Using Telehealth to Improve the Accuracy of Delirium Screening by Bedside Critical Care Nurses

Background Delirium affects up to 80% of patients in the intensive care unit (ICU) but is missed in up to 75% of cases. Telehealth in the ICU (tele-ICU) has become the standard for providing timely, expert care to remotely located ICUs. Objectives This pilot study assessed the feasibility and acceptability of using tele-ICU to increase the accuracy of delirium screening and recognition by ICU nurses. Methods The pilot sites included 4 ICUs across 3 hospitals. A geriatrician with delirium expertise remotely observed 13 bedside ICU nurses administering the Confusion Assessment Method for the ICU (CAM-ICU) to patients in real time via the tele-ICU platform and subsequently provided training on CAM-ICU performance and delirium management. Training evaluation consisted of a validated spot check form, a 2-item satisfaction/change-of-practice survey, and a qualitative question on acceptability. Results Thirteen ICU nurses were observed performing 26 bedside delirium assessments. The top observed barriers to accurate delirium screening were CAM-ICU knowledge deficits, establishment of baseline cognition, and inappropriate use of the “unable to assess” designation. The mean percentage of correct observations improved from 40% (first observation) to 90% (second observation) (P < .001). All 13 nurses strongly agreed that the training was beneficial and practice changing. Conclusions The use of tele-ICU to improve the accuracy of delirium screening by ICU nurses appears to be feasible and efficient for leveraging delirium expertise across multiple ICUs. Future studies should evaluate the effects of tele-ICU delirium training on patient-centered outcomes.

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LO022: Incidence and impact measurement of delirium induced by ED stay - INDEED

CJEM ◽

10.1017/cem.2016.59 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S37-S38

Author(s):

M. Émond ◽

P. Voyer ◽

R. Daoust ◽

M. Pelletier ◽

E. Gouin ◽

...

Keyword(s):

Phase 1 ◽

Confusion Assessment Method ◽

Assessment Method ◽

Hospital Length ◽

Cognitive Status ◽

Study Phase ◽

Inclusion Criteria ◽

Impact Measurement ◽

Ed Overcrowding ◽

The Mean

Introduction: Delirium is a dreadful complication in seniors’ acute care. Many studies are available on the incidence of delirium, however ED-induced delirium is far less studied. We aim to evaluate the incidence and impact of ED-induced delirium among older non-delirious admitted ED patients who have prolonged ED stays (≥ 8 hours). Methods: This prospective INDEED study phase 1 included patients recruited from 4 Canadian EDs. Inclusion criteria: 1) Patients aged 65 and over; 2) ED stay ≥ 8 hours; 3) Patient is admitted to the hospital; 4) Patient is non-delirious upon arrival and at the end of the first 8 hours; 5) Independent or semi-independent patient. Eligible patients were assessed by a research assistant after an 8 hour exposition to the ED and evaluated twice a day up to 24h after ward admission. Patients’ functional and cognitive status were assessed using validated OARS and TICS-m tools. The Confusion Assessment Method was used to detect incident delirium. Hospital length of stays (LOS) were obtained. Univariate and multivariate analyses were conducted to evaluate outcomes. Results: Of the 380 patients prospectively followed, mean age was 76.5 (± 8.9), male represent 50% and 16.5% very old seniors (> 85 y.o.). The overall incidence of ED-induced delirium was 8.4%. Distribution by the 4 sites was: 10%, 13.8%, 5.5% & 13.4%. The mean ED LOS varied from 29 to 48 hours. The mean hospital LOS was increase by 6.1 days in the delirious patients compared to non-delirious patient (p<0.05). Increase mean hospital LOS distribution by site was by: 6.9, 8.5, 4.3 and 5.2 days for the ED-induced delirium patients. Conclusion: ED-induced delirium was recorded in nearly one senior out of ten after a minimal 8 hour exposure in the ED environment. An episode of delirium increases hospital LOS by about a week and therefore could contribute to ED overcrowding.

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E.04 Coma and delirium are associated with low levels of brain tissue oxygen in critically ill patients

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.88 ◽

2016 ◽

Vol 43 (S2) ◽

pp. S17-S17

Author(s):

MD Wood ◽

D Maslove ◽

J Muscedere ◽

JG Boyd

Keyword(s):

Brain Tissue ◽

Critically Ill ◽

Critically Ill Patients ◽

Near Infrared ◽

Neurological Status ◽

Confusion Assessment Method ◽

Assessment Method ◽

Brain Tissue Oxygenation ◽

Low Levels ◽

Icu Delirium

Background: The cause of ICU delirium is unknown. We used near infrared spectroscopy (NIRS) to measure brain tissue oxygenation (BtO2) in critically ill patients, to test the hypothesis that poor cerebral oxygen delivery contributes to ICU delirium. Methods: Adult patients were enrolled if they required mechanical ventilation for >24 hours, and/or vasoactive agents. Patients were excluded if they had previous cognitive dysfunction, brain injury on admission, or a life expectancy <24 hours. BtO2 was measured for the first 24 hours of ICU admission. The confusion assessment method-ICU (CAM-ICU) was used to screen for delirium. Participants were designated to one of three groups on the basis of their predominant neurological status (comatose, delirious, or intact). Results: To date, 47 patients have been recruited. Both delirious and comatose patients’ had significantly lower BtO2 levels compared to intact patients (P<0.001). There was a significant correlation between hemoglobin and BtO2 (R2=0.347, P<0.01). However, when correlation analysis was conducted separately amongst the three groups, the delirious patients (R2=0.485, P<0.05) were the strongest contributors to this positive correlation. Conclusions: Delirious patients exhibited the lowest BtO2 recordings and demonstrated a significant association between Hb and BtO2. This study offers potential insight into the pathophysiology of ICU delirium.

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Agitation

Acute Care Casebook ◽

10.1093/med/9780190865412.003.0036 ◽

2018 ◽

pp. 180-183

Author(s):

Megan Rashid

Keyword(s):

Correct Diagnosis ◽

Altered Mental Status ◽

Confusion Assessment Method ◽

Assessment Method ◽

Early Mobility ◽

Confusion Assessment ◽

Life Threatening ◽

High Risk Populations ◽

Icu Delirium ◽

Abcdef Bundle

The case illustrates a classic example of intensive care unit (ICU) delirium, which often goes unrecognized but can adversely affect both morbidity and mortality. The Confusion Assessment Method for the ICU (CAM-ICU) is a validated tool for diagnosing delirium, but it remains a diagnosis of exclusion, and it is important to rule out potentially life-threatening medical causes of altered mental status. Treatment is difficult even with the correct diagnosis, and prevention is key. The ABCDEF bundle (assessing and managing pain, both SAT and SBT, choice of analgesia/sedation, delirium, early mobility, and family engagement) is a tool that identifies high-risk populations, and can help mitigate the prevalence of ICU delirium.

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Evaluation of the delirium early monitoring system (DEMS)

International Psychogeriatrics ◽

10.1017/s1041610216000983 ◽

2016 ◽

Vol 28 (11) ◽

pp. 1879-1887 ◽

Cited By ~ 4

Author(s):

Daniel Rippon ◽

Koen Milisen ◽

Elke Detroyer ◽

Elizabeta Mukaetova-Ladinska ◽

Beth Harrison ◽

...

Keyword(s):

Monitoring System ◽

Medical Records ◽

Medical Staff ◽

Daily Practice ◽

Confusion Assessment Method ◽

Assessment Method ◽

Secondary Outcome ◽

Assessment Scores ◽

Inpatient Settings ◽

Delirium Management

ABSTRACTBackground:Despite awareness of the negative health and financial outcomes of delirium, systems to routinely assess and manage the condition are absent in clinical practice. We report the development and pilot evaluation of a Delirium Early Monitoring System (DEMS), designed to be completed by non-medical staff to influence clinical processes within inpatient settings. Two versions of the DEMS are described based on a modified Confusion Assessment Method (DEMS-CAM) and Delirium Observation Screening Scale (DEMS-DOSS).Methods:Both versions of DEMS were piloted on a 20-bedded Psychogeriatric ward over 6 weeks. Training was administered to ward staff on the use of each version of the DEMS and data were collected via electronic medical records and completed assessment sheets. The primary outcome was patterns of DEMS use and the secondary outcome was the initiation of delirium management protocols. Data regarding the use of the DEMS DOSS and DEMS CAMS were analyzed using χ2 tests.Results:Completion rates for the DEMS CAM and DEMS DOSS were 79% and 68%, respectively. Non-medical staff were significantly more likely to use the DEMS-CAM as part of daily practice as opposed to the DEMS-DOSS (p<0.001). However, there was no difference between the use of the DEMS-CAM and DEMS-DOSS in triggering related actions such as documentation of assessment scores in patients’ medical records and implementation of delirium management protocols.Conclusions:This real world evaluation revealed that non-medical staff were able to incorporate delirium monitoring into their practice, on the majority of occasions, as part of their daily working routine. Further research is necessary to determine if the routine use of the DEMS can lead to improved understandings and practice of non-medical staff regarding delirium detection.

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Characterisation and outcome of neuropsychiatric symptoms in patients with anti-NMDAR encephalitis

Acta Neuropsychiatrica ◽

10.1017/neu.2019.46 ◽

2020 ◽

Vol 32 (2) ◽

pp. 92-98

Author(s):

Miguel Restrepo-Martinez ◽

Jesus Ramirez-Bermudez ◽

Leo Bayliss ◽

Mariana Espinola-Nadurille

Keyword(s):

Rating Scale ◽

Neuropsychiatric Symptoms ◽

Confusion Assessment Method ◽

Assessment Method ◽

Prospective Longitudinal Study ◽

Aspartate Receptor ◽

Immune Mediated ◽

The Mean ◽

Prospective Longitudinal ◽

Receptor Antibodies

AbstractBackground:Encephalitis due to anti-N-methyl-D-aspartate receptor antibodies (ANMDARE) is the most frequent immune-mediated encephalitis. It is distinguished by the subacute onset of neuropsychiatric symptoms.Objective:To evaluate the characteristic neuropsychiatric symptoms and their outcome in patients diagnosed with ANMDARE.Methods:This was a prospective, longitudinal study in patients with a diagnostic suspicion of ANMDARE that presented to the National Institute of Neurology from March 2018 to February 2019. A comparative analysis of two groups (positive N-methyl-D-aspartate receptor [NMDAR] vs. negative NMDAR antibodies in cerebrospinal fluid [CSF]) was done on admission and at discharge. Neuropsychiatric systematic assessments included the Neuropsychiatric Inventory Questionnaire, the Bush Francis Catatonia Rating Scale, the Confusion Assessment Method Severity, the Montreal Cognitive Assessment, and the Overt Agitation Severity Scale.Results:24 individuals were analysed: 14 had positive NMDAR antibodies, and 10 had negative NMDAR antibodies in CSF. On admission, agitation/aggression, euphoria/exaltation, and disinhibition were more common in patients with positive antibodies. Excited catatonia and delirium were diagnosed more frequently in patients with positive antibodies. At discharge, there was an important decrease in neuropsychiatric symptoms, but substantial cognitive impairment remained. The mean hospitalisation length was 41.71 (SD 39.33) days for patients with definitive ANMDARE (p 0.259).Conclusions:Neuropsychiatric symptoms profile in ANMDARE was associated with the early onset of euphoria/exaltation and disinhibition, accompanied by marked psychomotor agitation. When ANMDARE was suspected, the presence of excited-type catatonia and delirium showed a tendency to predict definitive ANMDARE. At discharged, most patients recovered from catatonia, delirium, and psychosis, but marked cognitive symptoms, anxiety, and depression persisted at discharge.

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Risk Factors and Incidence of Postoperative Delirium in Patients Undergoing Laryngectomy

Otolaryngology ◽

10.1177/0194599819864304 ◽

2019 ◽

Vol 161 (5) ◽

pp. 807-813 ◽

Cited By ~ 2

Author(s):

Yiru Wang ◽

Huiqian Yu ◽

Hui Qiao ◽

Chan Li ◽

Kaizheng Chen ◽

...

Keyword(s):

Risk Factors ◽

Postoperative Delirium ◽

Rating Scale ◽

Multivariable Analysis ◽

Diagnostic Algorithm ◽

Target Population ◽

Confusion Assessment Method ◽

Assessment Method ◽

Factors Associated ◽

The Mean

Objective To explore the risk factors and incidence of postoperative delirium (POD) in patients undergoing laryngectomy for laryngeal cancer. Study Design Prospective cohort study. Setting Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University. Subjects and Methods A total of 323 patients underwent laryngectomy from April 4, 2018, to December 28, 2018. Perioperative data were collected. The primary outcome was the presence of POD as defined by the Confusion Assessment Method diagnostic algorithm. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with POD. Results Of the patients who underwent laryngectomy during the study period, 99.1% were male, with a mean age of 60.0 years. Of these patients, 28 developed POD, with most episodes (88.1%) occurring during the first 3 postoperative days. The type of POD was hyperactive in 7 cases and hypoactive in 21 cases. The mean duration of POD was 1 day. The mean Delirium Rating Scale-Revised-98 score (a measure of POD severity) was 11.5. For the multivariable analysis, risk factors associated with POD included advanced cancer stage, lower educational level, higher American Society of Anesthesiologists classification, and intraoperative hypotension lasting at least 30 minutes. Intraoperative dexmedetomidine use was protective against POD. Conclusion This study identified risk factors associated with POD, providing a target population for quality improvement initiatives. Furthermore, intraoperative dexmedetomidine use can reduce POD.

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Predicting Hospital Mortality and Length of Stay: The Delirium Screening Checklist versus Confusion Assessment Method for Intensive Care Units

10.21203/rs.3.rs-754291/v1 ◽

2021 ◽

Author(s):

Hsiu Ching Li ◽

Cheryl Chia-Hui Chen ◽

Tony Yu-Chang Yeh ◽

Shih-Cheng Liao ◽

Adrian-Shengchun Hsu ◽

...

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Predictive Validity ◽

Confusion Assessment Method ◽

Assessment Method ◽

Apache Ii Score ◽

Care Hospital ◽

Confusion Assessment ◽

Icu Delirium

Abstract Background: Both the intensive care delirium screening checklist (ICDSC) and confusion assessment method for ICU (CAM-ICU) are valid tools for identification of delirium, however their relative predictive validity for important delirium outcomes, such as hospital mortality and LOS have not been well-established. We aim to compare the two tools for their predictive validity for outcomes related to delirium, hospital mortality and length of stay (LOS).Methods: The prospective cohort study conducted in six medical ICUs at a tertiary care hospital in Taiwan. The study enrolled consecutive adult patients (≥20 years) who were delirium free at ICU admission. Delirium was screened daily by trained research nurses using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation-Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups, respectively.Results: Delirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ =0.63; p < 0.001) was found between tools. Independent of age, APACHE II score, and Charlson comorbidity index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio [aOR] 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI, 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared to the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (aOR 2.97; 95% CI, 1.06 to 8.37 vs. 3.82; 95% CI, 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS.Conclusions: The ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients’ arousal when deciding which tool to use to maximize the effects of delirium identification on patient mortality.Trial registration: NCT 04206306

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Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital

Age and Ageing ◽

10.1093/ageing/afaa069 ◽

2020 ◽

Vol 49 (4) ◽

pp. 672-678 ◽

Cited By ~ 2

Author(s):

Emma Vardy ◽

Niamh Collins ◽

Umang Grover ◽

Rebecca Thompson ◽

Alexandra Bagnall ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Confusion Assessment Method ◽

Assessment Method ◽

Treatment Quality ◽

Training And Education ◽

Automated Coding ◽

Delirium Management ◽

Detection And Diagnosis

Abstract Background delirium is a common condition associated with hospital admission. Detection and diagnosis is important to identify the underlying precipitating cause and implement effective management and treatment. Quality improvement (QI) methodology has been applied in limited publications. There are even fewer publications of the role of development of the electronic health record (EHR) to enhance implementation. Methods we used QI methodology to improve delirium detection in the emergency department (ED). Plan Do Study Act (PDSA) cycles could be broadly categorised into technology, training and education and leadership. As part of the technology PDSA an electronic delirium pathway was developed as part of an NHS England digital systems improvement initiative (NHS England Global Digital Exemplar). The electronic pathway incorporated the 4AT screening tool, the Confusion Assessment Method, the TIME delirium management bundle, investigation order sets and automated coding of delirium as a health issue. Results development of the EHR combined with education initiatives had benefit in terms of the number of people assessed for delirium on admission to the ED and the total number of people diagnosed with delirium across the organisation. The implementation of a delirium pathway as part of the EHR improved the use of 4AT in those 65 years and over from baseline of 3% completion in October 2017 to 43% in January 2018. Conclusion we showed that enhancement of the digital record can improve delirium assessment and diagnosis. Furthermore, the implementation of a delirium pathway is enhanced by staff education.

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ICU delirium burden predicts functional neurologic outcomes

PLoS ONE ◽

10.1371/journal.pone.0259840 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0259840

Author(s):

Luis Paixao ◽

Haoqi Sun ◽

Jacob Hogan ◽

Katie Hartnack ◽

Mike Westmeijer ◽

...

Keyword(s):

Critical Illness ◽

Confusion Assessment Method ◽

Assessment Method ◽

Neurologic Outcome ◽

Post Discharge ◽

Mechanically Ventilated ◽

Neurological Outcomes ◽

Survival Status ◽

Neurologic Outcomes ◽

Icu Delirium

Background We investigated the effect of delirium burden in mechanically ventilated patients, beginning in the ICU and continuing throughout hospitalization, on functional neurologic outcomes up to 2.5 years following critical illness. Methods Prospective cohort study of enrolling 178 consecutive mechanically ventilated adult medical and surgical ICU patients between October 2013 and May 2016. Altogether, patients were assessed daily for delirium 2941days using the Confusion Assessment Method for the ICU (CAM-ICU). Hospitalization delirium burden (DB) was quantified as number of hospital days with delirium divided by total days at risk. Survival status up to 2.5 years and neurologic outcomes using the Glasgow Outcome Scale were recorded at discharge 3, 6, and 12 months post-discharge. Results Of 178 patients, 19 (10.7%) were excluded from outcome analyses due to persistent coma. Among the remaining 159, 123 (77.4%) experienced delirium. DB was independently associated with >4-fold increased mortality at 2.5 years following ICU admission (adjusted hazard ratio [aHR], 4.77; 95% CI, 2.10–10.83; P < .001), and worse neurologic outcome at discharge (adjusted odds ratio [aOR], 0.02; 0.01–0.09; P < .001), 3 (aOR, 0.11; 0.04–0.31; P < .001), 6 (aOR, 0.10; 0.04–0.29; P < .001), and 12 months (aOR, 0.19; 0.07–0.52; P = .001). DB in the ICU alone was not associated with mortality (HR, 1.79; 0.93–3.44; P = .082) and predicted neurologic outcome less strongly than entire hospital stay DB. Similarly, the number of delirium days in the ICU and for whole hospitalization were not associated with mortality (HR, 1.00; 0.93–1.08; P = .917 and HR, 0.98; 0.94–1.03, P = .535) nor with neurological outcomes, except for the association between ICU delirium days and neurological outcome at discharge (OR, 0.90; 0.81–0.99, P = .038). Conclusions Delirium burden throughout hospitalization independently predicts long term neurologic outcomes and death up to 2.5 years after critical illness, and is more predictive than delirium burden in the ICU alone and number of delirium days.

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