Delirium Clinical Trial
Official title:
A Multidisciplinary Delirium Prevention Strategy Involving Psychiatry in the Intensive Care Unit (ICU): Effects on Delirium Incidence and Outcomes
Delirium affects up to 80% of intensive care unit (ICU) patients and is associated with longer hospital stays, increased morbidity and mortality, and increased costs. There is no FDA-approved treatment for delirium; the most effective strategy is prevention by nonpharmacological methods. The investigators propose to study a comprehensive delirium prevention bundle that has been effective against delirium in preliminary studies in elderly in-hospital patients and elderly ICU patients. This delirium prevention bundle includes the novel addition of psychiatrists to daily ICU rounds, as these professionals are specially trained to screen for latent mental illness and provide treatment for these illnesses. The effects of daily psychiatric evaluation of ICU patients has never been systematically studied, as ICU professionals are well-equipped to manage ICU delirium. Psychiatric consultation is reserved for severe and/or refractory cases of delirium. The investigators hypothesize that a multidisciplinary rounding approach including psychiatry within the ICU team will help diagnose psychiatric components that may contribute to delirium at an earlier time point, and thus can reduce the incidence and duration of delirium. The investigators also hypothesize that the proposed multidisciplinary approach will shorten hospital and ICU lengths of stay, duration of mechanical ventilation, and decrease in-hospital mortality.
This is a prospective, single institution, controlled pilot study of adult patients admitted
to the surgical ICU. A sample size of 104 (52 per group) is targeted. Patients in the control
group will undergo usual care which includes ABCDEF bundle (Appendix 1) use, including daily
delirium screening using the CAM-ICU score (Appendix 2), but will not have routine
psychiatric involvement. Patients in the intervention group will also have ABCDEF bundle
performed, and additionally have psychiatry routinely participating in ICU rounds. A member
of the psychiatry team (attending, resident, or fellow) will round with the surgical ICU team
in the surgical ICU daily. On a daily basis, the ICU attending will review the list of the
ICU patients with the psychiatry team to determine if there are any changes to the patient's
management required.
Inclusion criteria are: 1. any patient >18 years of age admitted to the surgical ICU for >48
hours; 2. Patients admitted to the ICU <24 hours who have been in the hospital >48 hours; 3.
Patients who return to the ICU after being discharged from the ICU to the floor due a
complication or need for higher acuity care. Exclusion criteria are: 1. Patients in whom
CAM-ICU cannot be performed (severe dementia, stroke or other neurological condition,
encephalopathy, mental retardation, severe psychiatric disorder, vegetative state, severe
traumatic brain injury, deaf/blind, etc.); 2. Vulnerable patient populations (i.e. transplant
recipients); 3. Patients who don't speak or understand English; 4. Current alcohol or
substance abuse. Patients will be screened for eligibility on rounds daily. Study personnel
will obtain informed written consent from patients or their families.
A psychiatry attending, psychiatry resident, or psychiatry nurse practitioner will round with
the surgical ICU team on 7W daily until the target subject enrollment # of 52 is achieved. On
a daily basis, the ICU attending will review the list of the ICU patients with the psychiatry
team to determine if there are any changes to the patient's management required. The ABCDEF
bundle will be implemented on daily rounds, which includes daily screening for delirium using
the CAM-ICU scale.
Data which will be collected includes: age, gender, body mass index, history or alcohol or
substance abuse, admitting diagnosis, dementia, comorbid conditions, admitting SOFA score,
deliriogenic medications used during study enrollment, the interventions/medications used to
treat delirium as designated by psychiatry (in intervention group) and the ICU team (control
group), and the number of days from admission to study enrollment. Data on the incidence of
ICU delirium, duration of delirium/mechanical ventilation, in-house mortality, ICU and total
hospital length of stay will also be collected.
Descriptive statistics, including Student's t-test or Mann-Whitney U-test, for continuous
variables and χ2 or Fisher's exact test, for categorical variables, will be used to summarize
the data and compare characteristics between the 2 groups. The incidence of delirium will be
compared using χ2 test and multivariable logistic regression. Differences in the duration of
delirium and MV between the intervention and control groups will be analyzed by analysis of
variance (ANOVA). The length of stay will be compared by truncated negative binomial
regression, while mortality rates will be compared via logistic regression. A sensitivity
analysis will be performed in order to assess the possible confounding effect of the
non-randomized nature of our study design. A propensity score model for receipt of standard
care vs. psychiatric involvement will be performed in order to approximate a balanced
covariate distribution between the 2 groups as that would be expected by randomization. The
investigators will then use the propensity score for each subject to perform an inverse
probability weighted comparison of the groups on our trial outcomes.
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