Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds

Delirium is a key quality metric identified by The Society of Critical Care Medicine for intensive care unit (ICU) patients. If not recognised early, delirium can lead to increased length of stay, hospital and societal costs, ventilator days and risk of mortality. Clinical practice guidelines recommend ICU patients be assessed for delirium at least once per shift. An initial audit at our urban tertiary care hospital in Illinois, USA determined that delirium assessments were only being performed 31% of the time. Nurses completed simulation based education and were trained using delirium screening videos. After the educational sessions, delirium documentation increased from 40% (12/30) to 69% (41/59) (two-proportion test, p<0.01) for dayshift nurses and from 27% (8/30) to 61% (36/59) (two-proportion test, p<0.01) during the nightshift. To further increase the frequency of delirium assessments, the delirium screening tool was standardised and a critical care progress note was implemented that included a section on delirium status, management strategy and discussion on rounds. After the documentation changes were implemented, delirium screening during dayshift increased to 93% (75/81) (two-proportion test, p<0.01). Prior to this project, physicians were not required to document delirium screening. After the standardised critical care note was implemented, documentation by physicians was 95% (106/111). Standardising delirium documentation, communication of delirium status on rounds, in addition to education, improved delirium screening compliance for ICU patients.

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SNAPPE II score: predictor of mortality in NICU

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20190544 ◽

2019 ◽

Vol 6 (2) ◽

pp. 422

Author(s):

Sujana Rachuri ◽

Saritha Paul ◽

Jaidev M. D.

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Neonatal Intensive Care ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

P Value ◽

Care Hospital ◽

Hospital Data ◽

Mortality And Morbidity ◽

Risk Of Mortality

Background: Advances in the NICU (neonatal intensive care unit) have significantly decreased mortality and morbidity and increased survival rate in neonates. SNAPPE II (Score for Neonatal Acute Physiology-Perinatal Extension II) score, which is a modified version of the SNAP score (Score for Neonatal Acute Physiology) helps in predicting the neonatal mortality. The aim of the study was to assess the risk of mortality using SNAPPE II score in neonates admitted to NICU.Methods: It was a prospective validation study done in a tertiary care hospital. Data was collected from 116 new borns admitted to NICU within 48 hours of birth who required respiratory support between December 2017 to June 2018.Results: A total of 116 newborns admitted to the NICU was included in present study. Out of 116 babies, 56 (48%) had mild SNAPPE-II score, 44 (38%) had moderate score and 16 (14%) had severe score. Among the 44 babies with moderate score, 12 (27%) died, which was statistically significant (P<0.001). Among 16 babies with severe score, 13 (81%) babies died, which was highly statistically significant (P<0.0001). Urine output, seizures, serum pH in the first 24 hours of life are independent predictors of mortality with significant p value (0.001).Conclusions: The SNAPPE-II score recorded in the first 48 hours of life could be a good predictor of mortality in babies admitted to NICU.

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Mortality Review of Children Admitted in Pediatric Intensive Care Unit Over One Year in a Tertiary Care Hospital

Birat Journal of Health Sciences ◽

10.3126/bjhs.v6i1.37639 ◽

2021 ◽

Vol 6 (1) ◽

pp. 1369-1372

Author(s):

Pun Narayan Shrestha ◽

Sumit Agrawal ◽

Kosh Raj R C ◽

Prakash Joshi ◽

Ajit Rayamajhi

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Pediatric Intensive Care Unit ◽

Congenital Heart ◽

Tertiary Care ◽

Pediatric Intensive Care ◽

Critically Ill Children ◽

Care Hospital ◽

Female Ratio

Introduction: Childhood mortality is still high in developing countries. This can be reduced with good preventive and curative services especially with critical care. The treatment of critically ill children must be focused for better outcome. The pediatrics deaths audit and review provide feedback to health workers and to the institution. The outcome measures of critical care medicine include mortality, morbidity and disability rate. Objectives: The aim of this study is to review the causes and mode of death in children and length of PICU (pediatric intensive care unit) stay. Methodology: A retrospective study was conducted of the patients who were admitted and died within the period of 16 July 2019 to 15 July, 2020 at PICU of Kanti Children Hospital (KCH). Variables recorded were patient's demography, diagnosis, co- morbidities, complications, length of PICU stay (LOS), mode and time of death. Data were tabulated into MS Excel and analyzed using SPSS version 23. Result: Out of 718 admitted children, 99 (13.78%) died with male to female ratio of 1.8:1. The maximum death (75%) was observed in less than five year of age and most of them were from outside the Kathmandu valley. The leading causes of death were pneumonia (28%), sepsis (20%) and congenital heart diseases (21%). The common complications seen were disseminated intravascular coagulation (DIC), multi- organ dysfunction syndrome (MODS), acute kidney injury (AKI) (5.1 %) and acute respiratory distress syndrome (ARDS) (6.1%) and co- morbidities were congenital heart disease (CHD) (18.2%) and global developmental delay (GDD) (9.1%). Mechanical ventilation was needed in 80.8%. Most of the cases (86%) died despite active treatment and (75%) during off hours (4pm-9am). Conclusion: Pneumonia, sepsis and CHD were the main reason of death and most of them were from outside the valley.

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Impact of Early Reinitiation of Neuropsychiatric Medications on Agitation and Delirium in the Intensive Care Unit: A Retrospective Study

Annals of Pharmacotherapy ◽

10.1177/1060028020935589 ◽

2020 ◽

Vol 55 (1) ◽

pp. 15-24

Author(s):

Michaelia D. Cucci ◽

Brittany S. Cunningham ◽

Jaimini S. Patel ◽

Alan T. Shimer ◽

Dania I. Mofleh ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Intensive Care ◽

Primary Outcome ◽

Tertiary Care ◽

Group Versus ◽

Care Hospital ◽

Icu Patients ◽

Independent Risk Factors ◽

The Impact

Background: Approximately 17% of intensive care unit (ICU) patients are prescribed at least 1 home neuropsychiatric medication (NPM). When abruptly discontinued, withdrawal symptoms may occur manifesting as agitation or delirium in the ICU setting. Objective: To evaluate the impact of early reinitiation of NPMs. Methods: This was a retrospective, observational cohort of adult ICU patients in a tertiary care hospital. Patients were included if admitted to the ICU and prescribed a NPM prior to arrival. Study groups were based on the timing of reinitiation of at least 50% of NPMs: ≤72 hours (early group) versus >72 hours (late group). Results: The primary outcome was the proportion of patients with at least 1 agitation or delirium episode in the first 72 hours. Agitation and delirium were defined as at least 1 RASS assessment between +2 to +4 and a positive CAM-ICU assessment, respectively. A total of 300 patients were included, with 187 (62%) and 113 (38%) in the early and late groups, respectively. There was no difference in agitation or delirium (late 54 [48%] vs early 62 [33%]; adjusted odds ratio [aOR] = 1.5; 95% CI = 0.8-2.8; P = 0.193). Independent risk factors found to be associated with the primary outcome were restraints (aOR = 12.9; 95% CI = 6.9-24.0; P < 0.001) and benzodiazepines (BZDs; aOR = 2.0; 95% CI = 1.0-3.7; P = 0.038). Conclusions: After adjustment for baseline differences, there was no difference in agitation or delirium. Independent risk factors were restraint use and newly initiated BZDs.

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Prevalence of delirium in elderly intensive care unit patients of a tertiary care medical college hospital

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20194167 ◽

2019 ◽

Vol 6 (5) ◽

pp. 1504

Author(s):

Hemanth Kumar S. R. ◽

Apoorva E. Patel

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Older Patients ◽

Tertiary Care ◽

Care Hospital ◽

College Hospital ◽

Cross Sectional ◽

Icu Patients ◽

Poor Prognostic Factor ◽

Mechanically Ventilated

Background: Delirium is an acute disorder of attention and cognition. It occurs in 20% to 79% of hospitalized older patients. It is also common in ICU patients, occurring in 20% to 50% of non-mechanically ventilated ICU patients and in 60% to 80% of mechanically ventilated ICU patients. Hence delirium is a common, serious, and often fatal condition among older patients. The present study attempts to address the prevalence of Delirium in the Indian elderly population.Methods: A cross sectional study was conducted between January 2019 to June 2019 in a 50 bedded intensive care unit of a tertiary care hospital in Bengaluru, Karnataka. A total of 300 elderly patients aged 60 years and above, satisfying the inclusion criteria was included in the study. Patients were assessed for the presence of delirium within 24 hours of admission using Confusion Assessment Method for Intensive Care Unit (CAM-ICU). Various qualitative variables were expressed in terms of proportions.Results: Prevalence of delirium among elderly, non-ventilated ICU patients was 30% (90 out of 300 patients). Among them, 50 (55.5%) were females and remaining 40 (44.5%) were males. Mean age of the patients was 76 years. About 50 (55.5%) of them belonged to age group of 70-79 years. Most of the delirium patients (44.5%) belonged to hypoactive type of delirium followed by hyperactive (33.3%) and mixed (22.2%) type of delirium.Conclusions: Delirium in elderly ICU patients is significantly prevalent, which is a poor prognostic factor, leading to higher morbidity and mortality. Of the three subtypes- hypoactive delirium is the most common type of delirium among elderly. Yet, it is often overlooked or under-diagnosed. Hence clinicians and/or trained nursing staff managing the patients in the ICUs, should routinely screen the patients for delirium, using brief screening measures, which in turn can improve the patients’ outcome.

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Outpatient Follow-up Care After Hospital Discharge of Children With Complex Chronic Conditions at a Rural Tertiary Care Hospital

Clinical Pediatrics ◽

10.1177/00099228211047242 ◽

2021 ◽

pp. 000992282110472

Author(s):

Andrew Brown ◽

Mary Quaile ◽

Hannah Morris ◽

Dmitry Tumin ◽

Clayten L. Parker ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hospital Discharge ◽

Care Coordination ◽

Chronic Conditions ◽

Tertiary Care ◽

Care Hospital ◽

Icu Admission ◽

Complex Chronic Conditions

Objective To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge. Methods We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children’s hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded. Results Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission ( P = .020) and prolonged length of stay ( P = .004) were associated with decreased likelihood of completing recommended follow-up. Conclusions Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.

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