in their unit, with gaps in training and in clinical management, and the diagnostic tool used, and did not see it as a priority objective of the unit, partly due to a resistance to change and a latent interprofessional communication conflict. A change at the formative, attitudinal, and relational levels is urgently needed for the success of the program and the well-being of the children in the unit.

Knowledge, attitude and practice regarding hypoactive delirium among ICU nurses: A nationwide cross-sectional study

AIMS AND OBJECTIVES

This study aimed to assess the knowledge, attitude and practice (KAP) of intensive care unit (ICU) nurses in patients with hypoactive delirium in China.

BACKGROUND

The presentation of hypoactive delirium is not obvious and tends to be ignored. However, it has a high incidence and can cause critical impairment. Although nurses are the primary caregivers of patients, the evidence of the current status of KAP of hypoactive delirium among ICU nurses is insufficient in China.

DESIGN

The study participants were 2835 ICU nurses from 201 hospitals in 69 cities from 31 provinces in China.

METHODS

The current status of KAP of hypoactive delirium among ICU nurses was determined using a self-reported structured questionnaire, including 52 questions covering general personal information; three dimensions of KAP; and relevant issues. Descriptive analyses of the sample distribution were reported as percentages and medians. The factors were detected using univariate and multivariate analyses. To guide the reporting of the research, a STROBE checklist of cross-sectional studies was used.

RESULTS

Of the 3101 returned questionnaires, 2835 were analyzed. Approximately 64. 94 % and 53. 30 % of them were identified with a positive attitude and appropriate practice, respectively, whereas only 1. 48 % showed a good level of knowledge. The regression analysis showed that age, years of working in the ICU, educational background, professional title, caring for patients with delirium, attending training on hypoactive delirium and hospital grading were significantly associated with their KAP status(P＜005).

CONCLUSIONS

Hypoactive delirium is an ignored entity by nursing professionals, with no definite nursing procedure. This study shows that receiving relevant training is a factor affecting KAP status, indicating that training should be strengthened. Additionally, appropriate screening and nursing procedures should be developed to standardize the behavior of ICU nurses and improve the quality of care.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses have poor knowledge of hypoactive delirium and related training should be strengthened, especially for middle-aged nurses. Screening and nursing procedures should be set up, which is critical to promote nursing practice.

NO PATIENT OR PUBLIC CONTRIBUTION

None.

Incidence of Delirium in Critically Ill Patients With and Without COVID-19

BACKGROUND

It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19.

METHODS

This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium.

RESULTS

Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p  =  0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p  =  0.001).

CONCLUSION

COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

Knowledge, Attitude, Perception and Current Practices of Health Personnel in Managing Post-Stroke Delirium in a New Stroke Centre in Malaysia

Introduction

Despite the high prevalence of post-stroke delirium in Malaysia, there are no studies on good practices related to its management. This study aimed to analyse the knowledge, attitude, perception, and factors associated with current practices related to delirium in acute stroke patients among health personnel at Hospital Sultan Abdul Aziz Shah (HSAAS) (formerly known as Hospital Pengajar Universiti Putra Malaysia).

Methods

This cross-sectional study was conducted from 26 April 2021 to 9 May 2021 (17 weeks). All health personnel from various departments managing patients with acute stroke in our centre were invited to participate. An online questionnaire was disseminated to assess their knowledge, attitude, perception, and current practices concerning delirium. Multiple logistic regression was used to examine the association between the independent and dependent variables. The level of significance was set at P < 0.05.

Results

The response rate was 22.49% (47 of 209 participants). More than half (61.7%, n = 29) had good current practices towards delirium in acute stroke patients. A significant association was found between knowledge and current practices related to delirium (P = 0.024). However, there was no significant association between current practices and sociodemographic factors (age, ethnicity, gender and job position), attitude, perceptions, screening barriers, or health service organisation.

Conclusion

Most respondents had good current practices and knowledge in managing post-stroke delirium. Therefore, upskilling health personnel for managing this illness is essential to ensure good post-stroke care and improve prognosis related to delirium.

Potentially inappropriate medications with older people in intensive care and associated factors: a historic cohort study

BACKGROUND

The epidemiology of potentially inappropriate medications (PIMs) in critical care units remains limited, especially in terms of the factors associated with their use.

OBJECTIVE

To estimate the incidence and factors associated with PIMs use in intensive care units.

DESIGN AND SETTING

Historical cohort study was conducted in a high-complexity hospital in Brazil.

METHODS

A retrospective chart review was conducted on 314 patients aged ≥ 60 years who were admitted to intensive care units (ICUs) at a high-complexity hospital in Brazil. The dates were extracted from a "Patient Safety Project" database. A Chi-square test, Student's t-test, and multivariable logistic regression analyses were performed to assess which factors were associated with PIMs. The statistical significance was set at 5%.

RESULTS

According to Beers' criteria, 12.8% of the identified drugs were considered inappropriate for the elderly population. The incidence rate of PIMs use was 45.8%. The most frequently used PIMs were metoclopramide, insulin, antipsychotics, non-steroidal anti-inflammatory drugs, and benzodiazepines. Factors associated with PIMs use were the number of medications (odds ratio [OR] = 1.17), length of hospital stay (OR = 1.07), and excessive potential drug interactions (OR = 2.43).

CONCLUSIONS

Approximately half of the older adults in ICUs received PIM. Patients taking PIMs had a longer length of stay in the ICU, higher numbers of medications, and higher numbers of potential drug interactions. In ICUs, the use of explicit methods combined with clinical judgment can contribute to the safety and quality of medication prescriptions.

Confusion assessment method accurately screens for hepatic encephalopathy and predicts short-term mortality in hospitalized patients with cirrhosis

Hepatic encephalopathy (HE), a subtype of delirium, is common in cirrhosis and associated with poor outcomes. Yet, objective bedside screening tools for HE are lacking. We examined the relationship between an established screening tool for delirium, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and short-term outcomes while comparing its performance with previously established measures of cognitive function such as West Haven criteria (WHC). Prospectively enrolled adults with cirrhosis who completed the CAM-ICU from 6/2014-6/2018 were followed for 90 days. Blinded provider-assigned West Haven Criteria (WHC) and other measures of cognitive function were collected. Logistic regression was used to test associations between CAM-ICU status and outcomes. Mortality prediction by CAM-ICU status was assessed using Area under the Receiver Operating Characteristics curves (AUROC). Of 469 participants, 11% were CAM-ICU( +), 55% were male and 94% were White. Most patients were Childs-Pugh class C (59%). CAM-ICU had excellent agreement with WHC (Kappa = 0.79). CAM-ICU( +) participants had similar demographic features to those CAM-ICU(-), but had higher MELD (25 vs. 19, p < 0.0001), were more often admitted to the ICU (28% vs. 7%, p < 0.0001), and were more likely to be admitted for HE and infection. CAM-ICU( +) participants had higher mortality (inpatient:37% vs. 3%, 30-day:51% vs. 11%, 90-day:63% vs. 23%, p < 0.001). CAM-ICU status predicted mortality with AUROC of 0.85, 0.82 and 0.77 for inpatient, 30-day and 90-day mortality, respectively. CAM-ICU easily screens for delirium/HE, has excellent agreement with WHC, and identifies a hospitalized cirrhosis cohort with high short-term mortality.

Factors influencing the implementation of a ventilation weaning protocol in an adult intensive care unit: a qualitative multidisciplinary evaluation

PURPOSE

Development of protocolized care in the intensive care unit (ICU) improves patient outcomes, but presents multiple challenges. A mechanical ventilation weaning protocol (WP) was adopted in our institution but was underused. This study aimed to determine the factors that influenced the implementation of this protocol locally.

METHODS

We performed a qualitative descriptive study using semidirected interviews in small profession-specific focus groups. The interviews were based on a standardized guide covering the major domains found in the Consolidated Framework for Implementation Research. A total of 32 participants across four key professions were recruited. The interviews were transcribed and codified sequentially, followed by categorization and analysis.

RESULTS

Three broad factors emerged that negatively impacted the implementation of the WP. First, the goals of the WP differed between professional groups. This difference led to significant frustration and breaches in collaboration. Second, there was a lack of a continuous quality improvement process. Third, the WP was incompatible with the routine and procedures already in place at the time of implementation. Time-of-day of WP application and patient safety concerns were specifically identified issues.

CONCLUSIONS

Implementation of a continuous improvement process with regular and specific follow-up may help identify potential challenges and thus help ensure a more consistent use of the WP.

Assessing Barriers to Implementation of Machine Learning and Artificial Intelligence-Based Tools in Critical Care: Web-Based Survey Study

BACKGROUND

Although there is considerable interest in machine learning (ML) and artificial intelligence (AI) in critical care, the implementation of effective algorithms into practice has been limited.

OBJECTIVE

We sought to understand physician perspectives of a novel intubation prediction tool. Further, we sought to understand health care provider and nonprovider perspectives on the use of ML in health care. We aim to use the data gathered to elucidate implementation barriers and determinants of this intubation prediction tool, as well as ML/AI-based algorithms in critical care and health care in general.

METHODS

We developed 2 anonymous surveys in Qualtrics, 1 single-center survey distributed to 99 critical care physicians via email, and 1 social media survey distributed via Facebook and Twitter with branching logic to tailor questions for providers and nonproviders. The surveys included a mixture of categorical, Likert scale, and free-text items. Likert scale means with SD were reported from 1 to 5. We used student t tests to examine the differences between groups. In addition, Likert scale responses were converted into 3 categories, and percentage values were reported in order to demonstrate the distribution of responses. Qualitative free-text responses were reviewed by a member of the study team to determine validity, and content analysis was performed to determine common themes in responses.

RESULTS

Out of 99 critical care physicians, 47 (48%) completed the single-center survey. Perceived knowledge of ML was low with a mean Likert score of 2.4 out of 5 (SD 0.96), with 7.5% of respondents rating their knowledge as a 4 or 5. The willingness to use the ML-based algorithm was 3.32 out of 5 (SD 0.95), with 75% of respondents answering 3 out of 5. The social media survey had 770 total responses with 605 (79%) providers and 165 (21%) nonproviders. We found no difference in providers' perceived knowledge based on level of experience in either survey. We found that nonproviders had significantly less perceived knowledge of ML (mean 3.04 out of 5, SD 1.53 vs mean 3.43, SD 0.941; P<.001) and comfort with ML (mean 3.28 out of 5, SD 1.02 vs mean 3.53, SD 0.935; P=.004) than providers. Free-text responses revealed multiple shared concerns, including accuracy/reliability, data bias, patient safety, and privacy/security risks.

CONCLUSIONS

These data suggest that providers and nonproviders have positive perceptions of ML-based tools, and that a tool to predict the need for intubation would be of interest to critical care providers. There were many shared concerns about ML/AI in health care elucidated by the surveys. These results provide a baseline evaluation of implementation barriers and determinants of ML/AI-based tools that will be important in their optimal implementation and adoption in the critical care setting and health care in general.

Impact of a national collaborative project to improve the care of mechanically ventilated patients

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

Using a real-time ABCDEF compliance tool to understand the role of bundle elements in mortality and delirium

BACKGROUND

ABC-123, a novel Epic electronic medical record real-time score, assigns 0 to 3 points per bundle element to assess ABCDEF bundle compliance. We sought to determine if maximum daily ABC-123 score (ABC-MAX), individual bundle elements, and mobility were associated with mortality and delirium-free/coma-free intensive care unit (DF/CF-ICU) days in critically injured patients.

METHODS

We reviewed 6 months of single-center data (demographics, Injury Severity Score [ISS], Abbreviated Injury Scale of the head [AIS-Head] score, ventilator and restraint use, Richmond Agitation Sedation Score, Confusion Assessment Method for the ICU, ABC-MAX, ABC-123 subscores, and mobility level). Hospital mortality and likelihood of DF/CF-ICU days were endpoints for logistic regression with ISS, AIS-Head, surgery, penetrating trauma, sex, age, restraint and ventilator use, ABC-MAX or individual ABC-123 subscores, and mobility level or a binary variable representing any improvement in mobility during admission.

RESULTS

We reviewed 172 patients (69.8% male; 16.3% penetrating; median age, 50.0 years [IQR, 32.0-64.8 years]; ISS, 17.0 [11.0-26.0]; AIS-Head, 2.0 [0.0-3.0]). Of all patients, 66.9% had delirium, 48.8% were restrained, 51.7% were ventilated, and 11.0% died. Age, ISS, AIS-Head, and penetrating mechanism were associated with increased mortality. Restraints were associated with more than 70% reduction in odds of DF/CF-ICU days. Maximum daily ABC-123 score and mobility level were associated with decreased odds of death and increased odds of DF/CF-ICU days. Any improvement in mobility during hospitalization was associated with an 83% reduction in mortality odds. A and C subscores were associated with increased mortality, and A was also associated with decreased DF/CF-ICU days. B and D subscores were associated with increased DF/CF-ICU days. D and E subscores were associated with decreased mortality.

CONCLUSION

Maximum daily ABC-123 score is associated with reduced mortality and delirium in critically injured patients, while mobility is associated with dramatic reduction in mortality. B and D subscores have the strongest positive effects on both mortality and delirium.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Development and Evaluation of an Intensive Care Unit Video Series to Educate Staff on Delirium Detection

Background

Delirium affects up to 80% of patients who are mechanically ventilated in the intensive care unit (ICU) but often goes undetected because of incomplete and/or inaccurate clinician evaluation and documentation. A lack of effective, feasible, and sustainable educational methods represents a key barrier to efforts to optimize, scale, and sustain delirium detection competencies. Progress with such barriers may be addressed with asynchronous video-based education.

Objective

To evaluate a novel ICU Delirium Video Series for bedside providers via a knowledge assessment quiz and a feedback questionnaire.

Methods

An interdisciplinary team scripted and filmed an educational ICU Delirium Video Series, providing detailed instruction on delirium detection using the validated CAM-ICU (Confusion Assessment Method for the ICU). A cohort of bedside nurses subsequently viewed and evaluated the ICU Delirium Video Series using a feedback questionnaire and a previously developed knowledge assessment quiz pre- and post-video viewing.

Results

Twenty nurses from four ICUs viewed the ICU Delirium Video Series and completed the pre-post quiz and questionnaire. Ten (50%) respondents had 10 or more years of ICU experience, and seven (35%) reported receiving no CAM-ICU education locally. After video viewing, overall pre-post scores improved significantly (66% vs. 79%; P < 0.0001). In addition, after video viewing, more nurses reported comfort in their ability to evaluate and manage patients with delirium.

Conclusion

Viewing the ICU Delirium Video Series resulted in significant improvements in knowledge and yielded valuable feedback. Asynchronous video-based delirium education can improve knowledge surrounding a key bedside competency.

Thirst in adult patients in the intensive care unit: protocol for a scoping review

INTRODUCTION

Thirst is one of the most bothersome symptoms experienced by intensive care unit (ICU) patients. Effective diagnosis and management of thirst in the ICU is essential, particularly as patients are less sedated than previously and more aware of this problem. Currently, no overview of publications on thirst identification and management in ICU patients exists. The scoping review will address the broad question 'What is known about thirst as a symptom in adult critically ill patients?' It aims to provide an overview of the causes and risk factors, diagnosis and measurement, the symptom dimensions and its interaction with other symptoms, and thirst management.

METHODS AND ANALYSIS

The review will follow the Joanna Briggs Institute methodology framework to guide the process and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Methods include: defining the review questions, eligibility criteria, concepts of interest and context; and outlining the search strategy, study selection process, data extraction and analysis. PubMed, MEDLINE, EMBASE and CINAHL will be searched from inception to April 2022.

ETHICS AND DISSEMINATION

Ethical approval is not required, as the scoping review will synthesise information from available publications. The scoping review will be submitted for publication to a scientific journal, presented at relevant conferences and disseminated as part of future workshops with ICU support groups and the critical care professional community.

Association of analgosedation with psychiatric symptoms and health-related quality of life in ARDS survivors: Post hoc analyses of the DACAPO study

BACKGROUND

The acute respiratory distress syndrome (ARDS) is a life-threatening condition with the risk of developing hypoxia and thus requires for invasive mechanical ventilation a long-term analgosedation. Yet, prolonged analgosedation may be a reason for declining health-related quality of life (HRQoL) and the development of psychiatric disorders.

METHODS

We used data from the prospective observational nation‑wide ARDS study across Germany (DACAPO) to investigate the influence of sedation and analgesia on HRQoL and the risk of psychiatric symptoms in ARDS survivors 3, 6 and 12 months after their discharge from the intensive care unit (ICU). HRQoL was measured with the Physical and Mental Component Scale of the Short‑Form 12 Questionnaire (PCS‑12, MCS‑12). The prevalence of psychiatric symptoms (depression and post‑traumatic stress disorder [PTSD]) was assessed using the Patient Health Questionnaire‑9 and the Post‑Traumatic Stress Syndrome‑14. The associations of analgosedation with HRQoL and psychiatric symptoms were investigated by means of multivariable linear regression models.

RESULTS

The data of 134 ARDS survivors (median age [IQR]: 55 [44-64], 67% men) did not show any significant association between analgosedation and physical or mental HRQoL up to 1 year after ICU discharge. Multivariable linear regression analysis (B [95%‑CI]) yielded a significant association between symptoms of psychiatric disorders and increased cumulative doses of ketamine up to 6 months after ICU discharge (after 3 months: depression: 0.15 [0.05, 0.25]; after 6 months: depression: 0.13 [0.03, 0.24] and PTSD: 0.42 [0.04, 0.80)]).

CONCLUSIONS

Up to 1 year after ICU discharge, analgosedation did not influence HRQoL of ARDS survivors. Prolonged administration of ketamine during ICU treatment, however, was positively associated with the risk of psychiatric symptoms. The administration of ketamine to ICU patients with ARDS should be with caution.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02637011 (Registered 15 December 2015, retrospectively registered).

Recipe for primary prevention of delirium in hospitalized older patients

Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.

Implementation and Routinization of the ABCDE Bundle: A Mixed Methods Evaluation

BACKGROUND

The ABCDE (Awakening and Breathing Coordination, Delirium monitoring and management, and Early exercise/mobility) bundle has been associated with reductions in delirium incidence and improved patient outcomes but has not been widely adopted.

OBJECTIVE

The objective of this study was to determine how to facilitate ABCDE bundle adoption by examining the impact of different implementation strategies on bundle adherence rates and assessing clinicians' perceptions of the bundle and implementation efforts.

METHODS

This study examined the effect of 2 bundle implementation strategies on patient care in 8 adult intensive care units. The basic strategy included electronic health record (EHR) modification, whereas the enhanced strategy included EHR modification plus additional bundle training, clinical champions, and staff engagement. A total of 84 nurses, physicians, and therapists participated in interviews and a survey to assess bundle implementation.

RESULTS

Respondents indicated bundle use resulted in "best care" through care standardization and coordination and improved patient outcomes. Intensive care units in both intervention groups had significant improvements in bundle adherence after implementation efforts, but intensive care units in the basic intervention group outperformed other sites after initiating their own implementation strategies. Successful implementation tactics included incorporating the bundle into multidisciplinary rounds and providing ongoing support, training, and routine auditing and feedback.

DISCUSSION

The ABCDE bundle can improve quality of care and outcomes, and implementation can be accelerated through EHR tools, trainings, and performance feedback.

Delirium in Intensive Care Units: Perceptions of Physicians and Nurses

Delirium is an indicator of morbidity and mortality in intensive care unit (ICU) patients. It can lead to negative outcomes and longer hospital stays, thus increasing hospital costs. Despite national recommendations for daily assessment of delirium, it remains underdiagnosed. Many studies point to a lack of knowledge among health care professionals to accurately detect and manage ICU delirium. The aim of our study was to assess the knowledge, attitudes, and practices of Palestinian health care professionals regarding ICU delirium. The results of a cross-section observational study revealed that delirium appears to be often underrecognized or misdiagnosed in ICUs in Palestine. Therefore, it is critical to further educate the medical and nursing teams and to promote the use of validated tools that can aid in the assessment of this condition. In this way, the length of hospital stays and related health care costs can be reduced.

Cerebrospinal fluid catecholamines in delirium and dementia

Dopamine and noradrenaline are functionally connected to delirium and have been targets for pharmacological interventions but the biochemical evidence to support this notion is limited. To study the CSF levels of dopamine, noradrenaline and the third catecholamine adrenaline in delirium and dementia, these were quantified in three patient cohorts: (i) cognitively normal elderly patients (n = 122); (ii) hip fracture patients with or without delirium and dementia (n = 118); and (iii) patients with delirium precipitated by another medical condition (medical delirium, n = 26). Delirium was assessed by the Confusion Assessment Method. The hip fracture cohort had higher CSF levels of noradrenaline and adrenaline than the two other cohorts (both P < 0.001). Within the hip fracture cohort those with delirium (n = 65) had lower CSF adrenaline and dopamine levels than those without delirium (n = 52, P = 0.03, P = 0.002). Similarly, the medical delirium patients had lower CSF dopamine levels than the cognitively normal elderly (P < 0.001). Age did not correlate with the CSF catecholamine levels. These findings with lower CSF dopamine levels in hip fracture- and medical delirium patients challenge the theory of dopamine excess in delirium and question use of antipsychotics in delirium. The use of alpha-2 agonists with the potential to reduce noradrenaline release needs further examination.

Effectiveness of the ABCDEF bundle on delirium, functional outcomes and quality of life in intensive care patients: a study protocol for a randomised controlled trial with embedded process evaluation

INTRODUCTION

Hospital mortality for critically ill patients has decreased significantly throughout the developed world over the past two decades, attributable to improvements in the quality of intensive care, advances in critical care medicine and technologies that provide long-term multiorgan support. However, the long-term outcomes of intensive care unit (ICU) survivors is emerging as a real issue. Cognitive and physical impairments suffered by ICU survivors are common including profound weakness, pain and delirium which are inextricably linked. This study aims to determine the effectiveness of the Assess, prevent and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of sedation and analgesia; Delirium: assess, prevent and manage; Early mobility and exercise; Family engagement and empowerment (ABCDEF) bundle in reducing ICU-related short-term and long-term consequences of critical illness through a randomised controlled trial (RCT).

METHODS AND ANALYSIS

The study will be a single-centre, prospective RCT. A total of 150 participants will be recruited and randomised to either receive the ABCDEF bundle protocol or non-protocolised standard care for the duration of the participant's admission in the ICU. The primary outcome is delirium status measured using the Confusion Assessment Measure for ICU (CAM-ICU). Secondary outcomes include physical function measured by the Functional Independence Measure and quality of life measured by the European Quality of Life five dimensions, five-level questionnaire. A mixed-method process evaluation will contribute to understanding the experience of health teams who implement the ABCDEF bundle into practice.

ETHICS AND DISSEMINATION

Ethics approval was provided by the Metro South Health Human Research Ethics Committee (HREC) (EC00167) and the Griffith University's HREC prior to study commencement.Study results will be disseminated by presentations at conferences and via publications to peer-review journals.

TRIAL REGISTRATION NUMBER

ACTRN12620000736943; Pre-results.

Delirium-related distress in the ICU: A qualitative meta-synthesis of patient and family perspectives and experiences

BACKGROUND

Better understanding of patient and family member experiences of delirium and related distress during critical care is required to inform the development of targeted nonpharmacologic interventions.

OBJECTIVE

To examine and synthesize qualitative data on patient and family member delirium experiences and relieving factors in the Intensive Care Unit (ICU).

DESIGN

We conducted a systematic review and qualitative meta-synthesis. Eligible studies contained adult patient or family quotes about delirium during critical care, published in English in a peer-reviewed journal since 1980. Data sources included PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane and Clinicaltrials.gov.

METHODS

Systematic searches yielded 3238 identified articles, of which 14 reporting 13 studies were included. Two reviewers independently extracted data into a Microsoft Excel spreadsheet. Qualitative meta-synthesis was performed through line-by-line coding of relevant quotes, organization of codes into descriptive themes, and development of analytical themes. Five patients/family members with experience of ICU delirium contributed to the thematic analysis.

RESULTS

Qualitative meta-synthesis resulted in four major themes and two sub-themes. Key new patient and family-centric insights regarding delirium-related distress in the ICU included articulation of the distinct emotions experienced during and after delirium (for patients, predominantly fear, anger and shame); its 'whole-person' nature; and the value that patients and family members placed on clinicians' compassion, communication, and connectedness.

CONCLUSIONS

Distinct difficult emotions and other forms of distress are experienced by patients and families during ICU delirium, during which patients and families highly value human kindness and empathy. Future studies should further explore and address the many facets of delirium-related distress during critical care using these insights and include patient-reported measures of the predominant difficult emotions.

Adult sedation and analgesia in a resource limited intensive care unit - A Systematic Review and evidence based guideline

Background

Sedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol.

Methods

Preferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions.

Results

In this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions.

Discussion

Analgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings.

Conclusions

Analgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes.

•

Critically ill patients shall be awake, alert without pain, anxiety and delirium.

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Analgesia and sedation in the ICU shall be given as per needed after determined they are in need of.

•

Sedation breaks are paramount important as equal as spontaneous breathing trials.

•

Unnecessary deep sedations will increase hospital and personnel costs by increasing length of ICU stay.

Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey

PURPOSE

Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation.

METHODS

This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission.

RESULTS

Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital.

CONCLUSION

The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.

Nursing Insights on Delirium in the Intensive Care Unit: A Quality Improvement Study

Delirium is a common complication of critical illness. As frontline providers, nurses (registered nurses) are uniquely positioned to inform interventions to improve intensive care unit (ICU) patient outcomes. This article reports a study of attitudes and knowledge about ICU delirium assessment at an urban academic medical center. Findings suggest a knowledge deficit regarding the spectrum of delirium. ICU nurses also identified that a lack of effective collaboration within the treatment team was the biggest barrier to effective care for the patient with hypoactive delirium. The study findings indicate that both educational and management initiatives are needed to improve clinical practices for patients with manifestations of hypoactive and hyperactive delirium.

Family satisfaction in the intensive care unit, a cross-sectional study from Norway

BACKGROUND

Becoming critically ill represents not just a great upheaval for the patient in question, but also for the patient's closest family. In recent years, there has been a change in how the quality of the public health service is measured. There is currently a focus on how patients and their families perceive the quality of treatment and care. It can be challenging for patients to evaluate their stay in an intensive care unit (ICU) due to illness and treatment. Earlier studies show that the perceptions of the family and the patient may concur. It is important, therefore, to ascertain the family's level of satisfaction with the ICU stay. The aim of the study was to describe how the family evaluate their satisfaction with the ICU stay. A further aim was to identify which demographic variables were associated with differences in family satisfaction.

METHOD

The study had a cross-sectional design. A sample of 57 family members in two ICUs in Norway completed the questionnaire: Family satisfaction in the intensive care unit 24 (FS-ICU 24). Statistical analysis was conducted using the Mann-Whitney U test (U), Kruskal Wallis, Spearman rho and a performance-importance plot.

RESULTS

The results showed that families were very satisfied with a considerable portion of the ICU stay. Families were less satisfied with the information they received and the decision-making processes than with the nursing and care performed during the ICU stay. The results revealed that two demographic variables - relation to the patient and patient survival - significantly affected family satisfaction.

CONCLUSION

Although families were very satisfied with the ICU stay, several areas were identified as having potential for improvement. The results showed that some of the family demographic variables were significant for family satisfaction. The findings are clinically relevant since the results can strengthen intensive care nurses' knowledge when meeting the family of the intensive care patient.

Prevention and Management of Delirium in the Intensive Care Unit

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Early neuromuscular blocking agents for adults with acute respiratory distress syndrome: a systematic review, meta-analysis and meta-regression

OBJECTIVE

To determine whether neuromuscular blocking agents (NMBAs) can decrease the mortality of patients with acute respiratory distress syndrome (ARDS) and improve their clinical outcomes.

DESIGN

Systematic review, meta-analysis and meta-regression.

DATA SOURCES

PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov.

METHODS

Randomised controlled trials (RCTs) comparing the treatment effect of NMBAs with that of placebo (or traditional treatment) in patients with ARDS were carefully selected. The primary outcome was 90-day mortality. The secondary outcomes were 21-28 days mortality, NMBA-related complications (barotrauma, pneumothorax and intensive care unit (ICU)-acquired muscle weakness), days free of ventilation and days not in the ICU by day 28, Medical Research Council score, Acute Physiology and Chronic Health Evaluation II score and arterial oxygen tension (PaO₂)/fractional inspired oxygen (FiO₂) (at 48 hours and 72 hours). Random-effects meta-regression was used to explore models involving potential moderators. Trial sequential analysis was performed to estimate the cumulative effect on mortality across RCTs.

RESULTS

NMBAs were not associated with reduced 90-day mortality (risk ratio (RR) 0.85; 95% CI 0.66 to 1.09; p=0.20). However, they decreased the 21-28 days mortality (RR 0.71; 95% CI 0.53 to 0.96; p=0.02) and the rates of pneumothorax (RR 0.46; 95% CI 0.28 to 0.77; p=0.003) and barotrauma (RR 0.56; 95% CI 0.37 to 0.86; p=0.008). In addition, NMBAs increased PaO₂/FiO₂ at 48 hours (mean difference (MD) 18.91; 95% CI 4.29 to 33.53; p=0.01) and 72 hours (MD 12.27; 95% CI 4.65 to 19.89; p=0.002). Meta-regression revealed an association between sample size (p=0.042) and short-term mortality. Publication year (p=0.050), sedation strategy (p=0.047) and sample size (p=0.046) were independently associated with PaO₂/FiO₂ at 48 hours.

CONCLUSIONS

In summary, the results suggested that use of NMBAs might reduce 21-28 days mortality, NMBA-related complications and oxygenation. However, NMBAs did not reduce the 90-day mortality of patients with ARDS, which contradicts a previous meta-analysis.

PROSPERO REGISTRATION NUMBER

CRD42019139440.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study

BACKGROUND

Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.

METHODS

Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted.

RESULTS

Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067.

LIMITATIONS

Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness.

CONCLUSIONS

These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years.

FUTURE WORK

Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53388093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

An exploration of the reliability and usability of two delirium screening tools in an Australian intensive care unit: A pilot study

OBJECTIVE

To compare the inter-rater reliability and usability of two delirium screening tools designed for use in ICU; the Confusion Assessment Method for ICU and the Intensive Care Delirium Screening Checklist.

RESEARCH METHODOLOGY/DESIGN

A multiple methods design was used. The intra and inter rater reliability of the tools were evaluated using Kappa statistics and intra class correlation coefficients. Focus groups were conducted to explore ICU staff perceptions of the usability of the tools and feasibility of delirium screening.

SETTING

Private hospital ICU, Melbourne Australia.

RESULTS

66 patients were assessed for delirium; median age of 71 (IQR 62-75) years. Seventeen patients (26%) scored positive for delirium using the screening tools and 11 (17%) had delirium confirmed on the medical ICU discharge summary. Ten nurse assessors performed 99 paired assessments using the two tools sequentially, demonstrating the intra and inter-rater agreement and reliability of the tools was moderate to high. Four focus groups were conducted with 16 participants. Content analysis identified three themes: (i) current recognition of delirium, (ii) benefits of delirium screening, and (iii) future directions for delirium management. Time and medical staff indifference were identified as barriers to screening, facilitators were education and having a follow-up plan.

CONCLUSION

This study found that the reliability and usability of the CAM-ICU and ICDSC were acceptable and that using structured delirium screening was feasible as part of a wider, multi-disciplinary delirium management plan.

Prescribing Practices of Valproic Acid for Agitation and Delirium in the Intensive Care Unit

BACKGROUND

Analgesics, sedatives, and antipsychotics are commonly prescribed for agitation and delirium in the intensive care unit (ICU), but their use is limited by adverse effects and lack of efficacy. Valproic acid is an alternative treatment option.

OBJECTIVE

The primary objective of this study was to describe valproic acid prescribing in our institution's ICUs when used for agitation or delirium. Measures of effectiveness and safety were also assessed.

METHODS

This was a single-center, retrospective, institutional review board-approved cohort study of adult inpatients admitted to the ICU between January 2018 and August 2018. Patients who received valproic acid for the treatment of agitation or delirium for ≥24 hours were included. Prescribing practices were evaluated for dose, frequency, and route of administration. Effectiveness was assessed via agitation and delirium assessment tools and quantity of adjunctive agents used.

RESULTS

A total of 80 patients were included, with 35 receiving valproic acid alone and 45 in conjunction with antipsychotics. The most common valproic acid regimen was 250 mg orally 3 times daily. Delirium resolution occurred in 55% of patients: 24 in the valproic acid monotherapy group and 20 in the valproic acid plus antipsychotic group (69% vs 44%; P = 0.03). The incidence of delirium decreased from valproic acid day 0 to day 3 (93% vs 68%; P < 0.01), with no change in agitation (64% vs 63%; P = 0.28).

CONCLUSION AND RELEVANCE

Valproic acid is frequently prescribed in agitated, delirious patients at our institution and may have a role in the management of ICU delirium.

Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium

Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.

Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists

BACKGROUND

Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice.

METHODS

European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537.

RESULTS

In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%).

CONCLUSION

Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.

Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia

BACKGROUND

Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care.

OBJECTIVES

To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada.

METHODS

A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches.

RESULTS

All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium.

CONCLUSION

Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.

Delirium misdiagnosis risk in psychiatry: a machine learning-logistic regression predictive algorithm

BACKGROUND

Delirium is a frequent diagnosis made by Consultation-Liaison Psychiatry (CLP). Numerous studies have demonstrated misdiagnosis prior to referral to CLP. Few studies have considered the factors underlying misdiagnosis using multivariate approaches.

OBJECTIVES

To determine the number of cases referred to CLP, which are misdiagnosed at time of referral, to build an accurate predictive classifier algorithm, using input variables related to delirium misdiagnosis.

METHOD

A retrospective observational study was conducted at Alfred Hospital in Melbourne, collecting data from a record of all patients seen by CLP for a period of 5 months. Data was collected pertaining to putative factors underlying misdiagnosis. A Machine Learning-Logistic Regression classifier model was built, to classify cases of accurate delirium diagnosis vs. misdiagnosis.

RESULTS

Thirty five of 74 new cases referred were misdiagnosed. The proposed predictive algorithm achieved a mean Receiver Operating Characteristic (ROC) Area under the curve (AUC) of 79%, an average 72% classification accuracy, 77% sensitivity and 67% specificity.

CONCLUSIONS

Delirium is commonly misdiagnosed in hospital settings. Our findings support the potential application of Machine Leaning-logistic predictive classifier in health care settings.

Can haloperidol prophylaxis reduce the incidence of delirium in critically ill patients in intensive care units? A systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to evaluate the efficacy and safety of haloperidol in the prevention of delirium in intensive care unit (ICU) patients.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library for eligible randomized controlled trials up to July 2019. No publication type or language restrictions were applied.

RESULTS

Compared to the placebo, haloperidol did not significantly reduce the incidence of delirium in all ICU patients (relative risk (RR), 0.83; 95% confidence interval (CI), 0.62-1.10, p = 0.20). However, haloperidol prophylaxis could reduce the incidence of delirium exclusively in postoperative patients admitted to an ICU (RR, 0.63; 95% CI, 0.47-0.86, p = 0.004). We observed no significant differences between the haloperidol and placebo groups in terms of length of ICU stay, all-cause mortality, and adverse events.

CONCLUSIONS

The use of prophylactic haloperidol might reduce the incidence of delirium in postoperative patients admitted to an ICU, but not in all ICU patients.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BACKGROUND

Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes.

OBJECTIVES

To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.

METHODS

Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.

RESULTS

A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).

CONCLUSION

Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study

AIM

To identify the effects of each domain of the early and modified ABCDE bundle on post-intensive care syndrome (PICS).

DESIGN

This is a retrospective study.

METHODS

We analysed the data from electronic medical records of 91 intensive care patients who received therapeutic interventions in stages, based on the early ABCDE bundle (admitted to the intensive care unit [ICU] from June - August 2013) and 94 patients who received interventions using a modified ABCDE bundle developed through continuous quality improvement activities (admitted to the ICU from June to August 2014).

RESULTS

In the ABC domain, the percentage of patients showing sedation levels of alertness and calmness increased significantly from 58.2% using the early ABCDE bundle to 72.4% using the modified ABCDE bundle. Coma prevalence decreased significantly from 45.1% using the early ABCDE bundle to 28.7% using the modified ABCDE bundle. In the E domain, the percentage of patients receiving early mobility interventions increased significantly from 11% using the early ABCDE bundle to 54.3% using the modified ABCDE bundle.

CONCLUSION

The ABCDE bundle in the ICU helped prevent PICS by reducing deep sedation and immobilization among intensive care patients. To effectively use the ABCDE bundle, it is necessary for institutions to develop suitable protocols for each constituent element and to test their effectiveness.

IMPACT

The ABCDE bundle was a suitable tool to support evidence-based practice in intensive care patients, including oversedation and immobilization, which is related to the prevention of PICS. Individual institutions will need to actively use the ABCDE bundle in the ICU, by developing protocols and testing their effectiveness.

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study

Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation.

DESIGN

Multi-ICU proof-of-concept study and a single ICU before-after study.

SETTING

University hospital ICUs.

PATIENTS

Adult patients receiving mechanical ventilation.

INTERVENTIONS

An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers.

MEASUREMENTS AND MAIN RESULTS

We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application.

CONCLUSIONS

Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

Clinical management of delirium: The response depends on the subtypes. An observational cohort study in 602 patients

OBJECTIVE

The hypoactive, hyperactive, and mixed subtypes of delirium differently impact patient management and prognosis, yet the evidence remains sparse. Therefore, we examined the outcome of varying management strategies in the subtypes of delirium.

METHODS

In this observational cohort study, 602 patients were managed for delirium over 20 days with the following strategies: supportive care alone or in combination with psychotropics, single, dual, or triple+ psychotropic regimens. Cox regression models were calculated for time to remission and benefit rates (BRs) of management strategies.

RESULTS

Generally, the mixed subtype of delirium caused more severe and persistent delirium, and the hypoactive subtype was more persistent than the hyperactive subtype. The subtypes of delirium were similarly predictive for mortality (P = 0.697) and transfer to inpatient psychiatric care (P = 0.320). In the mixed subtype, overall, psychotropic drugs were administered more often (P = 0.016), and particularly triple+ regimens were administered more commonly compared to hypoactive delirium (P = 0.007). Patients on supportive care benefited most, whereas those on triple+ regimens did worst in terms of remission in all groups of hypoactive, hyperactive, and mixed subtypes (BR: 4.59, CI 2.01-10.48; BR: 4.59, CI 1.76-31.66; BR: 3.36, CI 1.73-6.52; all P < 0.05).

SIGNIFICANCE OF RESULTS

The mixed subtype was more persistent to management than the hypoactive and hyperactive subtypes. Delirium management remains controversial and, generally, supportive care benefited patients most. Psychopharmacological management for delirium requires careful choosing of and limiting the number of psychotropics.

Delirium in the Intensive Care Unit: Is Dexmedetomidine Effective?

Delirium in the intensive care unit affects approximately 30% of patients despite vigorous efforts to encourage the use of effective screening tools and preventive strategies. The success of pharmacological treatment of delirium remains equivocal; moreover, a paucity of research supports the use of atypical antipsychotic medications. However, dexmedetomidine appears to have a promising role in delirium management. This review includes an overview of the pathophysiology and types of delirium and describes 2 established tools used to screen for delirium. Published research related to the use of dexmedetomidine in the management of delirium is also discussed. The authors make recommendations for critical care nurses on dexmedetomidine use in the context of providing evidence-based nursing care to intensive care unit patients with delirium.