Theodore Speroff

Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (cam-icu)

ObjectiveTo develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation. DesignProspective cohort study. SettingThe adult medical and coronary intensive care units of a tertiary care, university-based medical center. PatientsThirty-eight patients admitted to the intensive care units. Measurements and Main Results We designed and tested a modified version of the Confusion Assessment Method for use in intensive care unit patients and called it the CAM-ICU. Daily ratings from intensive care unit admission to hospital discharge by two study nurses and an intensivist who used the CAM-ICU were compared against the reference standard, a delirium expert who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). A total of 293 daily, paired evaluations were completed, with reference standard diagnoses of delirium in 42% and coma in 27% of all observations. To include only interactive patient evaluations and avoid repeat-observer bias for patients studied on multiple days, we used only the first-alert or lethargic comparison evaluation in each patient. Thirty-three of 38 patients (87%) developed delirium during their intensive care unit stay, mean duration of 4.2 ± 1.7 days. Excluding evaluations of comatose patients because of lack of characteristic delirium features, the two critical care study nurses and intensivist demonstrated high interrater reliability for their CAM-ICU ratings with kappa statistics of 0.84, 0.79, and 0.95, respectively (p < .001). The two nurses’ and intensivist’s sensitivities when using the CAM-ICU compared with the reference standard were 95%, 96%, and 100%, respectively, whereas their specificities were 93%, 93%, and 89%, respectively. ConclusionsThe CAM-ICU demonstrated excellent reliability and validity when used by nurses and physicians to identify delirium in intensive care unit patients. The CAM-ICU may be a useful instrument for both clinical and research purposes to monitor delirium in this challenging patient population.

Costs associated with delirium in mechanically ventilated patients.

ObjectiveTo determine the costs associated with delirium in mechanically ventilated medical intensive care unit patients. DesignProspective cohort study. SettingA tertiary care academic hospital. PatientsPatients were 275 consecutive mechanically ventilated medical intensive care unit patients. InterventionsWe prospectively examined patients for delirium using the Confusion Assessment Method for the Intensive Care Unit. Measurements and Main ResultsDelirium was categorized as “ever vs. never” and by a cumulative delirium severity index. Costs were determined from individual ledger-level patient charges using cost-center-specific cost-to-charge ratios and were reported in year 2001 U.S. dollars. Fifty-one of 275 patients (18.5%) had persistent coma and died in the hospital and were excluded from further analysis. Of the remaining 224 patients, delirium developed in 183 (81.7%) and lasted a median of 2.1 (interquartile range, 1–3) days. Baseline demographics were similar between those with and without delirium. Intensive care unit costs (median, interquartile range) were significantly higher for those with at least one episode of delirium (

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Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals.

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Automated identification of postoperative complications within an electronic medical record using natural language processing.

35,521) vs. those with no delirium (

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A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement.

8,837–

Health-related quality of life after different types of solid organ transplantation.

21,471, p < .001). Total hospital costs were also higher in those who developed delirium (

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41,836,

The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description

22,782–