Delirium Bibliography

The searchable delirium bibliography page is one of our most popular features, allowing you to quickly gain access to the literature on delirium and acute care of older persons.  The HELP team keeps it updated for you on a monthly basis!  Feel free to search by author, title, keywords. It is primarily intended for clinicians and researchers interested in exploring these topics.

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Total Results: 3226

  • Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial. 2019 Wang, Y. Y. Yue, J. R. Xie, D. M. Carter, P. Li, Q. L. Gartaganis, S. L. Chen, J. Inouye, S. K.. JAMA Intern Med,
    • Title

      Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial.

    • Authors
      Wang, Y. Y. Yue, J. R. Xie, D. M. Carter, P. Li, Q. L. Gartaganis, S. L. Chen, J. Inouye, S. K.
    • Year
      2019
    • Journal
      JAMA Intern Med
    • URL
    • Abstract
      Importance: Postoperative delirium (POD) is a common condition for older adults, contributing to their functional decline. Objective: To investigate the effectiveness of the Tailored, Family-Involved Hospital Elder Life Program (t-HELP) for preventing POD and functional decline in older patients after a noncardiac surgical procedure. Design, Setting, and Participants: A 2-arm, parallel-group, single-blind, cluster randomized clinical trial was conducted from August 24, 2015, to February 28, 2016, on 6 surgical floors (gastric, colorectal, pancreatic, biliary, thoracic, and thyroid) of West China Hospital in Chengdu, China. Eligible participants (n = 281) admitted to each of the 6 surgical floors were randomized into a nursing unit providing t-HELP (intervention group) or a nursing unit providing usual care (control group). All randomized patients were included in the intention-to-treat analyses for the primary outcome of POD incidence. Statistical analysis was performed from April 3, 2016, to December 30, 2017. Interventions: In addition to receiving usual care, all participants in the intervention group received the t-HELP protocols, which addressed each patient's risk factor profile. Besides nursing professionals, family members and paid caregivers were involved in the delivery of many of the program interventions. Main Outcomes and Measures: The primary outcome was the incidence of POD, evaluated with the Confusion Assessment Method. Secondary outcomes included the pattern of functional and cognitive changes (activities of daily living [ADLs], instrumental activities of daily living [IADLs], Short Portable Mental Status Questionnaire [SPMSQ]) from hospital admission to 30 days after discharge, and the length of hospital stay (LOS). Results: Of the 475 patients screened for eligibility, 281 (171 [60.9%] male, mean [SD] age 74.7 [5.2] years) were enrolled and randomized to receive t-HELP (n = 152) or usual care (n = 129). Postoperative delirium occurred in 4 participants (2.6%) in the intervention group and in 25 (19.4%) in the control group, with a relative risk of 0.14 (95% CI, 0.05-0.38). The number needed to treat to prevent 1 case of POD was 5.9 (95% CI, 4.2-11.1). Participants in the intervention group compared with the control group showed less decline in physical function (median [interquartile range] for ADLs: -5 [-10 to 0] vs -20 [-30 to -10]; P < .001; for IADLs: -2 [-2 to 0] vs -4 [-4 to -2]; P < .001) and cognitive function (for the SPMSQ level: 1 [0.8%] vs 8 [7.0%]; P = .009) at discharge, as well as shorter mean (SD) LOS (12.15 [3.78] days vs 16.41 [4.69] days; P < .001). Conclusions and Relevance: The findings suggest that t-HELP, with family involvement at its core, is effective in reducing POD for older patients, maintaining or improving their physical and cognitive functions, and shortening the LOS. The results of this t-HELP trial may improve generalizability and increase the implementation of this program. Trial Registration: Chinese Clinical Trial Registry Identifier: ChiCTR-POR-15006944.
    • PubMed ID
  • Automated tracking of level of consciousness and delirium in critical illness using deep learning. 2019 Sun, H. Kimchi, E. Akeju, O. Nagaraj, S. B. McClain, L. M. Zhou, D. W. Boyle, E. Zheng, W. L. Ge, W. Westover, M. B.. NPJ Digital Medicine, 2:1
    • Title

      Automated tracking of level of consciousness and delirium in critical illness using deep learning.

    • Authors
      Sun, H. Kimchi, E. Akeju, O. Nagaraj, S. B. McClain, L. M. Zhou, D. W. Boyle, E. Zheng, W. L. Ge, W. Westover, M. B.
    • Year
      2019
    • Journal
      NPJ Digital Medicine
    • URL
    • Abstract
      Over- and under-sedation are common in the ICU, and contribute to poor ICU outcomes including delirium. Behavioral assessments, such as Richmond Agitation-Sedation Scale (RASS) for monitoring levels of sedation and Confusion Assessment Method for the ICU (CAM-ICU) for detecting signs of delirium, are often used. As an alternative, brain monitoring with electroencephalography (EEG) has been proposed in the operating room, but is challenging to implement in ICU due to the differences between critical illness and elective surgery, as well as the duration of sedation. Here we present a deep learning model based on a combination of convolutional and recurrent neural networks that automatically tracks both the level of consciousness and delirium using frontal EEG signals in the ICU. For level of consciousness, the system achieves a median accuracy of 70% when allowing prediction to be within one RASS level difference across all patients, which is comparable or higher than the median technician–nurse agreement at 59%. For delirium, the system achieves an AUC of 0.80 with 69% sensitivity and 83% specificity at the optimal operating point. The results show it is feasible to continuously track level of consciousness and delirium in the ICU.
    • PubMed ID
  • Impact of natural light exposure on delirium burden in adult patients receiving invasive mechanical ventilation in the ICU: a prospective study. 2019 Smonig, R. Magalhaes, E. Bouadma, L. Andremont, O. de Montmollin, E. Essardy, F. Mourvillier, B. Lebut, J. Dupuis, C. Neuville, M. Lermuzeaux, M. Timsit, J. F. Sonneville, R.. Ann Intensive Care, 9:1 (120)
    • Title

      Impact of natural light exposure on delirium burden in adult patients receiving invasive mechanical ventilation in the ICU: a prospective study.

    • Authors
      Smonig, R. Magalhaes, E. Bouadma, L. Andremont, O. de Montmollin, E. Essardy, F. Mourvillier, B. Lebut, J. Dupuis, C. Neuville, M. Lermuzeaux, M. Timsit, J. F. Sonneville, R.
    • Year
      2019
    • Journal
      Ann Intensive Care
    • URL
    • Abstract
      OBJECTIVE: To determine whether potential exposure to natural light via windows is associated with reduced delirium burden in critically ill patients admitted to the ICU in a single room. DESIGN: Prospective single-center study. SETTING: Medical ICU of a university hospital, Paris, France. PATIENTS: Adult patients receiving invasive mechanical ventilation. METHODS: Consecutive patients admitted to a single room with (LIGHT group) or without (DARK group) exposure to natural light via windows were evaluated for delirium. The primary endpoint was the incidence of delirium. Main secondary endpoints included incidence of severe agitation intervened with antipsychotics and incidence of hallucinations. RESULTS: A total of 195 patients were included (LIGHT group: n = 110; DARK group: n = 85). The incidence of delirium was similar in the LIGHT group and the DARK group (64% vs. 71%; relative risk (RR) 0.89, 95% CI 0.73-1.09). Compared with the DARK group, patients from the LIGHT group were less likely to be intervened with antipsychotics for agitation episodes (13% vs. 25%; RR 0.52, 95% CI 0.27-0.98) and had less frequent hallucinations (11% vs. 22%; RR 0.49, 95% CI 0.24-0.98). In multivariate logistic regression analysis, natural light exposure was independently associated with a reduced risk of agitation episodes intervened with antipsychotics (adjusted odds ratio = 0.39; 95% CI 0.17-0.88). CONCLUSION: Admission to a single room with potential exposure to natural light via windows was not associated with reduced delirium burden, as compared to admission to a single room without windows. However, natural light exposure was associated with a reduced risk of agitation episodes and hallucinations.
    • PubMed ID
  • Antipsychotics for preventing delirium in hospitalized adults a systematic review. 2019 Oh, E. S. Needham, D. M. Nikooie, R. Wilson, L. M. Zhang, A. Robinson, K. A. Neufeld, K. J.. Ann Intern Med, 171:7 (474-484)
    • Title

      Antipsychotics for preventing delirium in hospitalized adults a systematic review.

    • Authors
      Oh, E. S. Needham, D. M. Nikooie, R. Wilson, L. M. Zhang, A. Robinson, K. A. Neufeld, K. J.
    • Year
      2019
    • Journal
      Ann Intern Med
    • URL
    • Abstract
      Background: Delirium is an acute disorder marked by impairments in attention and cognition, caused by an underlying medical problem. Antipsychotics are used to prevent delirium, but their benefits and harms are unclear. Purpose: To conduct a systematic review evaluating the benefits and harms of antipsychotics for prevention of delirium in adults. Data Sources: PubMed, Embase, CENTRAL, CINAHL, and Psyc- INFO from inception through July 2019, without restrictions based on study setting, language of publication, or length of follow-up. Study Selection: Randomized, controlled trials (RCTs) that compared an antipsychotic with placebo or another antipsychotic, and prospective observational studies with a comparison group. Data Extraction: One reviewer extracted data and graded the strength of the evidence, and a second reviewer confirmed the data. Two reviewers independently assessed the risk of bias. Data Synthesis: A total of 14 RCTs were included. There were no differences in delirium incidence or duration, hospital length of stay (high strength of evidence [SOE]), and mortality between haloperidol and placebo used for delirium prevention. Little to no evidence was found to determine the effect of haloperidol on cognitive function, delirium severity (insufficient SOE), inappropriate continuation, and sedation (insufficient SOE). There is limited evidence that second-generation antipsychotics may lower delirium incidence in the postoperative setting. There is little evidence that short-term use of antipsychotics was associated with neurologic harms. In some of the trials, potentially harmful cardiac effects occurred more frequently with antipsychotic use. Limitations: There was significant heterogeneity in antipsychotic dosing, route of antipsychotic administration, assessment of outcomes, and adverse events. There were insufficient or no data available to draw conclusions for many of the outcomes. Conclusion: Current evidence does not support routine use of haloperidol or second-generation antipsychotics for prevention of delirium. There is limited evidence that second-generation antipsychotics may lower the incidence of delirium in postoperative patients, but more research is needed. Future trials should use standardized outcome measures.
    • PubMed ID
  • Antipsychotics for treating delirium in hospitalized adults a systematic review. 2019 Nikooie, R. Neufeld, K. J. Oh, E. S. Wilson, L. M. Zhang, A. Robinson, K. A. Needham, D. M.. Ann Internal Med, 171:7 (485-494)
    • Title

      Antipsychotics for treating delirium in hospitalized adults a systematic review.

    • Authors
      Nikooie, R. Neufeld, K. J. Oh, E. S. Wilson, L. M. Zhang, A. Robinson, K. A. Needham, D. M.
    • Year
      2019
    • Journal
      Ann Internal Med
    • URL
    • Abstract
      Background: Delirium is common in hospitalized patients and is associated with worse outcomes. Antipsychotics are commonly used; however, the associated benefits and harms are unclear. Purpose: To conduct a systematic review evaluating the benefits and harms of antipsychotics to treat delirium in adults. Data Sources: PubMed, Embase, CENTRAL, CINAHL, and Psyc- INFO from inception to July 2019 without language restrictions. Study Selection: Randomized controlled trials (RCTs) of antipsychotic versus placebo or another antipsychotic, and prospective observational studies reporting harms. Data Extraction: One reviewer extracted data and assessed strength of evidence (SOE) for critical outcomes, with confirmation by another reviewer. Risk of bias was assessed independently by 2 reviewers. Data Synthesis: Across 16 RCTs and 10 observational studies of hospitalized adults, there was no difference in sedation status (low and moderate SOE), delirium duration, hospital length of stay (moderate SOE), or mortality between haloperidol and second-generation antipsychotics versus placebo. There was no difference in delirium severity (moderate SOE) and cognitive functioning (low SOE) for haloperidol versus second-generation antipsychotics, with insufficient or no evidence for antipsychotics versus placebo. For direct comparisons of different secondgeneration antipsychotics, there was no difference in mortality and insufficient or no evidence for multiple other outcomes. There was little evidence demonstrating neurologic harms associated with short-term use of antipsychotics for treating delirium in adult inpatients, but potentially harmful cardiac effects tended to occur more frequently. Limitations: Heterogeneity was present in terms of dose and administration route of antipsychotics, outcomes, and measurement instruments. There was insufficient or no evidence regarding multiple clinically important outcomes. Conclusion: Current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.
    • PubMed ID
  • Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms. 2019 Mossello, E. Baroncini, C. Pecorella, L. Giulietti, C. Chiti, M. Caldi, F. Cavallini, M. C. Simoni, D. Baldasseroni, S. Fumagalli, S. Valoti, P. Stroppa, S. Parenti, K. Ungar, A. Masotti, G. Marchionni, N. Di Bari, M.. Eur Heart J Acute Cardiovasc Care,
    • Title

      Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms.

    • Authors
      Mossello, E. Baroncini, C. Pecorella, L. Giulietti, C. Chiti, M. Caldi, F. Cavallini, M. C. Simoni, D. Baldasseroni, S. Fumagalli, S. Valoti, P. Stroppa, S. Parenti, K. Ungar, A. Masotti, G. Marchionni, N. Di Bari, M.
    • Year
      2019
    • Journal
      Eur Heart J Acute Cardiovasc Care
    • URL
    • Abstract
      BACKGROUND: Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units. METHODS: All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection. RESULTS: Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient's features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93). CONCLUSIONS: Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.
    • PubMed ID
  • Dysfunction of the blood-brain barrier in postoperative delirium patients, referring to the axonal damage biomarker phosphorylated neurofilament heavy subunit. 2019 Mietani, K. Sumitani, M. Ogata, T. Shimojo, N. Inoue, R. Abe, H. Kawamura, G. Yamada, Y.. PLoS One, (e0222721)
    • Title

      Dysfunction of the blood-brain barrier in postoperative delirium patients, referring to the axonal damage biomarker phosphorylated neurofilament heavy subunit.

    • Authors
      Mietani, K. Sumitani, M. Ogata, T. Shimojo, N. Inoue, R. Abe, H. Kawamura, G. Yamada, Y.
    • Year
      2019
    • Journal
      PLoS One
    • URL
    • Abstract
      BACKGROUND: Delirium is the most common postoperative complication of the central nervous system (CNS) that can trigger long-term cognitive impairment. Its underlying mechanism is not fully understood, but the dysfunction of the blood-brain barrier (BBB) has been implicated. The serum levels of the axonal damage biomarker, phosphorylated neurofilament heavy subunit (pNF-H) increase in moderate to severe delirium patients, indicating that postoperative delirium can induce irreversible CNS damage. Here, we investigated the relationship among postoperative delirium, CNS damage and BBB dysfunction, using pNF-H as reference. METHODS: Blood samples were collected from 117 patients within 3 postoperative days. These patients were clinically diagnosed with postoperative delirium using the Confusion Assessment Method for the Intensive Care Unit. We measured intercellular adhesion molecule-1, platelet and endothelial cell adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, and P-selectin as biomarkers for BBB disruption, pro-inflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6), and pNF-H. We conducted logistic regression analysis including all participants to identify independent biomarkers contributing to serum pNF-H detection. Next, by multiple regression analysis with a stepwise method we sought to determine which biomarkers influence serum pNF-H levels, in pNF-H positive patients. RESULTS: Of the 117 subjects, 41 were clinically diagnosed with postoperative delirium, and 30 were positive for serum pNF-H. Sensitivity and specificity of serum pNF-H detection in the patients with postoperative delirium were 56% and 90%, respectively. P-selectin was the only independent variable to associate with pNF-H detection (P < 0.0001) in all 117 patients. In pNF-H positive patients, only PECAM-1 was associated with serum pNF-H levels (P = 0.02). CONCLUSIONS: Serum pNF-H could be an objective delirium biomarker, superior to conventional tools in clinical settings. In reference to pNF-H, P-selectin may be involved in the development of delirium-related CNS damage and PECAM-1 may contribute to the progression of delirium- related CNS damage.
    • PubMed ID
  • The 4 ‘a’s test for detecting delirium in acute medical patients: A diagnostic accuracy study. 2019 Maclullich, A. M. J. Shenkin, S. D. Goodacre, S. Godfrey, M. Hanley, J. Stíobhairt, A. Lavender, E. Boyd, J. Stephen, J. Weir, C. Macraild, A. Steven, J. Black, P. Diernberger, K. Hall, P. Tieges, Z. Fox, C. Anand, A. Young, J. Siddiqi, N. Gray, A.. Health Technol Assess, 23:40
    • Title

      The 4 ‘a’s test for detecting delirium in acute medical patients: A diagnostic accuracy study.

    • Authors
      Maclullich, A. M. J. Shenkin, S. D. Goodacre, S. Godfrey, M. Hanley, J. Stíobhairt, A. Lavender, E. Boyd, J. Stephen, J. Weir, C. Macraild, A. Steven, J. Black, P. Diernberger, K. Hall, P. Tieges, Z. Fox, C. Anand, A. Young, J. Siddiqi, N. Gray, A.
    • Year
      2019
    • Journal
      Health Technol Assess
    • URL
    • Abstract
      Background: Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. Methods: Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged = 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. Results: Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. Limitations: Patients were aged = 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. Conclusions: These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. Future work: Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. Trial registration: Current Controlled Trials ISRCTN53388093.
    • PubMed ID
  • Initiation and continuation of antipsychotic medicines in older people following non-psychiatric hospital admission. 2019 Kalisch Ellett, L. M. Pratt, N. L. Apajee, J. Roughead, E. E.. Int J Clin Pharm, 41:5 (1341-7)
    • Title

      Initiation and continuation of antipsychotic medicines in older people following non-psychiatric hospital admission.

    • Authors
      Kalisch Ellett, L. M. Pratt, N. L. Apajee, J. Roughead, E. E.
    • Year
      2019
    • Journal
      Int J Clin Pharm
    • URL
    • Abstract
      Background Internationally, antipsychotics are frequently initiated during hospital admission for older patients and use often continues post-discharge without indication. We located no Australian studies on this topic. Objective to identify the hospital admissions (excluding psychosis) associated with antipsychotic initiation and continuation in older Australians. Setting Australian Government Department of Veterans' Affairs. Method Retrospective analysis of administrative claims data for people admitted to hospital from 1 January 2014 to 31 December 2014, aged >/= 65 years, who were antipsychotic naive. Main outcome measure number of admissions associated with antipsychotic initiation, and the major diagnosis groups for these admissions. Where antipsychotics were initiated, we determined the time to cessation of antipsychotics after discharge. Results There were 142,009 hospital admissions for 66,415 people with a median age of 86 years. 921 (0.65%) admissions were associated with antipsychotic initiation, most commonly where the primary diagnoses were for mental and behavioural disorders excluding psychosis (17.8%) and injuries (16%). Fourteen percent of antipsychotic initiations were for primary diagnoses of delirium or dementia. When secondary diagnoses were considered, 55% of antipsychotic initiations were associated with delirium, dementia or both. The median duration of use among people who used antipsychotics was 132 days, and 40% continued use until death or one year follow-up. Conclusion Initiation of antipsychotics during hospital admissions was not frequent in this Australian population. Amongst those who did initiate antipsychotics, for almost half no diagnosis corresponding with an approved indication for use was recorded and long-term use of up to one year was common.
    • PubMed ID
  • Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs. 2019 Hsieh, S. J. Otusanya, O. Gershengorn, H. B. Hope, A. A. Dayton, C. Levi, D. Garcia, M. Prince, D. Mills, M. Fein, D. Colman, S. Gong, M. N.. Crit Care Med, 47:7 (885-893)
    • Title

      Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs.

    • Authors
      Hsieh, S. J. Otusanya, O. Gershengorn, H. B. Hope, A. A. Dayton, C. Levi, D. Garcia, M. Prince, D. Mills, M. Fein, D. Colman, S. Gong, M. N.
    • Year
      2019
    • Journal
      Crit Care Med
    • URL
    • Abstract
      Objectives: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost. Design: Prospective cohort study. Setting: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY). Patients: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014. Interventions: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD). Measurements and Main Results: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively. Conclusions: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.
    • PubMed ID
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