Predicting Hospital Mortality and Length of Stay: The Delirium Screening Checklist versus Confusion Assessment Method for Intensive Care Units

Abstract

Background: Both the intensive care delirium screening checklist (ICDSC) and confusion assessment method for ICU (CAM-ICU) are valid tools for identification of delirium, however their relative predictive validity for important delirium outcomes, such as hospital mortality and LOS have not been well-established. We aim to compare the two tools for their predictive validity for outcomes related to delirium, hospital mortality and length of stay (LOS).Methods: The prospective cohort study conducted in six medical ICUs at a tertiary care hospital in Taiwan. The study enrolled consecutive adult patients (≥20 years) who were delirium free at ICU admission. Delirium was screened daily by trained research nurses using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation-Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups, respectively.Results: Delirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ =0.63; p < 0.001) was found between tools. Independent of age, APACHE II score, and Charlson comorbidity index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio [aOR] 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI, 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared to the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (aOR 2.97; 95% CI, 1.06 to 8.37 vs. 3.82; 95% CI, 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS.Conclusions: The ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients’ arousal when deciding which tool to use to maximize the effects of delirium identification on patient mortality.Trial registration: NCT 04206306