Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis

PURPOSE

The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada.

MATERIAL AND METHODS

We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record.

RESULTS

44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events.

CONCLUSIONS

An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Preliminary clinical testing to inform development of the Critical Care Pain Observation Tool for Families (CPOT-Fam)

Introduction

Many patients in the intensive care unit (ICU) cannot communicate. For these patients, family caregivers (family members/close friends) could assist in pain assessment. We previously adapted the Critical Care Pain Observation Tool (CPOT) for family caregiver use (CPOT-Fam). In this study, we conducted preliminary clinical evaluation of the CPOT-Fam to inform further tool development.

Methods

For preliminary testing, we collected (1) pain assessments of patients in the ICU from family caregivers (CPOT-Fam) and nurses (CPOT) and determined the degree of agreement (kappa coefficient, κ) and (2) collected openended feedback on the CPOT-Fam from family caregivers. For refinement, we used preliminary testing data to refine the CPOT-Fam with a multidisciplinary working group.

Results

We assessed agreement between family caregiver and nurse pain scores for 29 patients. Binary agreement (κ) between CPOT-Fam and CPOT item scores (scores ≥2 considered indicative of significant pain) was fair, κ = 0.43 (95% confidence interval [CI] 0.18-0.69). Agreement was highest for the CPOT-Fam items ventilator compliance/vocalization (weighted κ = 0.48, 95% CI 0.15-0.80) and lowest for muscle tension (weighted κ = 0.10, 95% [CI] -0.17 to 0.20). Most participants (n = 19; 69.0%) reported a very positive experience using the CPOT-Fam, describing it as "good" and "easy-to-use/clear/straightforward." We iteratively refined the CPOT-Fam over five cycles using the data collected until no further revisions were suggested.

Conclusion

Our preliminary clinical testing suggests that family involvement in pain assessment in the ICU is well perceived. The CPOT-Fam has been further refined and is now ready for clinical pilot testing to determine its feasibility and acceptability.

Development and preclinical testing of the critical care pain observation tool for family caregiver use (CPOT-Fam)

Background and Aims

Pain assessment in noncommunicative intensive care unit (ICU) patients is challenging. For these patients, family caregivers (i.e., family members, friends) may be able to assist in pain assessment by identifying individualistic signs of pain due to their intimate patient knowledge. This study adapted the critical care pain observation tool (CPOT) to facilitate pain assessment in adult ICU patients by family caregivers.

Methods

This study was conducted through three distinct phases: (1)CPOT adaptation for family caregiver use (to create the CPOT-Fam): A working group met monthly to adapt the CPOT and develop educational material and sample cases for practice scoring until consensus was reached.(2)CPOT-Fam preclinical testing: Family caregiver study participants viewed educational materials and scored four randomly selected sample cases using the CPOT-Fam. Scores were compared to reference scores to assess agreement and identify CPOT-Fam sections requiring revision. Open-ended feedback on the CPOT-Fam was collected.(3)CPOT-Fam revision: the CPOT-Fam was revised by the working group considering score agreement and feedback received from study participants.

Results

Of the n = 30 participants, n = 14 (47.0%) had experience with an ICU patient. Agreement between CPOT-Fam participant scores and reference scores were highest for the vocalization dimension (Is the patient making any sounds?; Intraclass correlation coefficient; ICC = 1.0) and lowest for the body movements dimension (What are the patient's body movements like?; ICC = 0.85. Participants indicated they found the CPOT-Fam to be "informative" and "easy-to-use" but "not graphic enough"; participants also indicated that descriptors like "lack of breath" and "struggling to move" are helpful with identifying individualistic behaviors of pain exhibited by their loved ones.

Conclusion

The CPOT-Fam shows ease of use and may be of value in involving family caregivers in ICU care. Clinical pilot testing is needed to determine feasibility and acceptability and identify further areas for refinement.

Study protocol: development and pilot testing of the Critical Care Pain Observation Tool for families (CPOT-Fam)

Background

Patients in the intensive care unit (ICU) often have limited ability to communicate making it more difficult to identify and effectively treat their pain. Family caregivers or close friends of critically ill patients may be able to identify signs of pain before the clinical care team and could potentially assist in routine pain assessments. This study will adapt the Critical Care Pain Observation Tool (CPOT) for use by family members to create the CPOT-Fam and compare family CPOT-Fam assessments with nurse-provided CPOT assessments for a given patient.

Methods

This study will be executed in two phases:

1) Development of the CPOT-Fam — A working group of patient partners, ICU clinicians, and researchers will adapt the CPOT for use by family caregivers (creating the CPOT-Fam) and produce an accompanying educational module to deliver information on pain and how to use the tool. The CPOT-Fam will undergo preclinical testing with participants (i.e., members of the public and family caregivers of critically ill adults), who will complete the educational module and provide CPOT-Fam scores on sample cases. Feedback on the CPOT-Fam will be collected.

2) Pilot testing the CPOT — Fam family caregivers of critically ill adults will complete the educational module and provide information on the following: (1) demographics, (2) anxiety, (3) caregiving self-efficacy, and (4) satisfaction with care in the ICU. Family caregivers will then provide a proxy assessment of their critically ill loved one’s pain through the CPOT-Fam and also provide a subjective (i.e., questionnaire-based including open-ended responses) account of their loved one’s pain status. A comparison (i.e., agreement) will be made between family caregiver provided CPOT-Fam scores and ICU nurse-provided CPOT scores (collected from the provincial health information system), calculated independently and blinded to one another. Feasibility and acceptability of the CPOT-Fam will be determined.

Discussion

The results of this work will produce a family caregiver CPOT (i.e., CPOT-Fam), determine feasibility and acceptability of the CPOT-Fam, and compare pain assessments conducted by family caregivers and ICU nurses. The results will inform whether a larger study to determine a role for family caregivers in ICU pain assessment using the CPOT-Fam is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01102-3.

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Kidney disease is associated with an increased risk for postoperative morbidity and mortality. However, the incidence of major surgery on a population level is unknown. We aimed to determine the incidence of major surgery by level of kidney function.

STUDY DESIGN

Retrospective cohort study with entry from January 1, 2008, through December 31, 2009, and outcome surveillance from January 1, 2010, through December 31, 2016.

SETTING & PARTICIPANTS

Population-based study using administrative health data from Alberta, Canada; adults with an outpatient serum creatinine measurement or receiving maintenance dialysis formed the study cohort.

EXPOSURE

Participants were categorized into 6 estimated glomerular filtration rate (eGFR) categories: ≥60 (G1-G2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), and<15mL/min/1.73m² with (G5D) and without (G5) dialysis. eGFR was examined as a time-varying exposure based on means of measurements within 3-month ascertainment periods throughout the study period.

OUTCOME

Major surgery defined as surgery requiring admission to the hospital for at least 24 hours.

ANALYTICAL APPROACH

Incidence rates (IRs) for overall major surgery were estimated using quasi-Poisson regression and adjusted for age, sex, income, location of residence, albuminuria, and Charlson comorbid conditions. Age- and sex-stratified IRs of 13 surgery subtypes were also estimated.

RESULTS

1,455,512 cohort participants were followed up for a median of 7.0 (IQR, 5.3) years, during which time 241,989 (16.6%) underwent a major surgery. Age and sex modified the relationship between eGFR and incidence of surgery. Men younger than 65 years receiving maintenance dialysis experienced the highest rates of major surgery, with an adjusted IR of 243.8 (95% CI, 179.8-330.6) per 1,000 person-years. There was a consistent trend of increasing surgery rates at lower eGFRs for most subtypes of surgery.

LIMITATIONS

Outpatient preoperative serum creatinine measurement was necessary for inclusion and outpatient surgical procedures were not included.

CONCLUSIONS

People with reduced eGFR have a significantly higher incidence of major surgery compared with those with normal eGFR, and age and sex modify this increased risk. This study informs our understanding of how surgical burden changes with differing levels of kidney function.