Implementing Delirium Screening in the ICU: Secrets to Success

Brummel, Nathan E. MD, MSCI1,2,3,4,5; Vasilevskis, Eduard E. MD, MPH1,2,4,5,6; Han, Jin Ho MD, MSc6,7; Boehm, Leanne MSN, RN, ACNS-BC8; Pun, Brenda T. MSN, RN, ACNP4; Ely, E. Wesley MD, MPH, FCCM1,2,3,4,6

Abstract
Objective: To review delirium screening tools available for use in the adult ICU and PICU, to review evidence-based delirium screening implementation, and to discuss common pitfalls encountered during delirium screening in the ICU. Data Sources: Review of delirium screening literature and expert opinion. Results: Over the past decade, tools specifically designed for use in critically ill adults and children have been developed and validated. Delirium screening has been effectively implemented across many ICU settings. Keys to effective implementation include addressing barriers to routine screening, multifaceted training such as lectures, case-based scenarios, one-on-one teaching, and real-time feedback of delirium screening, and interdisciplinary communication through discussion of a patients delirium status during bedside rounds and through documentation systems. If delirium is present, clinicians should search for reversible or treatable causes because it is often multifactorial. Conclusion: Implementation of effective delirium screening is feasible but requires attention to implementation methods, including a change in the current ICU culture that believes delirium is inevitable or a normal part of a critical illness, to a future culture that views delirium as a dangerous syndrome which portends poor clinical outcomes and which is potentially modifiable depending on the individual patients circumstances.

http://journals.lww.com/ccmjournal/Abstract/2013/09000/Implementing_Delirium_Screening_in_the_I CU__.15.aspx?WT.mc_id=HPxADx20100319xMP

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Acute Respiratory Distress Syndrome After Spontaneous Intracerebral Hemorrhage*

Elmer, Jonathan MD1; Hou, Peter MD24; Wilcox, Susan R. MD46; Chang, Yuchiao PhD4,7; Schreiber, Hannah BA2; Okechukwu, Ikenna MD5; Pontes-Neto, Octvio MD, PhD8; Bajwa, Ednan MD, MPH4,9; Hess, Dean R. RRT, PhD4,10; Avery, Laura MD4,11; Duran-Mendicuti, Maria Alejandra MD4,12; Camargo, Carlos A. MD, DrPH4,5; Greenberg, Steven M. MD, PhD4,8; Rosand, Jonathan MD, MS4,8,13; Pallin, Daniel J. MD, MPH2,4; Goldstein, Joshua N. MD, PhD4,5,13

Abstract
Objectives: Acute respiratory distress syndrome develops commonly in critically ill patients in response to an injurious stimulus. The prevalence and risk factors for development of acute respiratory distress syndrome after spontaneous intracerebral hemorrhage have not been reported. We sought to determine the prevalence of acute respiratory distress syndrome after intracerebral hemorrhage, characterize risk factors for its development, and assess its impact on patient outcomes. Design: Retrospective cohort study at two academic centers. Patients: We included consecutive patients presenting from June 1, 2000, to November 1, 2010, with intracerebral hemorrhage requiring mechanical ventilation. We excluded patients with age less than 18 years, intracerebral hemorrhage secondary to trauma, tumor, ischemic stroke, or structural lesion; if they required intubation only during surgery; if they were admitted for comfort measures; or for a history of immunodeficiency. Interventions: None. Measurements and Main Results: Data were collected both prospectively as part of an ongoing cohort study and by retrospective chart review. Of 1,665 patients identified by database query, 697 met inclusion criteria. The prevalence of acute respiratory distress syndrome was 27%. In unadjusted analysis, high tidal volume ventilation was associated with an increased risk of acute respiratory distress syndrome (hazard ratio, 1.79 [95% CI, 1.132.83]), as were male sex, RBC and plasma transfusion, higher fluid balance, obesity, hypoxemia, acidosis, tobacco use, emergent hematoma evacuation, and vasopressor dependence. In multivariable modeling, high tidal volume ventilation was the strongest risk factor for acute respiratory distress syndrome development (hazard ratio, 1.74 [95% CI, 1.082.81]) and for inhospital mortality (hazard ratio, 2.52 [95% CI, 1.464.34]). Conclusions: Development of acute respiratory distress syndrome is common after intubation for intracerebral hemorrhage. Modifiable risk factors, including high tidal volume ventilation, are associated with its development and in-patient mortality.

http://journals.lww.com/ccmjournal/Abstract/2013/08000/Acute_Respiratory_Distress_Syndrome_Afte r.20.aspx?WT.mc_id=HPxADx20100319xMP

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ICU-Acquired Pneumonia With or Without Etiologic Diagnosis: A Comparison of Outcomes*

Giunta, Valeria MD1,2,3; Ferrer, Miquel MD, PhD1,2; Esperatti, Mariano MD1,2; Ranzani, Otavio T. MD1,2,4; Saucedo, Lina Maria MD1; Bassi, Gianluigi Li MD, PhD1,2; Blasi, Francesco MD, PhD3; Torres, Antoni MD, PhD1,2

Abstract
Objectives: The impact of ICU-acquired pneumonia without etiologic diagnosis on patients outcomes is largely unknown. We compared the clinical characteristics, inflammatory response, and outcomes between patients with and without microbiologically confirmed ICU-acquired pneumonia. Design: Prospective observational study. Setting: ICUs of a university teaching hospital. Patients: We prospectively collected 270 consecutive patients with ICU-acquired pneumonia. Patients were clustered according to positive or negative microbiologic results. Interventions: None. Measurements and Main Results: We compared the characteristics and outcomes between both groups. Negative microbiology was found in 82 patients (30%). Both groups had similar baseline severity scores. Patients with negative microbiology presented more frequently chronic renal failure (15 [18%] vs 11 [6%]; p = 0.003), chronic heart disorders (35 [43%] vs 55 [29%]; p = 0.044), less frequently previous intubation (44 [54%] vs 135 [72%]; p = 0.006), more severe hypoxemia (PaO2/FIO2: 16573 mmHg vs 19979 mmHg; p = 0.001), and shorter ICU stay before the onset of pneumonia (55 days vs 79 days; p = 0.001) compared with patients with positive microbiology. The systemic inflammatory response was similar between both groups. Negative microbiology resulted in less changes of empiric treatment (33 [40%] vs 112 [60%]; p = 0.005) and shorter total duration of antimicrobials (136 days vs 1712 days; p = 0.006) than positive microbiology. Following adjustment for potential confounders, patients with positive microbiology had higher hospital mortality (adjusted odds ratio 2.96, 95% confidence interval 1.247.04, p = 0.014) and lower 90-day survival (adjusted hazard ratio 0.50, 95% confidence interval 0.270.94, p = 0.031), with a nonsignificant lower 28-day survival. Conclusions: Although the possible influence of previous intubation in mortality of both groups is not completely discarded, negative microbiologic findings in clinically suspected ICU-acquired pneumonia are associated with less frequent previous intubation, shorter duration of antimicrobial treatment, and better survival. Future studies should corroborate the presence of pneumonia in patients with suspected ICUacquired pneumonia and negative microbiology.

http://journals.lww.com/ccmjournal/Abstract/2013/09000/ICU_Acquired_Pneumonia_With_or_Withou t_Etiologic.8.aspx?WT.mc_id=HPxADx20100319xMP

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