Delirium and mortality risk prediction: a story in evolution

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An Exploration of Critical Care Professionals\u27 Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

OBJECTIVES: The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation. DESIGN: Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used. SETTING: Sixty-eight academic, community, and federal ICUs. PARTICIPANTS: A total of 121 ICU professionals consisting of frontline and leadership professionals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient\u27s) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol. CONCLUSIONS: In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation

Memberships and CM Diagrams of the Open Cluster NGC 7243

The results of astrometric and photometric investigations of the open cluster NGC 7243 are presented. Proper motions of 2165 stars with root-mean-square error of 1.1 mas/yr were obtained by means of PDS scanning of astrometric plates covering the time interval of 97 years. A total of 211 cluster members down to V=15.5 mag have been identified. V and B magnitudes have been determined for 2118 and 2110 stars respectively. Estimations of mass (348Mo < M < 522Mo), age (t=2.5x10^8 yr), distance (r=698 pc) and reddening (E(B-V)=0.24) of the cluster NGC 7243 have been made.Comment: 24 pages, 15 figures. Submitted to Astronomy and Astrophysic

Tools to Detect Delirium Superimposed on Dementia:A Systematic Review

BACKGROUND: Delirium commonly occurs in patients with dementia. Though several tools for detecting delirium exist, it is unclear which are valid in patients with delirium superimposed on dementia. OBJECTIVES: Identify valid tools to diagnose delirium superimposed on dementia DESIGN: We performed a systematic review of studies of delirium tools, which explicitly included patients with dementia. SETTING: In-hospital patients PARTICIPANTS: Studies were included if delirium assessment tools were validated against standard criteria, and the presence of dementia was assessed according to standard criteria that used validated instruments. MEASUREMENTS: PubMed, Embase, and Web of Science databases were searched for articles in English published between January 1960 and January 2012. RESULTS: Nine studies fulfilled the selection criteria. Of the total of 1569 patients, 401 had dementia, and 50 had delirium superimposed on dementia. Six delirium tools were evaluated. One studyusing the Confusion Assessment Method (CAM) with 85% patients with dementia showed a high specificity (96–100%) and moderate sensitivity (77%).Two intensive care unit studies that used the CAM for the Intensive Care Unit (CAM-ICU) ICU reported 100% sensitivity and specificity for delirium among 23 dementia patients. One study using electroencephalography reported a sensitivity of 67% and a specificity of 91% among a population with 100% prevalence of dementia. No studies examined potential effects of dementia severity or subtype upon diagnostic accuracy. CONCLUSIONS: The evidence base on tools for detection of delirium superimposed on dementia is limited, although some existing tools show promise. Further studies of existing or refined tools with larger samples and more detailed characterization of dementia are now required to address the identification of delirium superimposed on dementia

Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS)

BACKGROUND: The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes. METHODS: The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort. DISCUSSION: This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes

X-ray Source Populations in the Region of the Open Clusters NGC 6633 and IC 4756

Using deep exposures (~10^5 s) with the ROSAT HRI, we have performed flux-limited surveys for X-ray sources in the vicinity of the Hyades-age open stellar clusters NGC 6633 and IC 4756, detecting 31 and 13 sources respectively. Our primary aim is to search for so-far unrecognised cluster members. We propose identifications or classifications (cluster member, field star, extragalactic field object) for the X-ray sources, based on published membership lists, and on X-ray:optical flux ratios and optical colour--magnitude diagrams. Results of simulating the expected X-ray-emitting source populations are compared with the ROSAT measurements and with the expected capabilities of the XMM mission. The simulations provide a novel method of comparing the activity levels of NGC 6633 and IC 4756 with that of the Hyades. The measurements and simulations confirm that cluster members are the major class of X-ray emitter in these fields at flux levels f_x > 10^{-14}/erg/cm^2/s (0.1--2.4 keV), contributing ~40 per cent of the total X-ray sources. We find 6 possible new members in NGC 6633, and 4 candidates in IC 4756; all require further observation to establish membership probability.Comment: 12 pages, 4 figure

Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units

PURPOSE: To compare demographics, intensive care units (ICU) admission characteristics, and ICU outcomes among adults with childhood-onset chronic conditions (COCC) admitted to U.S. pediatric and adult ICUs. MATERIALS AND METHODS: Retrospective cross-sectional analyses of 6,088 adults aged 19–40 years admitted in 2008 to 70 pediatric ICUs that participated in the Virtual Pediatric Intensive Care Unit Performance Systems and 50 adult ICUs that participated in Project IMPACT. RESULTS: COCC were present in 53% of young adults admitted to pediatric units, compared to 9% of those in adult units. The most common COCC in both groups were congenital cardiac abnormalities, cerebral palsy, and chromosomal abnormalities. Adults with COCC admitted to pediatric units were significantly more likely to be younger, have lower functional status, and be non-trauma patients than those in adult units. The median ICU length-of-stay was 2 days and the intensive care unit mortality rate was 5% for all COCC patients with no statistical difference between pediatric or adult units. CONCLUSIONS: There are marked differences in characteristics between young adults with COCC admitted to PICUs and adult ICUs. Barriers to accommodating these young adults may be reasons why many such adults have not transitioned from pediatric to adult critical care

Using data-driven rules to predict mortality in severe community acquired pneumonia

Prediction of patient-centered outcomes in hospitals is useful for performance benchmarking, resource allocation, and guidance regarding active treatment and withdrawal of care. Yet, their use by clinicians is limited by the complexity of available tools and amount of data required. We propose to use Disjunctive Normal Forms as a novel approach to predict hospital and 90-day mortality from instance-based patient data, comprising demographic, genetic, and physiologic information in a large cohort of patients admitted with severe community acquired pneumonia. We develop two algorithms to efficiently learn Disjunctive Normal Forms, which yield easy-to-interpret rules that explicitly map data to the outcome of interest. Disjunctive Normal Forms achieve higher prediction performance quality compared to a set of state-of-the-art machine learning models, and unveils insights unavailable with standard methods. Disjunctive Normal Forms constitute an intuitive set of prediction rules that could be easily implemented to predict outcomes and guide criteria-based clinical decision making and clinical trial execution, and thus of greater practical usefulness than currently available prediction tools. The Java implementation of the tool JavaDNF will be publicly available. © 2014 Wu et al

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Purpose Recalibration and determining discriminative power, internationally, of the existing delirium prediction model (PRE-DELIRIC) for intensive care patients. Methods A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The ten predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 h after ICU admission. The confusion assessment method for the intensive care unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data. Results A total of 2,852 adult ICU patients were screened of which 1,824 (64 %) were eligible for the study. Main reasons for exclusion were length of stay <1 day (19.1 %) and sustained coma (4.1 %). CAM-ICU compliance was mean (SD) 82 ± 16 % and inter-rater reliability 0.87 ± 0.17. The median delirium incidence was 22.5 % (IQR 12.8–36.6 %). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the eight participating centers remained good: 0.77 (95 % CI 0.74–0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved re-calibration of the PRE-DELIRIC model. Conclusions In this multinational study, we recalibrated the PRE-DELIRIC model. Despite differences in the incidence of predictors between the centers in the different countries, the performance of the PRE-DELIRIC-model remained good. Following validation of the PRE-DELIRIC model, it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients