Elizabeth Mauer

Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium*

Objectives: Delirium occurs frequently in adults and is an independent predictor of mortality. However, the epidemiology and outcomes of pediatric delirium are not well-characterized. The primary objectives of this study were to describe the frequency of delirium in critically ill children, its duration, associated risk factors, and effect on in-hospital outcomes, including mortality. Secondary objectives included determination of delirium subtype, and effect of delirium on duration of mechanical ventilation, and length of hospital stay. Design: Prospective, longitudinal cohort study. Setting: Urban academic tertiary care PICU. Patients: All consecutive admissions from September 2014 through August 2015. Interventions: Children were screened for delirium twice daily throughout their ICU stay. Measurements and Main Results: Of 1,547 consecutive patients, delirium was diagnosed in 267 (17%) and lasted a median of 2 days (interquartile range, 1–5). Seventy-eight percent of children with delirium developed it within the first 3 PICU days. Most cases of delirium were of the hypoactive (46%) and mixed (45%) subtypes; only 8% of delirium episodes were characterized as hyperactive delirium. In multivariable analysis, independent predictors of delirium included age less than or equal to 2 years old, developmental delay, severity of illness, prior coma, mechanical ventilation, and receipt of benzodiazepines and anticholinergics. PICU length of stay was increased in children with delirium (adjusted relative length of stay, 2.3; CI = 2.1–2.5; p < 0.001), as was duration of mechanical ventilation (median, 4 vs 1 d; p < 0.001). Delirium was a strong and independent predictor of mortality (adjusted odds ratio, 4.39; CI = 1.96–9.99; p < 0.001). Conclusions: Delirium occurs frequently in critically ill children and is independently associated with mortality. Some in-hospital risk factors for delirium development are modifiable. Interventional studies are needed to determine best practices to limit delirium exposure in at-risk children.

Low adoption of weight loss medications: A comparison of prescribing patterns of antiobesity pharmacotherapies and SGLT2s

To characterize the adoption of antiobesity pharmacotherapies, as compared with that of the newest antidiabetes pharmacotherapy, subtype 2 sodium‐glucose transport protein inhibitors (SGLT2s), among prescribers in the United States.

Cost Associated With Pediatric Delirium in the ICU.

Objective:To determine the costs associated with delirium in critically ill children. Design:Prospective observational study. Setting:An urban, academic, tertiary-care PICU in New York city. Patients:Four-hundred and sixty-four consecutive PICU admissions between September 2, 2014, and December 12, 2014. Interventions:None. Measurements and Main Results:All children were assessed for delirium daily throughout their PICU stay. Hospital costs were analyzed using cost-to-charge ratios, in 2014 dollars. Median total PICU costs were higher in patients with delirium than in patients who were never delirious (

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system

18,832 vs

Delirium in Children After Cardiac Bypass Surgery.

4,803; p < 0.0001). Costs increased incrementally with number of days spent delirious (median cost of

Carbohydrate-last meal pattern lowers postprandial glucose and insulin excursions in type 2 diabetes

9,173 for 1 d with delirium,

Role of Postoperative Radiotherapy in Pathologic Stage IIIA (N2) Non–Small Cell Lung Cancer in a Prospective Nationwide Oncology Outcomes Database

19,682 for 2–3 d with delirium, and

1: PROSPECTIVE ASSESSMENT OF PEDIATRIC DELIRIUM

75,833 for > 3 d with delirium; p < 0.0001); this remained highly significant even after adjusting for PICU length of stay (p < 0.0001). After controlling for age, gender, severity of illness, and PICU length of stay, delirium was associated with an 85% increase in PICU costs (p < 0.0001). Conclusions:Pediatric delirium is associated with a major increase in PICU costs. Further research directed at prevention and treatment of pediatric delirium is essential to improve outcomes in this population and could lead to substantial healthcare savings.

A Brain-Based Instruction Simulation Approach to Improve Code Team Response in an Internal Medicine Unit

BackgroundAlthough alert fatigue is blamed for high override rates in contemporary clinical decision support systems, the concept of alert fatigue is poorly defined. We tested hypotheses arising from two possible alert fatigue mechanisms: (A) cognitive overload associated with amount of work, complexity of work, and effort distinguishing informative from uninformative alerts, and (B) desensitization from repeated exposure to the same alert over time.MethodsRetrospective cohort study using electronic health record data (both drug alerts and clinical practice reminders) from January 2010 through June 2013 from 112 ambulatory primary care clinicians. The cognitive overload hypotheses were that alert acceptance would be lower with higher workload (number of encounters, number of patients), higher work complexity (patient comorbidity, alerts per encounter), and more alerts low in informational value (repeated alerts for the same patient in the same year). The desensitization hypothesis was that, for newly deployed alerts, acceptance rates would decline after an initial peak.ResultsOn average, one-quarter of drug alerts received by a primary care clinician, and one-third of clinical reminders, were repeats for the same patient within the same year. Alert acceptance was associated with work complexity and repeated alerts, but not with the amount of work. Likelihood of reminder acceptance dropped by 30% for each additional reminder received per encounter, and by 10% for each five percentage point increase in proportion of repeated reminders. The newly deployed reminders did not show a pattern of declining response rates over time, which would have been consistent with desensitization. Interestingly, nurse practitioners were 4 times as likely to accept drug alerts as physicians.ConclusionsClinicians became less likely to accept alerts as they received more of them, particularly more repeated alerts. There was no evidence of an effect of workload per se, or of desensitization over time for a newly deployed alert. Reducing within-patient repeats may be a promising target for reducing alert overrides and alert fatigue.

Scholarly Activity Training During Residency: Are We Hitting the Mark? A National Assessment of Pediatric Residents

Objectives: To describe the incidence of delirium in pediatric patients after cardiac bypass surgery and explore associated risk factors and effect of delirium on in-hospital outcomes. Design: Prospective observational single-center study. Setting: Fourteen-bed pediatric cardiothoracic ICU. Patients: One hundred ninety-four consecutive admissions following cardiac bypass surgery, 1 day to 21 years old. Interventions: Subjects were screened for delirium daily using the Cornell Assessment of Pediatric Delirium. Measurements and Main Results: Incidence of delirium in this sample was 49%. Delirium most often lasted 1–2 days and developed within the first 1–3 days after surgery. Age less than 2 years, developmental delay, higher Risk Adjustment for Congenital Heart Surgery 1 score, cyanotic disease, and albumin less than three were all independently associated with development of delirium in a multivariable model (all p < 0.03). Delirium was an independent predictor of prolonged ICU length of stay, with patients who were ever delirious having a 60% increase in ICU days compared with patients who were never delirious (p < 0.01). Conclusions: In our institution, delirium is a frequent problem in children after cardiac bypass surgery, with identifiable risk factors. Our study suggests that cardiac bypass surgery significantly increases children’s susceptibility to delirium. This highlights the need for heightened, targeted delirium screening in all pediatric cardiothoracic ICUs to potentially improve outcomes in this vulnerable patient population.