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

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

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

The Rise of the Hospitalist in California

Describes the growth and prevalence of "hospitalists," or hospital-based physicians, and current and future roles of hospitalists and hospitalist groups in California

Using phenotypic data from the Electronic Health Record (EHR) to predict discharge.

BACKGROUND: Timely discharge to post-acute care (PAC) settings, such as skilled nursing facilities, requires early identification of eligible patients. We sought to develop and internally validate a model which predicts a patients likelihood of requiring PAC based on information obtained in the first 24 h of hospitalization. METHODS: This was a retrospective observational cohort study. We collected clinical data and commonly used nursing assessments from the electronic health record (EHR) for all adult inpatient admissions at our academic tertiary care center from September 1, 2017 to August 1, 2018. We performed a multivariable logistic regression to develop the model from the derivation cohort of the available records. We then evaluated the capability of the model to predict discharge destination on an internal validation cohort. RESULTS: Age (adjusted odds ratio [AOR], 1.04 [per year]; 95% Confidence Interval [CI], 1.03 to 1.04), admission to the intensive care unit (AOR, 1.51; 95% CI, 1.27 to 1.79), admission from the emergency department (AOR, 1.53; 95% CI, 1.31 to 1.78), more home medication prescriptions (AOR, 1.06 [per medication count increase]; 95% CI 1.05 to 1.07), and higher Morse fall risk scores at admission (AOR, 1.03 [per unit increase]; 95% CI 1.02 to 1.03) were independently associated with higher likelihood of being discharged to PAC facility. The c-statistic of the model derived from the primary analysis was 0.875, and the model predicted the correct discharge destination in 81.2% of the validation cases. CONCLUSIONS: A model that utilizes baseline clinical factors and risk assessments has excellent model performance in predicting discharge to a PAC facility

Multi-institutional profile of adults admitted to pediatric intensive care units.

ImportanceGrowing numbers of persons with childhood-onset chronic illnesses are surviving to adulthood. Many use pediatric hospitals for their inpatient needs. To our knowledge, the prevalence and characteristics of adult pediatric intensive care unit patients have not been reported.ObjectivesTo estimate the proportion of adults admitted to pediatric intensive care units (PICUs), characterize them, and compare them with older adolescents.DesignOne-year cross-sectional analysis.SettingPediatric intensive care units in the United States that participated in the Virtual Pediatric Intensive Care Unit Systems.ParticipantsPediatric intensive care unit patients 15 years or older admitted in 2008.Main outcome measuresWe compared adults with adolescents across clinical characteristics and outcomes. Mixed-effects logistic regression was used to estimate the independent association of age with PICU mortality.ResultsSeventy PICUs had 67 629 admissions; 1954 admissions (2.7%) were patients 19 years or older; and 9105 admissions (13.5%) were patients aged 15 to 18 years. The proportion of adults (≥19 years) varied considerably by PICU (range, 0%-9.2%). As age increased, the proportion of patients who had a complex chronic condition and planned or perioperative admissions increased; the proportion of trauma-related admissions decreased. Patients aged 21 to 29 years had a 2 times (95% CI, 1.3-3.2; P = .004) greater odds of PICU mortality compared with adolescent patients, after adjusting for Paediatric Index of Mortality score, sex, trauma, and having a complex chronic condition. Being 30 years or older was associated with a 3.5 (95% CI, 1.3-9.7; P = .01) greater odds of mortality.Conclusions and relevanceIn this multi-institutional study, adults constituted a small but high-risk proportion of patients in some PICUs, suggesting that these PICUs should have plans and protocols specifically focused on this group

Improving Care Transitions for Hospitalized Veterans Discharged to Skilled Nursing Facilities: A Focus on Polypharmacy and Geriatric Syndromes

Geriatric syndromes and polypharmacy are common in older patients discharged to skilled nursing facilities (SNFs) and increase 30-day readmission risk. In a U.S.A. Department of Veterans Affairs (VA)-funded Quality Improvement study to improve care transitions from the VA hospital to area SNFs, Veterans (N = 134) were assessed for geriatric syndromes using standardized instruments as well as polypharmacy, defined as five or more medications. Warm handoffs were used to facilitate the transfer of this information. This paper describes the prevalence of geriatric syndromes, polypharmacy, and readmission rates. Veterans were prescribed an average of 14.7 medications at hospital discharge. Moreover, 75% of Veterans had more than two geriatric syndromes, some of which began during hospitalization. While this effort did not reduce 30-day readmissions, the high prevalence of geriatric syndromes and polypharmacy suggests that future efforts targeting these issues may be necessary to reduce readmissions among Veterans discharged to SNF