Implications of Objective Vs Subjective Delirium Assessment in Surgical Intensive Care Patients

1. Implications of Objective Vs Subjective Delirium Assessment in Surgical Intensive Care Patients SimonaCampa, Whitney Chavez, Brian Esser, Nelson Maravilla, Diona Payne, Brenda Zepeda California State University San Bernardino

2. Group #2 Participation • SimonaCampa – 100% • Whitney Chavez – 100% • Brian Esser– 100% • Nelson Maravilla– 100% • Diona Payne – 100% • Brenda Zepeda – 100%

3. Rationale for Conducting This Study • Delirium is an acute condition which effects up to 80% of hospitalized patients. • Nurses are responsible for assessing and caring for patients with delirium. • This study was conducted to evaluate the reliability and sustainability of sedation and delirium measurements in the Intensive Care Unit (ICU).

4. Purpose of the Study • This use of measurement tools for delirium and sedation are used in Intensive Care Units throughout the country. • The measurement tool that was used for delirium in this study was the Confusion Assessment Method (CAM-ICU). • The measurement tool that was used for sedations was the Richmond Agitation-Sedation Scale (RASS). • The purpose of this study was to examine if nurse patient assessments for delirium and sedation correlated with the CAM-ICU and RASS measurement tools.

5. Hypothesis • Dependent Variables • Patient meeting criteria for admission into the Intensive Care Unit. • Independent Variables • Age • Gender • Ethnicity • Intensive Care Unit Type (Medical or Surgical) • Psychosocial Behaviors

6. Theoretical or Empirical Support • Nurses and physicians perceptions of delirium characteristics may differ significantly which may result in a possible under or overdiagnosis of Delirium. • Most studies that compare subjective and objective assessments have centered on validation of assessment instruments with comparison against a reference standard rather than identifying reasons for discrepancies • Most studies prior have reported that delirium was severely underestimated in Intensive Care Units (ICUs)

7. Methods • An observational cohort study was performed in a surgical-cardiosurgical 31-bed intensive care unit of a university hospital. Patients’ delirium status was rated daily by bedside nurses on the basis of subjective individual clinical impressions and by medical students on the basis of scores on the objec- tive Confusion Assessment Method for the Intensive Care Unit.

8. Participants • Patients were excluded if they had severe pre- existing neurological impairments (eg, acute stroke, dementia, aphasia) and if they did not speak German. Demographic data, including age, weight, height, sex, Charlson Comorbidity Index,21 score on the Therapeutic Intervention Scoring System (TISS-28),22 and Simplified Acute Physiology Score (SAPS II),23 were obtained from patients’ files and clinical charts on the first day of ICU admission. ICU and hospital lengths of stay were retrieved from the clinic’s patient data managing system, and survival rates 180 days after surgery were obtained by mail and telephone interviews.

10. Measuring Instruments • Patient’s delirium status was rated daily by: • nurses on the basis of subjective individual clinical impressions.. Not really reliable but valid. • medical students on the basis of scores on the objective Confusion Assessment Method for Intensive Care Unit. Reliable and valid. • Nurses and CAM –ICU raters saw patients once a day, independently , and both assessments were done within 30 minutes. All of the nurses and raters were unaware of each other’s judgment . • No other delirium screening was performed

11. subjective CLINICAL impressions of delirium

12. CAM-ICU

13. PROCEDURE • In this prospective observational study patients admitted to the hospital from October 2007 though November 2007 had daily rating of the presence or absence of delirium by bedside nurses (with at least 5 years of job experience) according to nurses’ subjective clinical impression. The findings were recorded along with the patients’ demographic and medication data. • Patients were also assessed for delirium by 1 of 2 fourth-year medical students who used the CAM-ICU. Each medical student received bedside training in the use of CAM-ICU in five 15 minutes sessions before the start of the study (total of 75 minutes). • This study can be easily replicated by others

14. Man-Whitney Test – hospital length of stay Fisher Exact Test - # of patient receiving mechanical ventilation and age and sex Wilcoxon signed rank test – CAM-ICU vs subjective clinical impression P < .05 was considered significant. Results

15. Results Total of 170 were screened, but 10 were excluded from further analysis. • Subjective Clinical Impression vs CAM-ICU • 597 paired observations were completed from the 160 patients. Patients were classified as unable to assess with the CAMICU 161 times because of RASS scores of -4 or -5 (Total paried observation 436)

16. CAM-ICU • 160 patients • 62 patients (38.8%) developed delirium with CAM-ICU during their ICU stay. • 12 out of 62 were Hyperactive Delirium • 10 out of 62 were Mixed Delirium. • 40 out of 62 were hypoactive delirium; most appeared calm, quiet, or drowsy. • Most appeared calm, quiet, or drowsy

17. Subjective Clinical Impression • 160 patients (Total paried observation 436) • 128 paried observation (29.4%) deemed having delirium • 16 % of the paried observation had some disparate • 42 paried observation (9.6 %) deemed having delirium with Subjective clinical impression • With CAM-ICU it wasn't deemed. • 28 paried observation (6.4 %) deemed having delirium with Subjective clinical impression • With CAM-ICU it wasn't deemed.

18. Subjective Clinical Impression VS CAM-ICU • Agreement between CAM-ICU indications of delirium and subjective clinical impression differed depending on RASS scores. • (93% agreement) for patients with delirium • According to the CAM-ICU and agitated according to RASS scores (score >0). • (73%, 63% agreement) was low for patients who had delirium • according to the CAM-ICU and were calm, drowsy (score <0), or sedated (score = 0) according to RASS scores respestifuly • (90% agreement) for patients with no delirium • according to the CAM-ICU and were calm and alert according to RASS scores (score= 0). • (74%, 62% agreement) was low for patients who did not have delirium • according to the CAM-ICU but were drowsy (score <0, ) or agitated (score >0 ) according to RASS scores respectfuly.

19. Results • Wilcoxon signed rank test: non-parametric statistical hypothesis test used when comparing two related samples, matched samples, or repeated measurements on a single sample to assess whether their population mean ranks differ. • It is significantly more often deemed present by subjective clinical impression with P = .047 were P < .050

21. Limitation • First, the CAM-ICU is not a gold standard for diagnosis of delirium, and it should not be a substitute for a delirium expert such as a psychiatrist • Second, there study was performed in a single center in surgical patients, and thus might reflect only a segment of possible discrepancies of subjective vs objective rating of delirium. • Third, they did not recruit ICU nurses to perform the CAM-ICU testing. To minimize possible bias, we opted for medical students who were not familiar with the nursing staff or the patients’ medical history.

22. DISCUSSION What were the major conclusions? Subjective clinical impressions indicated delirium MORE often than the objective assessment with the CAM-ICU as the operational reference standard. Results confirm that even patients who appear alert and calm may have delirium, which can only be seen by using an objective assessment and not a subjective assessment. Objective monitoring may also increase the recognition of patients who are at risk for delirium-specific complications such as falls and pressure ulcers. Routine delirium monitoring with the CAM-ICU Flowsheet is an easy way to help detect delirium so that agreed-upon nonpharmacological and drug-cessation approaches could be applied before administration of new and potentially harmful medications is started. Can they be Justified? The conclusions can not be justified because the CAM-ICU is not a gold standard for diagnosis of delirium. Can the results be generalized? The results were generalized for this single center with surgical patients. However, in order for the study to be more generalized to a larger number of patients the study should be redone at a multicenter with a larger number of patients, including nonsurgical patients. This could extend the generalizbility of the results and lead delirium monitoring tools, to be suitable for use on a large scale.

23. RELEVANCE Usefulness and Relevance to clinical Nursing Practice to Improve Patient-Centered Care: This study can help nurses and physicians see how objective tools for monitoring delirium can provide the foundation and common language for monitoring and treating patients with delirium throughout the patients clinical course. Cross talk among members of the interdisciplinary ICU team is limited when only subjective impressions are available for monitoring delirium because differences of opinion are difficult to articulate and contrast. By decreasing the incidence of misdiagnosing delirium we can protect our patients, by minimizing the use of many unnecessary medications that can cause harmful side effects.

24. Reference: Guenther U, MD, Weykam J, Andorfer U, Theuerkauf N, MD, Popp J, MD, Ely E.W, MPH, Putensen C, MD. (2012) Implications of objective vs subjective delirium assessment in surgical intensive care patients. American Journal of Critical Care. Volume 21. 12-19