Slide 1Learning Objectives
bundle that was designed to decrease the
incidence and duration of delirium in
hospitalized critically ill patients.
use of a delirium prevention bundle in
hospitalized critical care patients.
assessing patients for delirium using the CAM-
ICU?
3. Does an intervention bundle prevent or reduce
delirium?
problematic to achieve?
contribute significantly to reduce or prevent
delirium?
Methods
• Design
– 23,430 observations (8,070 for
of observations.
Similar Units
January 2.836 2.707
February 2.894 2.496
March 2.673 3.095
April 3.690 3.783
May 3.271 2.718
June 2.700 3.932
July 2.661 3.657
Total 20.724 22.339
units
• Patients who have been
• Lateral transfers:
post surgery who had
Intensive Care Unit (CAM-ICU)2
1 Sessler, C.N., Gosnell, M.S., Grap, M.J., et al. (2002).
2 Ely, E.W., Inouye, S.K., Bernard, G.R., Gordon, S., Francis, J., May, L., Truman,
B., Speroff, T., Gautam, S.,Margolin, R., Hart, R.P., Dittus, R. (2001).
The Delirium Prevention Bundle
Prevent or Reduce duration
Female, n (%) 247 (48.5) 137 (50.9) 0.524
Race, n (%) 0.730
African-American 175 (35.4) 90 (34.8)
Asian 10 (2.0) 4 (1.5)
Hispanic 56 (11.3) 38 (14.7)
Other 10 (2.0) 6 (2.3)
Age Categories, n (%) 0.524
# Co morbidities n(%) 0.017
“0” delirium incidents > 1 Delirium Incident p
No. Days on Mech. Vent,
n (mean)95%CI
4.49
<0.0001
3.22
<0.0001
LOS in ICU >3 days, n (%) 134 (25.4) 162 (63.8) <0.001
No. Co Morbidities, n (%) <0.001
<3 232 (44.0) 68 (26.8)
3-5 214 (40.6) 109 (42.9)
>5 81 (15.4) 77 (30.3)
Female Gender n (%) 263 (50.0) 121 (48.0) 0.604
Age categories n (%) <0.001
n (%)
Days in Restraint >0,
Percent change in odds of delirium by day
# Subjects
(Observa-
tions)
(0.02)
+1.4
(0.02)
-13.7
(0.02)
-4.9
(0.47)
-11.0
Table 14. Results from Longitudinal Logistic Regression Analyses – of Mobility Elements
in Intervention Unit Only Percent change in odds of delirium by day
Variables Coding
Table 15. Results from Longitudinal Logistic Regression Analyses – of Out-of-Bed
Elements in Intervention Unit Only Percent change in odds of delirium by day
Variables Coding
w/feet planted
day) Code: (0,1) = (no,
yes) (-62.1, p=0.066)
Table 10. Results from Longitudinal Logistic Regression Analyses –Adjusted for Effects of Selected
Time-dependent Variables using only patients with GTE 2 days of non-missing delirium
Percent change in odds of delirium by day
Variables No.
LTD’s, adj. model
OR =4.61, p <0.001
Coded (0,1) = (<3, ≥3)
LTDs <3 442(1578) -1.0(0.81) +2.3(0.60) +3.3 0.58
LTDs ≥3 187(935) +2.3(0.26) -8.8(0.040) -10.9 0.018
Sedation Protocol, adj. model
OR = 1.81, p=0.34
Sed Prot = no 98(464) +6.1(0.024) +2.9(0.574) -3.0 0.59
Sed Prot = yes 22(29) +792(0.33) -37.5(0.42) -92.1 0.31
Sed Prot = NA 473(1961) +2.4(0.39) -1.6(0.69) -3.9 0.41
Total Complications, adj.
No. Comps = 0 453(1509) +6.7(0.004) +3.7(0.53) -2.8 0.64
No. Comps >0 317(996) +3.0(0.37) -3.1(0.21) -6.8 0.12
Table 10 continued
Hypoactive Symptoms, adj.
Any Hypoactive symptoms =
Any hypoactive symptoms =
Confusion, adj. model
Confusion = no 480(2128) +1.6(0.40) -7.5(0.018) -9.0 0.012
Confusion = yes 141(377) +6.1(0.20) +14.4(0.039) +7.8 0.35
Table 11. Results from Longitudinal Logistic Regression Analyses –of Selected Time-
dependent Variables in Intervention Unit Only, using only patients with GTE 2 days of non-
missing delirium
Variables No. Subjects
OR = 1.77, p = 0.19
Sleep elements, present?
Mobility elements, present?
OR = 0.15, p = 0.086
are restrained, or who have an ICU length of stay
>3 days are significantly more likely to develop
delirium.
• Delirium is more likely to occur in patients with more
invasive tubes, and in those in which significant
hypoxic events occur.
incidence of delirium in certain critically care
patients.
elements.
effect.
the CAM-ICU to assess patients for delirium.
• It is feasible to use a delirium prevention
bundle in the ICU setting.
• Hospitals should consider implementing a
core model of delirium prevention care that
combines evidence-based strategies with
routine ICU care.
needed to test the effectiveness of some
elements (sensory) of the delirium prevention
bundle.
delirium prevention bundle in a multi-site
study.
of a multidisciplinary consultation team in
treatment of delirium positive critically ill
patients.
Limitations
available for patients
early in the study
study proposal and researcher-generated data
collection tools, and supported and
encouraged nursing staff buy-in
• Jan Foster, PhD, RN
study proposal and staff training in the use of
the CAM-ICU
(2002). The Richmond Agitation-Sedation Scale:
Validity and reliability in adult intensive care unit
patients. American Journal of Respiratory Critical
Care Medicine, 166, 1338-1344.
S., Francis, J., May, L., Truman, B., Speroff, T.,
Gautam, S.,Margolin, R., Hart, R.P., Dittus, R.
(2001). Delirium in mechanically ventilated
patients: Validity and reliability of the confusion
assessment method for the intensive care unit
(CAM-ICU). Journal of the American Medical
Association, 286(21), 2703-2710.
Claudia DiSabatino Smith, PhD, RN, NE-BC St. Luke’s Hospital, Houston, Texas, USA
csmith1@sleh.com