Delirium Screening and Pharmacotherapy in the ICU: The Patients Are Not the Only Ones Confused.

Background: Delirium is difficult to measure in the Intensive Care Unit (ICU). It is possible that by considering the rate of screening, incidence, and rate of treatment with antipsychotic medications (APMs) for suspected delirium, a clearer picture can emerge. Methods: A retrospective, observational study was conducted at two ICUs in Australia, between April and June of 2020. All adult ICU patients were screened; those who spoke English and did not have previous neurocognitive pathology or intracranial pathology were included in the analysis. Data were collected from the hospitals' electronic medical records. The primary outcome was incidence of delirium based on the use of the Confusion Assessment Method for ICU (CAM-ICU). Secondary outcomes included measures of screening for delirium, treatment of suspected delirium with APMs, and identifying clinical factors associated with both delirium and the use of APMs. Results: From 736 patients that were screened, 665 were included in the analysis. The incidence of delirium was 11.3% (75/665); on average, the Richmond Agitation and Sedation Scale (RASS) was performed every 2.9 h and CAM-ICU every 40 h. RASS was not performed in 8.4% (56/665) of patients and CAM-ICU was not performed in 40.6% (270/665) of patients. A total of 17% (113/665) of patients were prescribed an APM, with quetiapine being the most used. ICU length of stay (LOS), APACHE-III score, and the use of alpha-2 agonists were associated with the presence of delirium, while ICU LOS, the use of alpha-2 agonists, and the presence of delirium were associated with patients receiving APMs. Conclusions: The incidence of delirium was lower than previously reported, at 11.3%. The rate of screening for delirium was low, while the use of APMs for delirium was higher than the incidence of delirium. It is possible that the true incidence is higher than what was measured. Critical prospective assessment is required to optimize APM indications in the ICU.

ICU Patients' Perception of Sleep and Modifiable versus Non-Modifiable Factors That Affect It: A Prospective Observational Study.

Background: Good sleep quantity and quality are essential for patient recovery while in the intensive care unit (ICU). Patients commonly report poor sleep while in the ICU, and therefore, identifying the modifiable factors that patients perceive as impacting their sleep is important to improve sleep and recovery. This study also assessed night-time light and sound levels in an ICU in an effort to find modifiable factors. Methods: A total of 137 patients (51F) aged 58.1 ± 16.8 years completed a survey including questions about their sleep before and during their ICU stay, factors contributing to poor sleep in the ICU, and perceived factors that may have improved their sleep in the ICU. Night-time light and sound levels were measured in patient rooms and nurses' stations. Results: Patients reported poorer sleep quantity and quality while in the ICU compared to home. Among the most common reasons for poor sleep, easily modifiable factors included noise (50.4%) and lights (45.3%), potentially modifiable factors included pain (46.7%), and non-modifiable factors included IV lines (42.3%). Patients felt their sleep would have been improved with interventions such as dimming lights (58.4%) and closing doors/blinds at night (42.3%), as well as potentially implementable interventions such as a sleeping pill (51.8%). Overnight sound levels in bedrooms were above the recommended levels (40 dB) and light levels averaged over 100 lux. Conclusions: Sleep quality and quantity were both worse in ICU than at home. Modifiable factors such as sound and light are common factors that patients perceive impact their sleep in the ICU. Readily implementable sleep management strategies aimed at minimizing the impacts of sound and light levels in the ICU are ways to improve patients' sleep in the ICU.

ICU Length of Stay and Factors Associated with Longer Stay of Major Trauma Patients with Multiple Rib Fractures: A Retrospective Observational Study.

Background: Chest injury with multiple rib fractures is the most common injury among major trauma patients in New South Wales (23%) and is associated with a high rate of mortality and morbidity. The aim of this study was to determine the intensive care unit (ICU) length of stay (LOS) among major trauma patients with multiple rib fractures and to identify factors associated with a prolonged ICU LOS. Materials and Methods: Single-centre, retrospective observational cohort study of adult patients with 3 or more traumatic rib fractures, who were admitted to ICU between June 2014 and June 2019. A comparison was made between patients who stayed in ICU for less than 7 days and those that stay for 7 or more days. Results: Among 215 patients who were enrolled, 150 (69.7%) were male, the median Injury Severity Score (ISS) was 24 (interquartile range (IQR): 17-32). The median ICU LOS was 4 (IQR: 2-7) days and the average ICU LOS was 6.5 (SD 8.5; 95% CI 5.3-7.6) days. The median number of rib fractures was 6 (IQR: 5-9) and 76 (35.3%) patients had a flail chest. Patients who stayed longer than 7 days in ICU had higher ISS, higher APACHE-II score, greater number of rib fractures, higher rate of lung contusions, and required more respiratory support of any type. Conclusions: ISS, number of rib fractures, lung contusion, and flail chest were associated with prolonged ICU LOS in patients with traumatic multiple rib fractures.

Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial.

PURPOSE: Delirium is common in the critically ill, highly distressing to patients and families and associated with increased morbidity and mortality. Results of studies on preventative use of melatonin in various patient groups have produced mixed results. The aim of this study was to determine whether administration of melatonin decreases the prevalence of delirium in critically ill patients. METHODS: Multicentre, randomized, placebo-controlled, double-blind trial across 12 Australian ICUs recruiting patients from July 2016 to September 2019. Patients of at least 18 years requiring ICU admission with an expected length of stay (LOS) greater than 72 h; enrolled within 48 h of ICU admission. Indistinguishable liquid melatonin (4 mg; n = 419) or placebo (n = 422) was administered enterally at 21:00 h for 14 consecutive nights or until ICU discharge. The primary outcome was the proportion of delirium-free assessments, as a marker of delirium prevalence, within 14 days or before ICU discharge. Delirium was assessed twice daily using the Confusion Assessment Method for ICU (CAM-ICU) score. Secondary outcomes included sleep quality and quantity, hospital and ICU LOS, and hospital and 90-day mortality. RESULTS: A total of 847 patients were randomized into the study with 841 included in data analysis. Baseline characteristics of the participants were similar. There was no significant difference in the average proportion of delirium-free assessments per patient between the melatonin and placebo groups (79.2 vs 80% respectively, p = 0.547). There was no significant difference in any secondary outcomes including ICU LOS (median: 5 vs 5 days, p = 0.135), hospital LOS (median: 14 vs 12 days, p = 0816), mortality at any time point including at 90 days (15.5 vs 15.6% p = 0.948), nor in the quantity or quality of sleep. There were no serious adverse events reported in either group. CONCLUSION: Enteral melatonin initiated within 48 h of ICU admission did not reduce the prevalence of delirium compared to placebo. These findings do not support the routine early use of melatonin in the critically ill.

The Effects of Introducing a Mobile App-Based Procedural Logbook on Trainee Compliance to a Central Venous Catheter Insertion Accreditation Program: Before-and-After Study.

BACKGROUND: To reduce complications associated with central venous catheter (CVC) insertions, local accreditation programs using a supervised procedural logbook are essential. To increase compliance with such a logbook, a mobile app could provide the ideal platform for training doctors in an adult intensive care unit (ICU). OBJECTIVE: The aim of this paper was to compare trainee compliance with the completion of a logbook as part of a CVC insertion accreditation program, before and after the introduction of an app-based logbook. METHODS: This is a retrospective observational study of logbook data, before and after the introduction of a purpose-built, app-based, electronic logbook to complement an existing paper-based logbook. Carried out over a 2-year period in the adult ICU of the John Hunter Hospital, Newcastle, NSW, Australia, the participants were ICU trainee medical officers completing a CVC insertion accreditation program. The primary outcome was the proportion of all CVC insertions documented in the patients' electronic medical records appearing as logbook entries. To assess logbook entry quality, we measured and compared the proportion of logbook entries that were approved by a supervisor and contained a supervisor's signature for the before and after periods. We also analyzed trainee participation before and after the intervention by comparing the total number of active logbook users, and the proportion of first-time users who logged 3 or more CVC insertions. RESULTS: Of the 2987 CVC insertions documented in the electronic medical records between April 7, 2019, and April 6, 2021, 2161 (72%) were included and separated into cohorts before and after the app's introduction. Following the introduction of the app-based logbook, the percentage of CVC insertions appearing as logbook entries increased from 3.6% (38/1059) to 20.5% (226/1102; P<.001). There was no difference in the proportion of supervisor-approved entries containing a supervisor's signature before and after the introduction of the app, with 76.3% (29/38) and 83.2% (188/226), respectively (P=.31). After the introduction of the app, there was an increase in the percentage of active logbook users from 15.3% (13/85) to 62.8% (54/86; P<.001). Adherence to one's logbook was similar in both groups with 60% (6/10) of first-time users in the before group and 79.5% (31/39) in the after group going on to log at least 3 or more CVCs during their time working in ICU. CONCLUSIONS: The addition of an electronic app-based logbook to a preexisting paper-based logbook was associated with a higher rate of logbook compliance in trainee doctors undertaking an accreditation program for CVC insertion in an adult ICU. There was a large increase in logbook use observed without a reduction in the quality of logbook entries. The overall trainee participation also improved with an observed increase in active logbook users and no reduction in the average number of entries per user following the introduction of the app. Further studies on app-based logbooks for ICU procedural accreditation programs are warranted.

Statistical analysis plan for the Prophylactic Melatonin for Delirium in Intensive Care (ProMEDIC): a randomised controlled trial.

RATIONALE: Delirium is defined as acute organic brain dysfunction characterised by inattention and disturbance of cognition. It is common in the intensive care unit and is associated with poorer outcomes. Good quality sleep is important in the prevention and management of delirium. Melatonin is a natural hormone secreted by the pineal gland which helps in the regulation of the sleep-wake cycle. It is possible that melatonin supplementation in intensive care improves sleep and prevents delirium. METHODS AND DESIGN: The 'Prophylactic Melatonin for Delirium in Intensive Care' study is a multi-centre, randomised, double-blinded, placebo-controlled trial. The primary objective of this study is to determine whether melatonin given prophylactically decreases delirium in critically ill patients. A total of 850 ICU patients have been randomised (1:1) to receive either melatonin or a placebo. Participants were monitored twice daily for symptoms of delirium. RESULTS: This paper and the attached additional files describe the statistical analysis plan (SAP) for the trial. The SAP has been developed and submitted for publication before the database has been locked and before the treatment allocation has been unblinded. The SAP contains details of analyses to be undertaken, which will be reported in the primary and secondary publications. DISCUSSION: The SAP details the analyses that will be done to avoid bias coming from knowledge of the results in advance. This trial will determine whether prophylactic melatonin administered to intensive care unit patients helps decrease the rate and the severity of delirium. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry (ANZCTR) ACTRN1261600043647 , registration date: 06 April 2016. WHO Trial Number - U1111-1175-1814.

Respiratory Support during Bronchiolitis Due to One Virus versus More Than One Virus: An Observational Study.

Bronchiolitis is common during infancy and frequently leads to pediatric intensive care unit (PICU) admission. This study aimed to determine if there is a difference in the duration of respiratory support when bronchiolitis is due to one virus or more than one virus. This is a retrospective, observational study of cases admitted to PICU with confirmed bronchiolitis. There were 306 cases analyzed, 70% (215/306) were infected by a single virus and 30% (91/306) were infected with more than one virus. Both groups had similar duration of respiratory support and PICU length of stay (LOS). Hospital LOS was longer for the group with more than one virus.

Medical Emergency Team Event Characteristics from an Australian Pediatric Hospital: A Single-Center, Retrospective Study.

OBJECTIVES: To describe the characteristics of medical emergency team (MET) events at an Australian pediatric, tertiary-care center in a way that would allow for comparison with other MET systems. METHODS: A retrospective, single-center, observational study. Consecutive MET events that occurred between January 2013 and July 2014 at Princess Margaret Hospital for Children in Perth, Western Australia, were included. RESULTS: There were 46 445 hospital admissions during the study period and 197 MET events in children. This gives a rate of 4.2 MET events per 1000 admissions. Out of 197 pediatric MET events analyzed, there were 2 deaths (1.0%) that occurred during the MET events. All 197 patients were actively treated, with none receiving "do not attempt resuscitation" orders. Of pediatric MET events, 24% (48 of 197) were admitted to the PICU, and 75% (149 of 197) stayed in the ward where the call was made. CONCLUSIONS: In this tertiary-care, pediatric hospital in Australia, the MET event rate and the rate of admission to the PICU because of MET events are lower than those reported for US pediatric hospitals. Despite these differences, Australian data suggest that outcomes are similar to US pediatric hospitals.

Prophylactic Melatonin for Delirium in Intensive Care (Pro-MEDIC): study protocol for a randomised controlled trial.

BACKGROUND: Delirium is an acute state of brain dysfunction characterised by fluctuating inattention and cognitive disturbances, usually due to illness. It occurs commonly in the intensive care unit (ICU), and it is associated with greater morbidity and mortality. It is likely that disturbances of sleep and of the day-night cycle play a significant role. Melatonin is a naturally occurring, safe and cheap hormone that can be administered to improve sleep. The main aim of this trial will be to determine whether prophylactic melatonin administered to critically ill adults, when compared with placebo, decreases the rate of delirium. METHODS: This trial will be a multi-centre, randomised, placebo-controlled study conducted in closed ICUs in Australia. Our aim is to enrol 850 adult patients with an expected ICU length of stay (LOS) of 72 h or more. Eligible patients for whom there is consent will be randomised to receive melatonin 4 mg enterally or placebo in a 1:1 ratio according to a computer-generated randomisation list, stratified by site. The study drug will be indistinguishable from placebo. Patients, doctors, nurses, investigators and statisticians will be blinded. Melatonin or placebo will be administered once per day at 21:00 until ICU discharge or 14 days after enrolment, whichever occurs first. Trained staff will assess patients twice daily to determine the presence or absence of delirium using the Confusion Assessment Method for the ICU score. Data will also be collected on demographics, the overall prevalence of delirium, duration and severity of delirium, sleep quality, participation in physiotherapy sessions, ICU and hospital LOS, morbidity and mortality, and healthcare costs. A subgroup of 100 patients will undergo polysomnographic testing to further evaluate the quality of sleep. DISCUSSION: Delirium is a significant issue in ICU because of its frequency and associated poorer outcomes. This trial will be the largest evaluation of melatonin as a prophylactic agent to prevent delirium in the critically ill population. This study will also provide one of the largest series of polysomnographic testing done in ICU. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ANZCTR) number: ACTRN12616000436471 . Registered on 20 December 2015.