Lillie M. Shortridge-Baggett

Risk factors for delirium in intensive care patients: a prospective cohort study

IntroductionDelirium is a common complication in the intensive care unit. The attention of researchers has shifted from the treatment to the prevention of the syndrome necessitating the study of associated risk factors.MethodsIn a multicenter study at one university hospital, two community hospitals and one private hospital, all consecutive newly admitted adult patients were screened and included when reaching a Glasgow Coma Scale greater than 10. Nurse researchers assessed the patients for delirium using the NEECHAM Confusion Scale. Risk factors covered four domains: patient characteristics, chronic pathology, acute illness and environmental factors. Odds ratios were calculated using univariate binary logistic regression.ResultsA total population of 523 patients was screened for delirium. The studied factors showed some variability according to the participating hospitals. The overall delirium incidence was 30%. Age was not a significant risk factor. Intensive smoking (OR 2.04), daily use of more than three units of alcohol (OR 3.23), and living alone at home (OR 1.94), however, contributed to the development of delirium. In the domain of chronic pathology a pre-existing cognitive impairment was an important risk factor (OR 2.41). In the domain of factors related to acute illness the use of drains, tubes and catheters, acute illness scores, the use of psychoactive medication, a preceding period of sedation, coma or mechanical ventilation showed significant risk with odds ratios ranging from 1.04 to 13.66. Environmental risk factors were isolation (OR 2.89), the absence of visit (OR 3.73), the absence of visible daylight (OR 2.39), a transfer from another ward (OR 1.98), and the use of physical restraints (OR 33.84).ConclusionsThis multicenter study indicated risk factors for delirium in the intensive care unit related to patient characteristics, chronic pathology, acute illness, and the environment. Particularly among those related to the acute illness and the environment, several factors are suitable for preventive action.

The Measurement of Delirium: Review of Scales

This review describes the characteristics and evaluates the psychometric qualities (process of testing and the results) of thirteen delirium instruments. Delirium instruments differ in goal (diagnosis, screening symptoms severity), type of data on which the rating is based (observation, interview or test of patients), the rater qualities required, the number of items and the rating time needed. Most instruments are based on the Diagnostic Statistical Manual criteria and measure signs and symptoms as described by these criteria. Reliability of delirium instruments shows good to excellent results. Validity of the delirium instruments is overall fair to good. Differences exist, however, in the degree to which reliability and validity were tested and the quality of the testing procedures. Most instruments are not further developed and tested after the initial study. Conclusion of this review is that most delirium instruments show promising results but need further testing. Testing is needed in different samples and on a broader range of aspects with regard to reliability and validity. Much emphasis should be given to the procedures used in future studies. Ease of use is an aspect of testing that is so far not taken into account, however, is important for use of instruments in clinical practice. A minority of instruments can be seen as “ready to use” instruments meaning well tested in more than one sample with good results. For screening high-risk, elderly hospitalized patients, the NEECHAM Confusion Scale and the Delirium Observation Screening Scale are recommended. The Confusion Assessment Method is the best diagnostic tool and the Delirium Rating Scale shows best results in screening symptom severity. For ICU patients the CAM-ICU is recommended. The MDAS is well tested in cancer patients. Nurses, however, have not yet tested the DRS and MDAS in practice.

A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients

BackgroundSeveral reports indicate a high incidence of intensive care delirium. To develop strategies to prevent this complication, validated instruments are needed. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is widely used. A binary result diagnoses delirium. The Neelon and Champagne (NEECHAM) Confusion Scale recently has been validated for use in the ICU and has a numeric assessment. This scale allows the patients to be classified in four categories: non-delirious, at risk, confused, and delirious. In this study, we investigated the results of the NEECHAM scale in comparison with the CAM-ICU.MethodsA consecutive sample of 172 non-intubated patients in a mixed ICU was assessed after a stay in the ICU for at least 24 hours. All adult patients with a Glasgow Coma Scale score of greater than 9 were included. A nurse researcher simultaneously assessed both scales once daily in the morning. A total of 599 paired observations were made.ResultsThe CAM-ICU showed a 19.8% incidence of delirium. The NEECHAM scale detected incidence rates of 20.3% for delirious, 24.4% for confused, 29.7% for at risk, and 25.6% for normal patients. The majority of the positive CAM-ICU patients were detected by the NEECHAM scale. The sensitivity of the NEECHAM scale was 87% and the specificity was 95%. The positive predictive value and the negative predictive value were 79% and 97%, respectively. The diagnostic capability in cardiac surgery patients proved to be lower than in other patients.ConclusionIn non-intubated patients, the NEECHAM scale identified most cases of delirium which were detected by the CAM-ICU. Additional confused patients were identified in the categorical approach of the scale. The NEECHAM scale proved to be a valuable screening tool compared with the CAM-ICU in the early detection of intensive care delirium by nurses.

Long term outcome after delirium in the intensive care unit

AIMS AND OBJECTIVES This research studied the long term outcome of intensive care delirium defined as mortality and quality of life at three and six months after discharge of the intensive care unit. BACKGROUND Delirium in the intensive care unit is known to result in worse outcomes. Cognitive impairment, a longer stay in the hospital or in the intensive care unit and a raised mortality have been reported. DESIGN A prospective cohort study. METHODS A population of 105 consecutive patients was included during the stay at the intensive care unit in July-August 2006. The population was assessed once a day for delirium using the NEECHAM Confusion Scale and the CAM-ICU. Patients were visited at home by a nurse researcher to assess the quality of life using the Medical Outcomes Study Short-Form General Health Survey at three and six months after discharge of the intensive care unit. Delirious and non delirious patients were compared for mortality and quality of life. RESULTS Compared to the non delirious patients, more delirious patients died. The total study population discharged from the intensive care unit, scored lower for quality of life in all domains compared to the reference population. The domains showed lower results for the delirious patients compared to the non delirious patients. CONCLUSIONS Mortality was higher in delirious patients. All patients showed lower values for the quality of life at three months. The delirious patients showed lower results than the non delirious patients. RELEVANCE TO CLINICAL PRACTICE Nurses are the first caregivers to observe patients. The fluctuating delirious process is often not noticed. Long term effects are not visible to the interdisciplinary team in the hospital. This paper would like to raise the awareness of professionals for long term outcomes for patients having experienced delirium in the intensive care unit.

Validity of the malnutrition screening tool for older adults at high risk of hospital readmission.

Malnutrition is a serious problem in older adults, particularly for those at risk of hospital readmission. The essential step in managing malnutrition is early identification using a valid nutrition screening tool. The purpose of this study was to validate the Malnutrition Screening Tool (MST) in older adults at high risk of hospital readmission. Two RNs administered the MST to identify malnutrition risk and compared it with the comprehensive Subjective Global Assessment (SGA) to assess nutritional status for patients 65 and older who had at least one risk factor for hospital readmission. The MST demonstrates substantial sensitivity, specificity, and agreement with the SGA. These findings indicate that nursing staff can use the MST as a valid tool for routine screening and rescreening to identify patients at risk of malnutrition. Use of the MST may prevent hospital-acquired malnutrition in acute hospitalized older adults at high risk of readmission.

Establishing content validity of a survey research instrument: the older patients in acute care survey-United States.

Geriatric nursing competency in the acute care setting is a social mandate for the 21st century. This article reports on the content validation of an Australian research instrument, the Older Patients in Acute Care Survey (OPACS) that examines the attitudes, the knowledge, and the practices of nurses working with acute care patients. The OPACS tool was developed primarily to assist nurse educators to assess attitudes, knowledge, and practices of nursing staff in caring for older patients in the acute care setting; to evaluate the implementation of institution-specific educational interventions; and to improve quality of care given to older patients. An overall content validity index (CVI) for the OPACS was calculated (CVI = .918), revealing high content validity. Opinions (CVI = .92) and practices (CVI = .97) subconstructs revealed high content validity as well. Therefore, results indicate that the OPACS has high content validity in the U.S. acute care setting and could assist nurse educators in establishing and enhancing nurse competency in the care for geriatric patients in the future.

Development and pilot test of a peer-support based Cardiac-Diabetes Self-Management Program: A study protocol

BackgroundPeople with cardiac disease and type 2 diabetes have higher hospital readmission rates (22%) compared to those without diabetes (6%). Self-management is an effective approach to achieve better health outcomes; however there is a lack of specifically designed programs for patients with these dual conditions. This project aims to extend the development and pilot test of a Cardiac-Diabetes Self-Management Program incorporating user-friendly technologies and the preparation of lay personnel to provide follow-up support.Methods/DesignA randomised controlled trial will be used to explore the feasibility and acceptability of the Cardiac-Diabetes Self-Management Program incorporating DVD case studies and trained peers to provide follow-up support by telephone and text-messaging. A total of 30 cardiac patients with type 2 diabetes will be randomised, either to the usual care group, or to the intervention group. Participants in the intervention group will received the Cardiac-Diabetes Self-Management Program in addition to their usual care. The intervention consists of three face-to-face sessions as well as telephone and text-messaging follow up. The face-to-face sessions will be provided by a trained Research Nurse, commencing in the Coronary Care Unit, and continuing after discharge by trained peers. Peers will follow up patients for up to one month after discharge using text messages and telephone support. Data collection will be conducted at baseline (Time 1) and at one month (Time 2). The primary outcomes include self-efficacy, self-care behaviour and knowledge, measured by well established reliable tools.DiscussionThis paper presents the study protocol of a randomised controlled trial to pilot evaluates a Cardiac-Diabetes Self-Management program, and the feasibility of incorporating peers in the follow-ups. Results of this study will provide directions for using such mode in delivering a self-management program for patients with both cardiac condition and diabetes. Furthermore, it will provide valuable information of refinement of the intervention program.Trial Registration NumberACTRN12611000086965

Psychometric Properties of the Chinese Version of the Perceived Therapeutic Efficacy Scale for Type 2 Diabetes

BACKGROUND/PURPOSE The purpose of this study was to test the psychometric properties of the Perceived Therapeutic Efficacy Scale (PTES) for type 2 diabetes with a Taiwanese sample. The mortality rate and health care cost of diabetes have dramatically increased in Taiwan, with many people with diabetes lacking the ability to control their disease appropriately. Addressing this problem requires enhancing self-efficacy towards self-management. Thus, there is a particular need for research into developing a diabetes-specific self-efficacy measurement instrument in Taiwan. METHODS This study was undertaken in two stages. Stage 1 consisted of forward and back translation of the PTES into Chinese and examination of content validity. Stage 2 established the validity and reliability of the Chinese version of PTES (C-PTES). A total of 230 people with type 2 diabetes aged 30 years or more from a diabetes outpatient clinic and taking oral medicine were recruited for psychometric testing. RESULTS Significant criterion-related validity was demonstrated between the C-PTES and the Summary of Diabetes Self-Care Activities scores (r=0.32; p<0.01). Convergent validity was confirmed as the C-PTES converged well with the General Self-Efficacy Scale in measuring self-efficacy (r=0.42; p<0.01); construct validity using factor analysis composed a single subscale. Internal consistency showed Cronbachs alpha was 0.95 and the test-retest reliability (Pearsons correction) was 0.79 (p<0.01) and a Bland-Altman plot showed that 97% of the subjects were within two standard deviations of the mean. CONCLUSION The results of reliability and validity strengthen confidence in using the C-PTES. The C-PTES requires future studies to confirm the psychometric properties.

Psychometric Properties of the Diabetes Management Self-Efficacy Scale in Korean Patients with Type 2 Diabetes

Objectives. The aims of this study were to perform a cultural translation of the DMSES and evaluate the psychometric properties of the translated scale in a Korean population with type 2 diabetics. Methods. This study was conducted in patients with diabetes recruited from university hospitals. The first stage of this study involved translating the DMSES into Korean using a forward- and backward-translation technique. The content validity was assessed by an expert group. In the second stage, the psychometric properties of the Korean version of the DMSES (K-DMSES) were evaluated. Results. The content validity of the K-DMSES was satisfactory. Sixteen-items clustered into four-subscales were extracted by exploratory factor analysis, and supported by confirmatory factor analysis. The construct validity of the K-DMSES with the Summary of Diabetes Self-Care Activities scale was satisfactory (r = 0.50, P<0.001). The Cronbachs alpha and intraclass correlation coefficient were 0.92 and 0.85 (P<0.001; 95% CI = 0.75–0.91), respectively, which indicate excellent internal consistency reliability and test-retest reliability. Conclusions. The K-DMSES is a brief instrument that has demonstrated good psychometric properties. It is therefore feasible to use in practice, and is ready for use in clinical research involving Korean patients with type 2 diabetes.

Screening for type 2 diabetes mellitus in patients with mental illness: application of a self-assessment score for diabetes mellitus risk.

Various methods for diabetes risk assessment have been developed over a decade, but they were not evaluated in patients with mental illness. This study examined the feasibility and utility of a self-assessment score for type 2 diabetes mellitus (DM2) risk among patients with mental illness. DM2 risk was assessed by patients with mental illness as well as clinicians via a self-assessment questionnaire, and the resulting scores were compared to each other as well as with actual diagnosis. Of 100 patients, nine patients were newly revealed to have DM2 and 34 patients have pre-DM2. Patients tended to underreport risk factors - obesity and physical activity - so perceived to have lower risk. Sensitivity of the self-assessment score was different when used by patients and by clinicians despite correlation coefficient of 0.82. Based on positive predictive values, we may expect one out of two patients who have high scores actually have DM2 or pre-DM2. Also, the discrimination capability was reasonably high (AUC=0.79), comparable to its performance observed in general populations. The self-assessment score has potential as a simple and adjunct tool to identify a high risk group of DM2/pre-DM2 among persons with mental illness, especially, when used together with health care providers.