The Impact of Delirium in the Intensive Care Unit on ... · The Impact of Delirium in the Intensive Care Unit ... Dementia Fever, ... van den Boogaard et al. Crit Care Med 2012; 40:

The Impact of Delirium in the Intensive Care Unit

on Patient Length of Stay (LOS) and Mortality:

A Multi-Center Epidemiology Study

Long Beach Memorial

Study Team Louise DuBos RN, BSN

Martha Gadberry RN, BSN, CCRN Myrna Czaplicki RN, BSN

Mary Anne Francisco RN, BSN, CCRN

Dominique Jorgensen RN, BSN

Elaine Kee RN

Eugenia Lupisan RN, BSN, CCRN

Brent Lopez RN, BSN

Heather Newport RN

Dana Sipin RN, BSN

Orange Coast Memorial

Study Team

Timothy Horttor RN, BSN, CCRN Lynda Steele RN, BSN, CCRN

Dionne Perry RN, BSN, CCRN

Hesna Taban RN

Tanya Vernon RN

Peggy Kalowes RN, PhD, CNS, FAHA, Principal Investigator

Objectives

1. State the prevalence of delirium in critically

ill patients.

2. List two characters highly associated with

the development of delirium in critically ill

patients.

3. Describe the impact of delirium on patient

outcomes.

The Origin

Long Beach Memorial and

Miller Children’s Hospital Long Beach Orange Coast Memorial Medical Center

Delirium Definition

• National Institutes of Health

– Sudden severe confusion and rapid changes in

brain function that occur with physical or mental

illness.

• American Psychiatric Association, DSM IV

– A disturbance of consciousness, attention, and

perception that develops over a short time

(usually hours to days) that can fluctuate during

the course of the day.

A Working Definition

• Reversible, Acute brain dysfunction

– May persist for weeks or more

• Acute waxing and waning mental status

– Somnolence

– Agitation

– Normal

• Inattention, distractibility

• Disorganized thinking

– Disorientation

– Memory problems

– Incoherent speech, non-purposeful behavior

Types of Delirium

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Mixed Type 54.9% Hypoactive

43.5%

Hyperactive 1.6%

Peterson et al. JAGS 2006; 54: 479

Risk Factors

Predisposing (Host) Factors

Precipitating Factors

Factors of critical illness Iatrogenic / Environmental factors

Hypertension High severity of illness Immobility (bedrest, catheters, restraints,

tubes)*

Smoking Acidosis* Medications-sedatives and analgesics (benzodiazepines/opioids), anticholinergics* Age greater than 65 years Respiratory disease

Alcoholism Metabolic/electrolyte

abnormalities* Sleep disturbances*

Dementia Fever, infection, sepsis* Isolation precautions*

Vision/hearing impairment Anemia* No visitors*

Hypotension* Use of physical restraints*

Girard et al. Critical Care 2008; 12 Suppl 3: 1-9

*Potentially modifiable factors

DELIRIUM

Iatrogenic/

Environmental

Factors

Development of Delirium

Prevalence

• 16-89%, depending on patient population

• Internationally 32.3%

• Specialized units have higher delirium rates

• Ventilated patients > 80%

Salluh et al. DECCA 2010;14 (6) R210

Roberts et al. Aust. Crit Care 2005; 18(1) 8-9, 11-14

Thomason et al. Crit Care; 2005 9(4) R375-R381

Ely et al. Crit Care med; 2001 29(7) 1370-1379

Bergeron et al. Intensive Care Med; 2001; 28 859-864

Ely et al. Crit Care Med; 2007; 35 112-117

Cost

• Affects 2 to 3 million elderly patients per year

• Over 17.5 million inpatient days

• Over $4 billion in Medicare expenditures

• Total cost of caring for delirious patients

receiving mechanical ventilation is estimated

at $6.5 to $20.4 billion annually in the U.S.

Girard et al. Crit Care 2008; 3: 1-9

Milbrandt et al. Crit Care Med 2001; 32: 955-962

Martins et al. Frontiors in Neuology 2012; 3: 1-12

Jaskson et al. Crit Care Med 2010; 182: 183-191

Halpern & Pastores Crit Care Med; 2010; 38: 65-71

Complications/Outcomes

• Pulling tubes and lines, failed extubation

• Increased ventilator days, ICU length of stay

(LOS), and hospital LOS

• Discharged to an institution

• Long-term cognitive impairment

• Increased mortality Ely et al. JAMA 2004; 291 (14): 1753-1762

Shehabi et al. Crit Care Med; 2010; 38 (12): 2311-2318

Pisani et al. AM J Respir Crit Care Med; 2009; 180(11): 1092-1097

Lat et al. Crit Care Med 2009; 37(96): 1898-1905

van den Boogaard et al. Crit Care Med 2012; 40: 112-118

Dubois et al. Intensive Care Med 2001; 27 1297-1304

Salam et al. Intensive Care Med 2004; 30 1334-1339

Ely et al. Intensive Care Med 2001; 27 1893-1900

Girard et al. Crit Care Med 2010; 28(7): 1513-1520

Monitoring

• Missed or Under Diagnosed

• Screening Tools

– Confusion Assessment Method for the

Intensive Care Unit (CAM-ICU)

– Intensive Care Delirium Screening

Checklist (ICDSC)

• 2002 Society of Critical Care Medicine

• 2011 American Association of Critical Care

Nurses

• 2013 Society of Critical Care Medicine

Impact of Delirium in the ICU on Patient LOS and

Mortality: A Multi-Center Epidemiology Study

Study Aims

• Examine the epidemiology of delirium (prevalence

and duration) and its impact on relevant clinical

outcomes (ICU/hospital mortality, Length of Stay in

ICU and in-hospital, and ventilator days).

• Examine demographic and predisposing factors

that may serve as predictive variables for the

development of delirium (age, gender, severity of

illness; medications; medical diagnosis) and the

related impact on length of stay and mortality.

End Points

• Identification of Delirium

• Discharge from the ICU without development

of delirium

Methodology • Design: Multi-center, observational study (N=430)

to examine the epidemiology of delirium among ICU

patients & it’s impact on patient outcomes.

• Sample: ICU/CCU-LBM (N=250); ICU-OCMMC

(N=180).

• Inclusion: Patients were enrolled if admitted for

≥24 hours, ≥18 years, English or Spanish speaking.

• Excluded if receiving End of life care; if suffering

from severe mental illness, ETOH-related delirium

or active withdrawal, or aphasic stroke.

Demographic Tool The Impact of Delirium on Patient Outcomes Among

Intensive Care Units: A Multi-Site Epidemiology Study LBM TEAM

Peggy Kalowes RN, PhD, CNS, FAHA, Principal Investigator; Louise DuBos , RN, BSN; Martha Gadberry, RN,

BSN, CCRN, Sub-Investigators; Study Team- Dana Sipin, RN, BSN; Myrna Cyzplecki, RN, BSN; Karen

Benavides RN, MSN, CNS; Brent Lopez, RN, BSN; Gina Lupisan, RN, BSN, CCRN

OCMC TEAM

Lynda Steele RN, BSN, Sub-Investigator; Study Team- Timothy Horttor RN-C, BSN, CCRN; Kimberly Driscoll

RN, BSN, CCRN, Dionne Perry RN, BSN, CCRN; Tanya Vernon RN;

Hesna Taban RN

Name of Data Collector:_____________________________________ Date:____________

MR #________________________ Room #:__________________SUBJECT ID #

Patient Project Enrollment Criteria

Inclusion Criteria

1. Patients admitted for ≥ 24 hours

2. Aged ≥ 18 years

3. English or Spanish speaking

Exclusion Criteria –

1. Admitted for ≤ 24 hours

2. Under 18 years of age

3. Receiving end-of-life comfort care or withdrawal of treatment

4. History of severe mental illness, admission with an alcohol-related delirium,

admission for an aphasic stroke

AGE:________________ Gender Male Female

Charlson Comorbidity Index Score (CCI) Day-1__________

Admitted to ICU From: ER OR Special Procedure Other Hospital Other Floor Rapid Response: Y N Code Blue: Y N Therapeutic Hypothermia Y N

Hospital Admit date:______________

ICU Admission date: ______________

ICU Discharge date: ______________

Hospital Discharge date:___________ Length of ICU Stay: ______________ Hospital Length of Stay:___________ Total # Ventilator days: _________

ICU Admitting Diagnosis

Sepsis-SIRS

Diabetes/DKA

Cerebral Infarct

Cerebral Hemorrhage

Liver Failure

Pneumonia

COPD

CHF

Cardio Vascular disease

Trauma (specify)_____________________________

Traumatic Brain Injury

GI Bleed

Renal Failure

Cancer

Other____________________________________

Risk Factors

Acidosis

Metabolic/electrolyte abnormalities

Fever, infection, sepsis

Anemia

Hypotension

Bedrest

Sedatives

Analgesic medication

Isolation

No visitors

Physical restraints

Anticholinergic medications

HTN

Vision or hearing impairment

History of depression

Pre-existing dementia

Alcohol or Drug Abuse (current)

Smoking

Discharge to:

Home

LTAC

Other acute hospital

SNF

Expired

NOTES

Delirium Monitoring Tool

Study ID#:

DELIRIUM MONITORING TOOL

Item Legend Date

RASS Current Score

CAM-ICU* Current UTA, + , or -

GCS Current Total Score

Total Daily Dose of

Sedatives Given (Day Prior)

Versed (mg)

Ativan (mg)

Propofol (mg)

Seroquel (mg)

Haldol (mg)

Other:

Total Daily Dose of

Analgesia Given (Day Prior)

Fentanyl (mcg)

Morphine (mg)

Dilaudid (mg)

Other:

Mechanical Vent. Current Yes/No

Vasoactive Drips Current Yes/No

SAT Ordered? Day Prior Yes/No

SAT Done? Day Prior Yes/No

SBT Ordered? Day Prior Yes/No

SBT Done? Day Prior Yes/No

Mobility** Current BR, OOB, PT

P/S Protocol

Ordered Current Yes/No

RN Assessing Current Initials

*NC = UTA = Unable to Assess, + = Positive, - = negative **BR=Bedrest, OOB=Out of Bed or Dangle by RN, PT=PT or OT Ordered

Charlson Comorbidity Index

Richmond Agitation-Sedation

Scale (RASS)

CAM-ICU

Study Flow Diagram

739 Screened for

Eligibility

126 Not Eligible

Non-English /

Spanish Speaking

613 Eligible patient

Intention-to-Treat (ITT)

422 Included in final study

analysis

134 Patients with Delirium 288 Patients No Delirium

(negative CAM-ICU)

(8) Excluded from

final analysis due to

incomplete data or

were too ill to

continue in the study

430

Enrolled in Study

183 Not Enrolled 99 refused

44 No interpreter

40 Unable to obtain

consent

Admission & Hospital

Characteristics Delirium Status

All Patients

(n=422)

Delirium

(n=134 )

No Delirium

(n=288 )

Admitted from:

ER 192 (45.5%) 70 (52.2%) 122 (42.4%)

OR 117 (27.7%) 27 (20.1%) 90 (31.3%)

Special Procedure 14 (3.3%) 1 (0.7%) 13 (4.5%)

Other Hospital 13 (3.1%) 6 (4.5%) 7 (2.4%)

Other Floor 86 (20.4%) 30 (22.4%) 56 (19.4%)

Hospital/Unit:

LBM ICU 117 (27.7%) 49 (36.6%) 68 (23.6%)

LBM CCU 130 (30.8%) 38 (28.4%) 92 (31.9%)

OCMMC ICU 175 (41.5%) 47 (35.1%) 128 (44.4%)

Delirium Prevalence

Hospital/ Unit

LBM ICU LBM CCU OCMMC

ICU

All Patients 422 117 130 175

Delirium 134 (32%) 49 (42%) 38 (29%) 47 (27%)

No Delirium 288 (68%) 68 (58%) 92 (71%) 128 (73%)

Patient Characteristics

Factors

All Patients

(n=422)

Delirium

(n=134 )

No Delirium

(n=288 )

p

value

Age, yrs mean (SD)

64.2 (±17.4)

68.6 (±15.6)

62.2 (±17.8)

<.001

Female gender n (%) 175 (41.5%) 61 (45.5%) 114 (39.6%) .249

GCS average from

ICU admit to

endpoint (SD)

14.0 (±3.5) 12.0 (±5.6) 14.9 (±1.2) <.001

GCS evaluated at

end point date (SD)

13.8 (±2.3) 11.5 (±3.0) 14.9 (±0.4) <.001

Admission Diagnosis

Primary ICU Admit

Diagnosis

All Patients

(n=422)

n %

Delirium

(n=134 )

n %

No Delirium

(n=288 )

n %

Cardio Vascular

Disease

127 (30.2%) 27 (20.3%) 100 (34.7%)

Sepsis-Sirs 57 (13.5%) 30 (22.6%) 27 (9.4%)

CHF 21 (5.0%) 11 (8.3 %) 10 (3.5%)

GI Bleed 20 (4.8%) 3 (2.3%) 17 (5.9%)

Other (pre-defined

diagnoses) including

trauma

86 (20.4%) 31 (23.3%) 55 (19.1%)

Other (general) 110 (26.1%) 31 (23.3%) 79 (27.4%)

Predisposing Risk Factors

Factors

All Patients

n=422

n %

Delirium

n=134

n %

No Delirium

n=288

n %

p

value

Hypertension 286 (67.8%) 96 (71.6%) 190 (66.0%) .246

Smoking 41 (9.7%) 15 (11.2%) 26 (9.0%) .484

Age ≥ 65

years

233 (55.2%) 91 (67.9%) 142 (49.3%) <.001

Alcoholism 28 (6.6%) 16 (11.9%) 12 (4.2%0 .003

Dementia 12 (2.8%) 8 (6.0%) 4 (1.4%) .013

Vision/Hearing

Impairment

67 (15.9%) 27 (20.1%) 40 (13.9%) .101

Factors of Critical Illness

Factors

All Patients

n=422

n %

Delirium

n=134

n %

No Delirium

n=288

n %

p

value

Acidosis 40 (9.5%) 22 (16.4%) 18 (6.3%) .001

Metabolic/

electrolyte

Abnormalities

137 (32.5%) 56 (41.8%) 81 (28.1%) .005

Fever/Infection 94 (22.3%) 51 (38.1) 43 (14.9%) <.001

Anemia 122 (28.9%) 39 2 (9.1%) 83 (28.8%) .952

Hypotension 82 (19.4%) 39 (29.1%) 43 (14.9%) .001

CCI median*

points (IQR)

2* (1-4) 3* (1-5) 2* (1-4) .002

Iatrogenic/

Environmental Factors

Factors

All Patients

n=422

n %

Delirium

n=134

n %

No Delirium

n=288

n %

p value

Bedrest 293 (69.4%) 122 (91.0%) 171 (59.4%) <.001

Restraints 27 (6.4%) 23 (17.2%) 4 (1.4%) <.001

Sedatives 121 (28.7%) 69 (51.5%) 52 (18.1%) <.001

Analgesics 241 (57.1%) 84 (62.7%) 157 (54.5%) .114

Isolation

Precautions

37 (8.8%) 25 (18.7%) 12 (4.2%) <.001

Mechanical

ventilation

81 (19.2%) 67 (50.0%) 14 (4.9%) <.001

Vasopressors 126 (29.9%) 66 (49.3%) 60 (20.8%) <.001

Sedatives

Sedatives Used

All Patients

n=422

n %

Delirium

n=134

n %

No Delirium

n=288

n %

p value

Versed 76 (18.0%) 46 (34.3%) 30 (10.4%) <.001

Ativan 57 (13.5%) 20 (14.9%) 37 (12.8%) .561

Propofol 40 (9.5%) 24 (17.9%) 16 (5.6%) <.001

Seroquel 3 (0.7%) 1 (0.7%) 2 (0.7%) .683

Haldol 11 (2.6%) 11 (8.2%) 0 (0.0%) <.001

Other Sedation 24 (5.7%) 10 (7.5%) 14 (4.9%) .283

Any sedatives

used 162 (38.4%) 82 (61.2%) 80 (27.8%) <.001

Analgesics

Analgesics

Used

All Patients

n=422

n %

Delirium

n=134

n %

No Delirium

n=288

n %

p value

Fentanyl 103 (24.4%) 54 (40.3%) 49 (17.0%) <.001

Morphine 144 (34.1%) 38 (28.4%) 106 (36.8%) .088

Dilaudid 120 (28.4%) 27 (20.1%) 93 (32.3%) .010

Other

Analgesia

119 (28.2%) 20 (14.9%) 99 (34.4%) <.001

Any

analgesia

used

294 (69.7%) 99 (73.9%) 195 (67.7%) .199

Patient Outcomes

Factors

All Patients

(n=422)

n %

Delirium

(n=134 )

n %

No

Delirium

(n=288 )

n %

p

value

ICU LOS days*

(mean)

3* (2-5) 6* (4-11) 2* (2-3.5) <.001

>1 ICU

readmission

during same

hospital admit

19 (4.5%) 8 (6.0%) 11 (3.8%) .321

Mortality

(at discharge)

27 (6.5%) 23 (18.1%) 4 (1.4%) <.001

Univariate analysis of factors associated

with increased mortality (n = 27)

Variables Unadjusted OR (95% CI) p

value

Age >=65 years 5.11 (1.73-15.04) .003

Female gender 0.98 (0.44-2.16) .951

Delirium during ICU admission 15.6 (5.3-46.3) <.001

Mechanical ventilation 9.73 (4.19-22.60) <.001

Use of vasopressors 8.70 (3.42-22.14) <.001

Increased Charlson Comorbidity

Index

1.25 (1.09-1.43) .001

ICU admitting diagnosis .118



Variables Unadjusted OR (95% CI) p value

Hypertension 2.15 (0.80-5.81) .131

Smoking 0.74 (0.17-3.22) .683

Alcoholism 0.53 (0.07-4.09) .546

Dementia All 27 patients who expired did

not have history of dementia

Vision/Hearing

Impairment

1.24 (0.45-3.40) .678

Predisposing Risk Factors




Acidosis 3.88 (1.53-9.88) .004

Metabolic/

Electrolyte

Abnormalities

2.02 (0.92-4.42) .080

Fever/ Infection 3.62 (1.64-8.01) .002

Anemia 2.86 (1.30-6.27) .009

Hypotension 3.23 (1.43-7.26) .005

Factors of Critical Illness




Bedrest 3.67 (1.36-9.89) .010

Restraints 4.17 (1.43-12.2) .009

Sedatives 3.45 (1.56-7.61) .002

Versed 6.47 (2.88-14.55) <.001

Analgesics 1.86 (0.80-4.35) .152

Fentanyl 5.30 (2.35-11.97) <.001

Isolation Precaution 6.41 (2.64-15.58) <.001

Iatrogenic/ Environmental Factors

Multivariate analysis of factors associated


Variables Coefficient Adjusted OR (95% CI) p value

Age ≥ 65 and Delirium 4.402 81.64 (3.53-1889.23) .006

Age ≥ 65 and no Delirium during

ICU admit -3.919 0.02 (0.00-1.14) .058

CCI 0.514 1.67 (1.25-2.23) .000

Acidosis 2.951 19.13 (2.29- 159.65) .006

GCS average during ICU

admission

-0.914 0.40 (0.25-0.65) .000

Invasive mechanical ventilation

use

-2.905 0.05 (0.00-0.83) .036

Analgesics 3.309 27.36 (2.90-258.26) .004

Isolation Precautions 2.901 18.18 (2.19-150.93) .007

No delirium during ICU admit 3.633 37.81 (0.58-2459.23) .088

ICU LOS (days) -0.046 0.95 (0.76-1.20) .692

ICU LOS and Hypotension 0.457 1.58 (1.19-2.10) .002

Conclusions

• Delirium: a frequent and serious event

• Overall Prevalence: 32%

• Prevalence in mechanically ventilated patients: 83%

• More likely: sepsis diagnosis. Less likely: cardiovascular

diagnosis.

• Longer ICU length of stay: median of 6 days vs 2 days

• Overall Mortality: 27 patients (6.5%)

• Mortality with Delirium: 23 patients (18.1%). Mortality

without Delirium = 4 patients (1.4%)

• Patients who expired: older age, lower GCS, higher CCI

score, sedatives and analgesics, vasopressors,

mechanical ventilation

Limitations

• Consenting critically ill

patients/surrogates

• Once daily delirium assessments

• Large study teams

• No intervention

Clinical Implications

• Correlation ≠ Causation

• Goals of Delirium Management

• Treatment vs Prevention

• Best Practices

Questions ?

Delirium Study Team

Martha Gadberry RN, BSN, CCRN

(562) 933-7159

[email protected]

Timothy Horttor RN, BSN, CCRN

(714) 378-7240

[email protected]

The Impact of Delirium in the Intensive Care Unit on ... · The Impact of Delirium in the Intensive Care Unit ... Dementia Fever, ... van den Boogaard et al. Crit Care Med 2012; 40:

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