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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
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.
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
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
Univariate analysis of factors associated
with increased mortality (n = 27)
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
Univariate analysis of factors associated
with increased mortality (n = 27)
Variables Unadjusted OR (95% CI) p value
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
Univariate analysis of factors associated
with increased mortality (n = 27)
Variables Unadjusted OR (95% CI) p value
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
with increased mortality (n = 27)
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
Timothy Horttor RN, BSN, CCRN
(714) 378-7240