Relationship between Delirium and Night-Time Interruptions in ICU

Background: This dissertation examined the phenomenon of delirium in the intensive care unit (ICU) setting. Delirium is a form of cognitive disturbance with a physiologic etiology and complex, multifactorial mechanisms of causation and risk. Delirium in the ICU patient presents a significant risk for adverse outcomes including increased mortality, length of stay, falls, and restraint use. ICU delirium can lead to persistent cognitive impairment beyond discharge and frequent skilled nursing placement. Identifying delirium requires accurate diagnosis that is optimized when validated instruments are used. Sleep deprivation has been linked to adverse health consequences including delirium. Previous studies investigating the relationship between sleep and delirium have focused on the effects of light, noise, medications, and mechanical ventilation. Limited knowledge existed on the role night-time interruptions caused by routine hospital processes played in the prevalence of delirium. Objectives: This body of work aimed to determine the prevalence of ICU delirium in a sample of ICU patients and discover if there was a relationship between night-time sleep interruptions and delirium in a subset of patients undergoing cardiac surgery. A secondary purpose was to study the relationship between delirium, falls, and restraint use in adult cardiac surgery patients in ICU. The work will be presented in three manuscripts. Methods: A data-based retrospective cross-sectional design was used to describe the documentation of delirium in three acute care hospitals with mixed medical, surgical, and trauma ICU\u27s. A descriptive design using a subset of patients from the pre-collected data was used to identify relationships between independent risk variables and delirium in a sample of cardiovascular surgical ICU patients. Results: The first manuscript titled Preventing ICU Delirium: A Patient-Centered Approach to Reducing Sleep Disruption was published in Dimensions of Critical Care Nursing with the purpose of describing the state of the science regarding sleep as a risk factors for developing delirium and research evidence on the ill health effects of sleep loss. A patient centered approach was introduced to improve sleep in ICU by re-evaluating the necessity of routine processes that disrupt sleep in the critically ill. The second manuscript titled Delirium Assessment and Prevalence in Critical Care Patients. The article presents the frequency of delirium assessment and the prevalence of ICU delirium. The differences among amongst the three hospitals regarding ICU length of stay and assessment percent were also presented. In order to treat delirium, it must first be recognized. This study indicated the clinicians may be missing the delirium diagnosis because the assessment was not being done. The third manuscript is titled The Relationship Between Night-time Interruptions in ICU. The final manuscript describes the results of an observational study using retrospective data on the frequency ICU patients are awakened at night for routine laboratory and diagnostic tests. In addition, the relationship between the frequencies of sleep interruptions and delirium prevalence was presented. While no relationship was found, the results suggest ICU patients are awoken frequently at night and more studies are needed to understand if sleep deprivation in critically ill patients leads to poor health outcomes

Modelling distributions of Aedes aegypti and Aedes albopictus using climate, host density and interspecies competition.

Florida faces the challenge of repeated introduction and autochthonous transmission of arboviruses transmitted by Aedes aegypti and Aedes albopictus. Empirically-based predictive models of the spatial distribution of these species would aid surveillance and vector control efforts. To predict the occurrence and abundance of these species, we fit a mixed-effects zero-inflated negative binomial regression to a mosquito surveillance dataset with records from more than 200,000 trap days, representative of 53% of the land area and ranging from 2004 to 2018 in Florida. We found an asymmetrical competitive interaction between adult populations of Aedes aegypti and Aedes albopictus for the sampled sites. Wind speed was negatively associated with the occurrence and abundance of both vectors. Our model predictions show high accuracy (72.9% to 94.5%) in validation tests leaving out a random 10% subset of sites and data since 2017, suggesting a potential for predicting the distribution of the two Aedes vectors

Testing a Strategy to Identify Incidence of Nurse Suicide in the United States.

The aim of this study was to test a strategy for quantifying incidence of nurse suicide using San Diego County data as a pilot for national investigation.Worldwide, 1 person dies by suicide every 40 seconds; more than 1 000 000 suicides occur yearly. Suicide rates for nurses in the United States have not been evaluated. This methodological article tested a strategy to identify incidence of nurse suicide compared with those of physicians and the general public.Deidentified San Diego County Medical Examiner data from 2005 to 2015 were analyzed with a descriptive epidemiologic approach.Overall RN (18.51) and physician (40.72) incidences of suicide per 100 000 person-years were higher than the San Diego general population, excluding nurses (15.81) normalized to 100 000 person-years.Establishing incidence of nurse suicide is confounded by variation in reporting mechanisms plus incomplete availability of nurse gender data. Relatively small outcome numbers compared with the general population may underestimate results. Research using a larger sample is indicated. Nurse executives may decrease risk by proactively addressing workplace stressors

Testing a Strategy to Identify Incidence of Nurse Suicide in the United States.

The aim of this study was to test a strategy for quantifying incidence of nurse suicide using San Diego County data as a pilot for national investigation.Worldwide, 1 person dies by suicide every 40 seconds; more than 1 000 000 suicides occur yearly. Suicide rates for nurses in the United States have not been evaluated. This methodological article tested a strategy to identify incidence of nurse suicide compared with those of physicians and the general public.Deidentified San Diego County Medical Examiner data from 2005 to 2015 were analyzed with a descriptive epidemiologic approach.Overall RN (18.51) and physician (40.72) incidences of suicide per 100 000 person-years were higher than the San Diego general population, excluding nurses (15.81) normalized to 100 000 person-years.Establishing incidence of nurse suicide is confounded by variation in reporting mechanisms plus incomplete availability of nurse gender data. Relatively small outcome numbers compared with the general population may underestimate results. Research using a larger sample is indicated. Nurse executives may decrease risk by proactively addressing workplace stressors

Nurse Suicide: Breaking the Silence

The purpose of this paper is to raise awareness of and begin to build an open dialogue regarding nurse suicide. Recent exposure to nurse suicide raised our awareness and concern, but it was disarming to find no organization-specific, local, state, or national mechanisms in place to track and report the number or context of nurse suicides in the United States. This paper describes our initial ex-ploration as we attempted to uncover what is known about the prevalence of nurse suicide in the United States. Our goal is to break through the culture of silence regarding suicide among nurses so that realistic and accurate appraisals of risk can be established and preventive measures can be developed

A Survey of Delirium Self-Reported Knowledge and Practices among Emergency Physicians in the United States

Objective: This study aimed to evaluate United States emergency physicians’ self-reported knowledge and practices regarding the detection, prevention, and management of delirium, a common and deadly syndrome that disproportionately affects older emergency department (ED) patients. Knowledge and practices of the broader emergency physician community about these priority topics in geriatric emergency medicine are understudied. Design: Electronic self-administered online survey Setting: United States Participants: One-hundred ninety-seven emergency physicians of the American College of Emergency Physicians Emergency Medicine Practice Research Network Measures: Descriptive statistics were generated from survey responses. Results: Of 734 physicians in the research network who were sent the survey, 197 (27%) responded. Most respondents reported intermediate (46%) or advanced (46%) knowledge of delirium detection and management and intermediate (61%) or advanced (21%) knowledge of delirium prevention. Forty percent reported low concern or neutrality over discharging a patient with delirium from the ED. There was high variability in respondents’ perception about the prioritization of delirium in their EDs, and only 14% reported the ED where they worked had a protocol addressing delirium. Participants identified multiple challenges in diagnosing, preventing, and managing delirium, including the physical space and logistics of the emergency care environment (82%), challenges identifying delirium in patients with dementia (75%), and time constraints (64%). Most (69%) perceived utility in increased clinician education on delirium. Conclusions: Surveyed emergency physicians self-report a high knowledge of delirium detection and management, in contrast to prior research demonstrating low ED delirium detection rates. The variable institutional prioritization of delirium reported also does not align with that of geriatric emergency medicine experts and associations, suggesting a need for strategies to bridge this gap

Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment

Introduction: The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization. Methods: We provided a five-question survey to 52 EPs, gauging previous experience referring patients to home-based healthcare, patient selection, and motivators and challenges when considering home-based options as an alternative to admission. In addition, we conducted three focus groups and four interviews. Results: Of participating EPs, 92% completed the survey, 38% reported ordering home-based healthcare from the ED as an alternative to admission, 90% ranked cellulitis among the top three medical conditions for home-based healthcare, 90% ranked “reduce unnecessary hospitalizations and observation stays” among their top three perceived motivators for using home-based care, and 77% ranked “no existing process in place to refer to home-based care” among their top three perceived barriers. Focus group and interview themes included the need for alternatives to admission; the longer-term benefits of home-based healthcare; the need for streamlined transition processes; and the need for highly qualified home-care staff capable of responding the same day or within 24 hours. Conclusion: The study found that EPs are receptive to referring patients for home-based healthcare following ED treatment and believe people with certain diagnoses are likely to benefit, with the dominant barrier being the absence of an efficient referral process

Predictive Accuracy of the Veterans Aging Cohort Study Index for Mortality With HIV Infection

BackgroundBy supplementing an index composed of HIV biomarkers and age (restricted index) with measures of organ injury, the Veterans Aging Cohort Study (VACS) index more completely reflects risk of mortality. We compare the accuracy of the VACS and restricted indices (1) among subjects outside the Veterans Affairs Healthcare System, (2) more than 1-5 years of prior exposure to antiretroviral therapy (ART), and (3) within important patient subgroups.MethodsWe used data from 13 cohorts in the North American AIDS Cohort Collaboration (n = 10, 835) limiting analyses to HIV-infected subjects with at least 12 months exposure to ART. Variables included demographic, laboratory (CD4 count, HIV-1 RNA, hemoglobin, platelets, aspartate and alanine transaminase, creatinine, and hepatitis C status), and survival. We used C-statistics and net reclassification improvement (NRI) to test discrimination varying prior ART exposure from 1 to 5 years. We then combined Veterans Affairs Healthcare System (n = 5066) and North American AIDS Cohort Collaboration data, fit a parametric survival model, and compared predicted to observed mortality by cohort, gender, age, race, and HIV-1 RNA level.ResultsMean follow-up was 3.3 years (655 deaths). Compared with the restricted index, the VACS index showed greater discrimination (C-statistics: 0.77 vs. 0.74; NRI: 12%; P < 0.0001). NRI was highest among those with HIV-1 RNA <500 copies per milliliter (25%) and age ≥50 years (20%). Predictions were similar to observed mortality among all subgroups.ConclusionsVACS index scores discriminate risk and translate into accurate mortality estimates over 1-5 years of exposure to ART and for diverse patient subgroups from North American