Patient Factors That Influence Reliable Delirium Assessments in a Medical Intensive Care Unit During the Routine Clinical Practice

Abstract

This study aimed to determine patient and therapeutic characteristics of patients in the medical intensive care unit (MICU) that contribute to inconsistent results of delirium assessments performed during routine clinical practice. Therefore, electronic health records were reviewed and compared with secondary data collected from the same medical ICU patients who were assessed using the Confusion Assessment Method in the ICU (CAM-ICU). Of 5,241 cases involving 762 patients, 827 (15.78%) cases showed disagreement between assessments. Continuous renal replacement therapy, physical restraint use, and altered mental status were factors that increased the likelihood of inconsistencies between assessments. A significant positive correlation was found between the CAM-ICU disagreement rate and the total number of assessments per month. To maximize the reliability of delirium assessments, individual-targeted approaches considering the patient’s level of consciousness and type of treatment implemented are required, along with ensuring a stable, and regulated working environment and customized educational programs.

Keywords

delirium electronic health records intensive care units CAM-ICU validation study

Get full access to this article

View all access options for this article.

References

Z. P.

Gao

X. L.

Zhao

X. L.

(2018). Factors associated with unplanned extubation in the intensive care unit for adult patients: A systematic review and meta-analysis. Intensive and Critical Care Nursing, 47, 62–68. https://doi.org/10.1016/j.iccn.2018.03.008

Y. S.

Jin

Hur

E. Y.

Lee

S. M.

(2019). Operative and anaesthetic factors influencing on delirium in the intensive care unit: An analysis of electronic health records. Journal of Clinical Nursing, 28(7-8), 1327–1335. https://doi.org/10.1111/jocn.14749

Barman

Pradhan

Bhattacharyya

Dey

Bhattacharjee

Tesia

S. S.

Mitra

J. K.

(2018). Diagnostic accuracy of delirium assessment methods in critical care patients. Journal of Critical Care, 44, 82–86. https://doi.org/10.1016/j.jcrc.2017.10.013

Boettger

Nuñez

D. G.

Meyer

Richter

Fernandez

S. F.

Rudiger

Schubert

Jenewein

(2017). Delirium in the intensive care setting and the Richmond agitation and sedation scale (RASS): Drowsiness increases the risk and is subthreshold for delirium. Journal of Psychosomatic Research, 103, 133–139. https://doi.org/10.1016/j.jpsychores.2017.09.011

Boot

(2012). Delirium: A review of the nurses role in the intensive care unit. Intensive and Critical Care Nursing, 28(3), 185–189. https://doi.org/10.1016/j.iccn.2011.11.004

Burk

R. S.

Grap

M. J.

Munro

C. L.

Schubert

C. M.

Sessler

C. N.

(2014). Predictors of agitation in critically ill adults. American Journal of Critical Care, 23(5), 414–423. https://doi.org/10.4037/ajcc2014714

Chen

T. J.

Chung

Y. W.

Chang

H. R.

Chen

P. Y.

C. R.

Hsieh

S. H.

Chiu

H. Y.

(2021). Diagnostic accuracy of the CAM-ICU and ICDSC in detecting intensive care unit delirium: A bivariate meta-analysis. International Journal of Nursing Studies, 113, 103782. https://doi.org/10.1016/j.ijnurstu.2020.103782

de Almeida

T. M.

de Azevedo

L. C.

Nosé

P. M.

de Freitas

F. G.

Machado

F. R

. (2016). Risk factors for agitation in critically ill patients. Revista Brasileira de Terapia Intensiva, 28(4), 413–419. https://doi.org/10.5935/0103-507x.20160074

Devlin

J. W.

Fong

J. J.

Howard

E. P.

Skrobik

McCoy

Yasuda

Marshall

(2008). Assessment of delirium in the intensive care unit: Nursing practices and perceptions. American Journal of Critical Care, 17(6), 555–565.

10.

Devlin

J. W.

Skrobik

Gélinas

Needham

D. M.

Slooter

A. J. C.

Pandharipande

P. P.

Watson

P. L.

Weinhouse

G. L.

Nunnally

M. E.

Rochwerg

Balas

M. C.

van Den Boogaard

Bosma

K. J.

Brummel

N. E.

Chanques

Denehy

Drouot

Fraser

G. L.

Harris

J. E.

…, Alhazzani

(2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825–e873. https://doi.org/10.1097/ccm.0000000000003299

11.

Ely

E. W.

Inouye

S. K.

Bernard

G. R.

Gordon

Francis

May

Truman

Speroff

Gautam

Margolin

Hart

R. P.

Dittus

(2001). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). The Journal of the American Medical Association, 286(21), 2703–2710. https://jamanetwork.com/journals/jama/articlepdf/194422/JCE10051.pdf

12.

Ely

E. W.

Margolin

Francis

May

Truman

Dittus

Speroff

Gautam

Bernard

G. R.

Inouye

S. K.

(2001). Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine, 29(7), 1370–1379.

13.

Ewers

Bloomer

M. J.

Hutchinson

(2021). An exploration of the reliability and usability of two delirium screening tools in an Australian intensive care unit: A pilot study. Intensive and Critical Care Nursing, 62, 102919. https://doi.org/10.1016/j.iccn.2020.102919

14.

Grams

M. E.

Rabb

(2012). The distant organ effects of acute kidney injury. Kidney International, 81(10), 942–948. https://doi.org/10.1038/ki.2011.241

15.

Gunawardena

Smithard

D. G.

(2019). The attitudes towards the use of restraint and restrictive intervention amongst healthcare staff on acute medical and frailty Wards-A brief literature review. Geriatrics, 4(3), 50. https://doi.org/10.3390/geriatrics4030050

16.

Gusmao-Flores

Salluh

J. I.

Chalhub

R. Á.

Quarantini

L. C.

(2012). The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: A systematic review and meta-analysis of clinical studies. Critical Care, 16(4), R115. https://doi.org/10.1186/cc11407

17.

Haenggi

Blum

Brechbuehl

Brunello

Jakob

S. M.

Takala

(2013). Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC. Intensive Care Medicine, 39(12), 2171–2179. https://doi.org/10.1007/s00134-013-3034-5

18.

Hayhurst

C. J.

Pandharipande

P. P.

Hughes

C. G.

(2016). Intensive care unit delirium: A review of diagnosis, prevention, and treatment. Anesthesiology, 125(6), 1229–1241. https://doi.org/10.1097/aln.0000000000001378

19.

Montgomery

Traynor

Chang

Kuo

K. N.

Chang

Chen

(2020). Diagnostic performance of delirium assessment tools in critically ill patients: A systematic review and meta-analysis. Worldviews on Evidence-Based Nursing, 17(4), 301–310. https://doi.org/10.1111/wvn.12462W.

20.

Inouye

S. K.

van Dyck

C. H.

Alessi

C. A.

Balkin

Siegal

A. P.

Horwitz

R. I.

(1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941–948.

21.

Inouye

S. K.

Westendorp

R. G.

Saczynski

J. S.

(2014). Delirium in elderly people. Lancet, 383(9920), 911–922. https://doi.org/10.1016/S0140-6736(13)60688-1

22.

Jung

J. H.

Lim

J. H.

Kim

E. J.

H. C.

Kang

M. K.

Lee

Min

Y. K.

Park

E. Z.

Song

X. H.

Kim

H. R.

Lee

S. M.

(2013). The experience of delirium care and clinical feasibility of the CAM-ICU in a Korean ICU. Clinical Nursing Research, 22(1), 95–111. https://doi.org/10.1177/1054773812447187

23.

Lawson

T. N.

Tan

Thrane

S. E.

Happ

M. B.

Mion

L. C.

Tate

Balas

M. C.

(2020). Predictors of new-onset physical restraint use in critically ill adults. American Journal of Critical Care, 29(2), 92–102. https://doi.org/10.4037/ajcc2020361

24.

Moon

K. J.

Jin

Lee

S. M.

(2018). Development and validation of an automated delirium risk assessment system (auto-DelRAS) implemented in the electronic health record system. International Journal of Nursing Studies, 77, 46–53. https://doi.org/10.1016/j.ijnurstu.2017.09.014

25.

Nishimura

Yokoyama

Yamauchi

Koizumi

Harasawa

Yasuda

Mimura

Igita

Suzuki

Uchiide

Seino

Nomura

Yamazaki

Ishigooka

(2016). Sensitivity and specificity of the confusion assessment method for the intensive care unit (CAM-ICU) and the intensive care delirium screening checklist (ICDSC) for detecting post-cardiac surgery delirium: A single-center study in Japan. Heart & Lung: The Journal of Acute and Critical Care, 45(1), 15–20. https://doi.org/10.1016/j.hrtlng.2015.11.001

26.

Oxenboll-Collet

Egerod

Christensen

Jensen

Thomsen

(2016). Nurses’ and physicians’ perceptions of Confusion Assessment Method for the intensive care unit for delirium detection: Focus group study. Nursing in Critical Care, 23(1), 16–22. https://doi.org/10.1111/nicc.12254

27.

Pandharipande

P. P.

Girard

T. D.

Jackson

J. C.

Morandi

Thompson

J. L.

Pun

B. T.

Brummel

N. E.

Hughes

C. G.

Vasilevskis

E. E.

Shintani

A. K.

Moons

K. G.

Geevarghese

S. K.

Canonico

Hopkins

R. O.

Bernard

G. R.

Dittus

R. S.

Ely

E. W.

; the BRAIN-ICU Study Investigators. (2013). Long-term cognitive impairment after critical illness. New England Journal of Medicine, 369(14), 1306–1316. https://doi.org/10.1056/NEJMoa1301372

28.

Panitchote

Tangvoraphonkchai

Suebsoh

Eamma

Chanthonglarng

Tiamkao

Limpawattana

(2015). Under-recognition of delirium in older adults by nurses in the intensive care unit setting. Aging Clinical and Experimental Research, 27(5), 735–740. https://doi.org/10.1007/s40520-015-0323-6

29.

Patel

S. B.

Poston

J. T.

Pohlman

Hall

J. B.

Kress

J. P.

(2014). Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. American Journal of Respiratory and Critical Care Medicine, 189(6), 658–665. https://doi.org/10.1164/rccm.201310-1815OC

30.

Pun

B. T.

Gordon

S. M.

Peterson

J. F.

Shintani

A. K.

Jackson

J. C.

Foss

Harding

S. D.

Bernard

G. R.

Dittus

R. S.

Ely

E. W.

(2005). Large-scale implementation of sedation and delirium monitoring in the intensive care unit: A report from two medical centers. Critical Care Medicine, 33(6), 1199–1205.

31.

Rice

K. L.

Bennett

Gomez

Theall

K. P.

Knight

Foreman

M. D.

(2011). Nurses’ recognition of delirium in the hospitalized older adult. Clinical Nurse Specialist, 25(6), 299–311. https://doi.org/10.1097/NUR.0b013e318234897b

32.

Roh

Y. S.

(2021). The training needs of Korean intensive care unit nurses regarding delirium. Intensive and Critical Care Nursing, 62, 102954. https://doi.org/10.1016/j.iccn.2020.102954

33.

Rowley-Conwy

(2018). Barriers to delirium assessment in the intensive care unit: A literature review. Intensive and Critical Care Nursing, 44, 99–104. https://doi.org/10.1016/j.iccn.2017.09.001

34.

Salehi

Najafi Ghezeljeh

Hajibabaee

Joolaee

(2020). Factors behind ethical dilemmas regarding physical restraint for critical care nurses. Nursing Ethics, 27(2), 598–608. https://doi.org/10.1177/0969733019858711

35.

Sessler

C. N.

Gosnell

M. S.

Grap

M. J.

Brophy

G. M.

O'Neal

P. V.

Keane

K. A.

Tesoro

E. P.

Elswick

R. K.

(2002). The Richmond agitation-sedation scale: Validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 166(10), 1338–1344. https://doi.org/10.1164/rccm.2107138

36.

Smith

J. M.

Van Aman

M. N.

Schneiderhahn

M. E.

Edelman

Ercole

P. M.

(2017). Assessment of delirium in intensive care unit patients: Educational strategies. Journal of Continuing Education in Nursing, 48(5), 239–244. https://doi.org/10.3928/00220124-20170418-09

37.

Soja

S. L.

Pandharipande

P. P.

Fleming

S. B.

Cotton

B. A.

Miller

L. R.

Weaver

S. G.

Lee

B. T.

Ely

E. W.

(2008). Implementation, reliability testing, and compliance monitoring of the confusion assessment method for the intensive care unit in trauma patients. Intensive Care Medicine, 34(7), 1263–1268. https://doi.org/10.1007/s00134-008-1031-x

38.

Steinseth

E. B.

Høye

Hov

(2018). Use of the CAM-ICU during daily sedation stops in mechanically ventilated patients as assessed and experienced by intensive care nurses - a mixed-methods study. Intensive and Critical Care Nursing, 47, 23–29. https://doi.org/10.1016/j.iccn.2018.04.005

39.

Tandukar

Palevsky

P. M.

(2019). Continuous renal replacement therapy: Who, when, why, and how. Chest, 155(3), 626–638. https://doi.org/10.1016/j.chest.2018.09.004

40.

Teece

Baker

Smith

(2020). Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit. Journal of Clinical Nursing, 29(1-2), 5–19. https://doi.org/10.1111/jocn.15052

41.

Tingsvik

Bexell

Andersson

A. C.

Henricson

(2013). Meeting the challenge: ICU-nurses' experiences of lightly sedated patients. Australian Critical Care, 26(3), 124–129. https://doi.org/10.1016/j.aucc.2012.12.005

42.

Tyndall

Bailey

Elliott

(2020). Pragmatic development of an evidence-based intensive care unit-specific falls risk assessment tool: The Tyndall Bailey falls risk assessment tool. Australian Critical Care, 33(1), 65–70. https://doi.org/10.1016/j.aucc.2019.02.003

43.

van Eijk

M. M.

van Den Boogaard

van Marum

R. J.

Benner

Eikelenboom

Honing

M. L.

van der Hoven

Horn

Izaks

G. J.

Kalf

Karakus

Klijn

I. A.

Kuiper

M. A.

de Leeuw

F. E.

de Man

van der Mast

R. C.

Osse

R. J.

de Rooij

S. E.

Spronk

P. E.

…, Slooter

A. J

. (2011). Routine use of the confusion assessment method for the intensive care unit: A multicenter study. American Journal of Respiratory and Critical Care Medicine, 184(3), 340–344. https://doi.org/10.1164/rccm.201101-0065OC

44.

van Eijk

M. M. J.

van Marum

R. J.

Klijn

I. A. M.

de Wit

Kesecioglu

Slooter

A. J. C

. (2009). Comparison of delirium assessment tools in a mixed intensive care unit. Critical Care Medicine, 37(6), 1881–1885. https://doi.org/10.1097/ccm.0b013e3181a00118

45.

Vasilevskis

E. E.

Morandi

Boehm

Pandharipande

P. P.

Girard

T. D.

Jackson

J. C.

Thompson

J. L.

Shintani

Gordon

S. M.

Pun

B. T.

Ely

E. W.

(2011). Delirium and sedation recognition using validated instruments: Reliability of bedside intensive care unit nursing assessments from 2007 to 2010. Journal of the American Geriatrics Society, 59(Suppl 2), S249–S255. https://doi.org/10.1111/j.1532-5415.2011.03673.x

46.

Zamoscik

Godbold

Freeman

(2017). Intensive care nurses' experiences and perceptions of delirium and delirium care. Intensive and Critical Care Nursing, 40, 94–100. https://doi.org/10.1016/j.iccn.2017.01.003