Clinical PotpourriRoutine delirium monitoring is independently associated with a reduction of hospital mortality in critically ill surgical patients: A prospective, observational cohort study
Introduction
Delirium is defined as a disturbance in attention accompanied by a change in either cognition or consciousness that fluctuates over the course of the day and results from an underlying medical condition [1]. The incidence of delirium in critically ill patients has a wide variability depending on the mode of diagnosis, screening, and the patients under observation [2], [3], [4], [5]. Various studies have shown that delirious patients have an increased length of hospitalization [6], as well as a higher risk for long-term cognitive impairment [7] and functional impairments [8]. There are also studies stating a higher risk for mortality, which is a matter of current discussion [2]. The practice guideline of the Society of Critical Care Medicine [9] and national societies [10] recommend a frequent screening for delirium with particular assessment tools. These tools have been developed to allow a valid and reliable screening for delirium in clinical routine [3]. In comparison to a subjective, clinical evaluation, the use of validated scores improves the physician's and nurse's ability to detect delirium [11].
Delirium monitoring is part of the evidence-based organizational approach referred to as the “ABCDEF bundle” (Awakening and Breathing Coordination, Choice of sedatives, Delirium monitoring, Early mobility, Fast sleep) [12]. In this respect, feasibility and effectiveness have been shown for the implementation of parts of this bundle [13]: Considering the single features of the bundle, there is a body of literature favoring protocol-based sedation and showing negative effects of a continuous benzodiazepine-driven sedation [14], compared with a regime favoring nonbenzodiazepine sedation [15] and favoring less sedation [16]. In addition, early mobility has proven benefits for the patient [17]. In contrast, the distinct value of delirium monitoring in clinical routine has not been addressed so far and remains hypothetical. This might be one potential cause for the low implementation of delirium screening in clinical practice [18].
We set up a prospective cohort study to address this issue. We hypothesized that adherence to delirium monitoring, as an additional level of care, would result in a reduction of mortality in ventilated and nonventilated patients.
Section snippets
Materials and methods
In this prospective, observational, clinical trial (International Standard Registered Clinical Trial Record: 76100795) patients were included between July 2007 and October 2007. The data acquisition was performed on 2 intensive care units (ICUs) of a tertiary care medical center in Germany. The local ethics committee of the Charité–Universitätsmedizin Berlin, Berlin, Germany, approved the study and waived informed consent (ethical vote no. EA1/132/07, protocol no. 1.0, date of approval January
Cohort characteristics
Of 355 screened ICU patients, 185 participants were included in our final analysis (Fig. 2). Eighty-seven patients received MV, and 98 patients were NMV. The most common admission diagnosis, according to the International Classification of Diseases, Tenth Revision, was a malignancy of the digestive tract (65 [35.1%]), followed by severe injuries (35 [18.9%]). Other causes for admission were nonmalignant diseases of the digestive system (21 [11.4%]), diseases of the nervous system (16 [8.7%]),
Discussion
This single-center, cohort study of a surgical ICU population revealed that higher delirium-monitoring adherence was independently associated with a reduction of in-hospital mortality in MV patients.
Delirium monitoring is an integral part of guideline recommendations and ICU bundles [9]. In contrast, a point prevalence analysis within an international survey showed that 73% of observed patients were not monitored with a validated delirium score [18]. Despite the low implementation rates,
Conclusion
In conclusion, our data suggest that MV patients may profit from a daily delirium screening, as delirium-monitoring adherence was independently associated with lower in-hospital mortality. Nevertheless, considering the limitations of our study, these results should be confirmed in a broader ICU setting including other patient populations.
Acknowledgments
Alawi Luetz is a participant in the Charité Clinical Scientist Program funded by the Charité–Universitätsmedizin Berlin and the Berlin Institute of Health (internal institutional grant program).
References (31)
- et al.
The implementation of a nonpharmacologic protocol to prevent intensive care delirium
J Crit Care
(2016) - et al.
Outcomes Associated With Delirium in Older Patients in Surgical ICUs
Chest
(2009) - et al.
A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial
Lancet
(2010) - et al.
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
Lancet
(2009) - et al.
Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial
Lancet
(2008) The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer
BMC Med
(2014)- et al.
Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit
JAMA
(2004) - et al.
Different assessment tools for intensive care unit delirium: which score to use?
Crit Care Med
(2010) - et al.
The attributable mortality of delirium in critically ill patients: prospective cohort study
BMJ
(2014) - et al.
The impact of delirium in the intensive care unit on hospital length of stay
Intensive Care Med
(2001)
Long-term cognitive impairment after critical illness
N Engl J Med
Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit
Crit Care Med
Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version
Ger Med Sci
Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients
Crit Care Med
Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care
Crit Care
Cited by (34)
Pharmacologic Management of Delirium in the Intensive Care Unit
2022, Clinics in Chest MedicineCitation Excerpt :Two tools are recommended based on extensive validation research: the Confusion Assessment Method for the ICU (CAM-ICU)10 and the Intensive Care Delirium Screening Checklist (ICDSC).11 Both are easy to implement into clinical practice and may effect patient outcomes; a prospective cohort found that adherence to delirium screening was associated with reduced in-hospital mortality.12 Whereas each tool has high sensitivity when used by trained clinicians, ICDSC is less specific,10,11 and a prospective study comparing CAM-ICU and ICDSC found that CAM-ICU more accurately diagnosed delirium.13
Critical care guidelines on pain, agitation and delirium management: Which one to use? A systematic literature search and quality appraisal with AGREE II
2020, Journal of Critical CareCitation Excerpt :The latter is an essential topic in critical care, as it affects the vast majority of critically ill patients [19]. Its adequate management has been shown to improve patient outcomes in terms of decreased duration of mechanical ventilation, incidence of pain and agitation, ICU length of stay and in-hospital mortality [20-22]. As management strategies have changed immensely in the last decades, pain, agitation/sedation and delirium management has become a highly challenging area for critical care practitioners.
Differences in 90-day mortality of delirium subtypes in the intensive care unit: A retrospective cohort study
2019, Journal of Critical CareCitation Excerpt :Although we cannot rule out that the drawbacks of a retrospective study may have biased our results, e.g. by excluding patients who could not be assigned to the delirium subtypes, we have ensured high-quality data, and thus the accuracy and validity of the outcomes found. Second, this was a single center study which may reduce the generalizability of the results, despite that the demographic measures of the included patients at baseline seem comparable with other studies [2,23]. Third, the delirium prevalence rate in this cohort was relatively low which could be explained by a relatively high proportion of elective surgical patients with lower delirium incidence rates [22].
- 1
The first 2 authors have contributed equally to this work.