Routine Use of the Confusion Assessment Method for the Intensive Care Unit

Eijk, Maarten M. van; Boogaard, Mark van den; Marum, Rob J. van; Benner, P.; Eikelenboom, Piet; Honing, Marina L. H.; Hoven, Ben van der; Horn, Janneke; Izaks, Gerbrand J.; Kalf, Annette; Karakus, Attila; Klijn, Ine; Kuiper, Michael; Leeuw, Frank‐Erik de; Man, Tjarda de; Mast, Roos C. van der; Osse, Robert-Jan; Rooij, Sophia E. de; Spronk, Peter E.; Voort, Peter Hj van der; Gool, Willem A. van; Slooter, Arjen J. C.

doi:10.1164/rccm.201101-0065oc

Cited by 246 publications

(180 citation statements)

References 25 publications

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“…Fourth, we assessed the presence of delirium using the CAM-ICU. The performance of this assessment tool in daily practice has been re-evaluated recently [8,9], and also been discussed in sedated patients [38,39] and may not be as accurate as in the original validation studies [10,11], however, ongoing bedside education results in a better performance [40]. On the other hand, in the reevaluation studies the CAM-ICU was measured only once and compared with an expert screening, while in our multinational study the delirium diagnosis was based on all consecutive CAM-ICU screenings during a patients' complete ICU stay, increasing its sensitivity.…”

Section: Discussionmentioning

confidence: 99%

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Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

et al. 2014

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This is the accepted version of the paper.This version of the publication may differ from the final published version. Methods: A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The 10 predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 hours after ICU admission. The confusion assessment method for the Intensive Care Unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data. Permanent repository linkResults: 2,852 adult ICU patients were screened of which 1,824 (64%) were eligible for the study. Main reasons for exclusion were length of stay <1day (19.1%) and sustained coma (4.1%). CAM-ICU compliance was mean (SD) 82±16% and inter-rater reliability 0.87±0.17. The median delirium incidence was 22.5% (IQR 12.8%-36.6%). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the 8 participating centers remained good: 0.77 (95%CI:0.74-0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved recalibration of the PRE-DELIRIC model. Conclusions:In this multinational study we recalibrated the PRE-DELIRIC-model. Despite differences in the incidence of predictors between the centers in the different countries the performance of the PRE-DELIRICmodel remained good. Following validation of the PRE-DELIRIC model it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients.4

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Section: Discussionmentioning

confidence: 99%

“…There are several delirium assessment tools for ICU patients such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Although recent studies [8,9] showed a lower accuracy of the CAM-ICU than in the original studies [10,11], this screening tool has the highest sensitivity and specificity [12,13].…”

Section: Introductionmentioning

confidence: 99%

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

et al. 2014

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“…Temporary alterations in consciousness might be severe enough to preclude assessment of CAM-ICU, but might resolve before delirium symptoms are detected. Added to the relatively low sensitivity of the CAM-ICU for delirium (39), this might artificially lower the apparent incidence of delirium. If anything, this would mean that our already striking findings could be an underestimate of the strength of the relationships.…”

Section: Discussionmentioning

confidence: 99%

Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

Naidech

Beaumont²,

Rosenberg³

et al. 2013

Am J Respir Crit Care Med

105

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Rationale: The prognostic significance of delirium symptoms in intensive care unit (ICU) patients with focal neurologic injury is unclear. Objectives: To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life (QOL) after intracerebral hemorrhage. Methods: We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0 [no symptoms] to 6 [dead]), and QOL outcomes with Neuro-QOL at 28 days, 3 months, and 12 months. Measurements and Main Results: Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days after intracerebral hemorrhage presentation, and were associated with longer ICU length of stay (mean 3.5 d longer in ever vs. never delirious patients; 95% confidence interval, 1.5-8.3; P ¼ 0.004) after correction for age, admit National Institutes of Health (NIH) Stroke Scale, and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (odds ratio, 8.7; 95% confidence interval, 1.4-52.5; P ¼ 0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition-executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up. Conclusions: After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL. Keywords: delirium; outcomes; quality of lifeThe symptoms of delirium, a potential consequence of multiple clinical disease states and physiologic aberrations, include a shift in baseline mental status, inattention, and disorganized thinking or altered level of consciousness. Although nonspecific, this syndrome is an independent predictor of higher mortality (1), longer length of stay (LOS), higher cost of care, and worse long-term cognitive outcomes in medical, surgical, burn, and trauma intensive care unit (ICU) patients (2). There are few such data, however, in ICU patients with focal neurologic injury without systemic illness.Risk factors for delirium symptoms are typically global (infection [3] and intravenous sedation, particularly benzodiazepines [BZDs]) (4, 5) as opposed to focal lesions (e.g., hematoma). Most mechanically ventilated patients are delirious during hospitalization (1), potentially because of the sedation regimen (e.g., BZD infusion), but sedation is typically minimized in neurologically injured patients to permit repeated neurologic assessment that may lead to an acute intervention (6).Screening tests for delirium have been recently validated in neurologically ill patients (7-9), including ischemic stroke (7, 10) and intracerebra...

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“…Theoretically, blinding would overcome this limitation, but this is impossible to apply in a study on the effects of ICU environment. Because of the high specificity of the CAM-ICU performed in daily practice by bedside nurses [25], who were not aware of the aim of the study, their CAM-ICU screening was taken into account in the daily mental status classification.…”

Section: Discussionmentioning

confidence: 99%

“…If the patient was inaccessible, the evaluation was repeated between 3 and 5 P.M. Delirium often has a fluctuating course. To minimize the influence of this fluctuation the research physicians inspected the medical and nursing charts, including the results of the twice-daily CAM-ICU screening by trained bedside ICU nurses [25]. In case of doubt, a neurologist or psychiatrist was consulted who had the decisive vote with regard to the classification of mental status.…”

Section: Delirium Assessmentmentioning

confidence: 99%

Intensive care unit environment may affect the course of delirium

et al. 2012

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Purpose: Delirium is a common disorder in intensive care unit (ICU) patients. It is unclear whether ICU environment affects delirium. We investigated the influence of ICU environment on the number of days with delirium during ICU admission. Methods: In this prospective before-after study, ICU delirium was compared between a conventional ICU with wards and a single-room ICU with, among others, improved daylight exposure. We included patients admitted for more than 24 h between March and June 2009 (ICU with wards) or between June and September 2010 (single-room ICU). Patients who remained unresponsive throughout ICU admission were excluded. The presence of delirium in the preceding 24 h was assessed daily with the confusion assessment method for the ICU (CAM-ICU) by research physicians combined with evaluation of medical and nursing charts. The number of days with delirium was investigated with Poisson regression analysis. Results: We included 55 patients (449 observation days) in the ICU with wards and 75 patients (468 observation days) in the single-room ICU. After adjusting for confounding, the number of days with delirium decreased by 0.4 days (95 % confidence interval 0.1-0.7) in the singleroom ICU (p = 0.005). The incidence of delirium during ICU stay was similar in the ICU with wards (51 %) and in the single-room ICU (45 %, p = 0.53). Conclusions: This study is the first to show that ICU environment may influence the course of delirium in ICU patients.

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Routine Use of the Confusion Assessment Method for the Intensive Care Unit

Abstract: Specificity of the CAM-ICU as performed in routine practice seems to be high but sensitivity is low. This hampers early detection of delirium by the CAM-ICU.

Cited by 246 publications

References 25 publications

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

Intensive care unit environment may affect the course of delirium

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