Mortality Rates in a Diverse Cohort of Mechanically Ventilated Patients With Novel Coronavirus in the Urban Midwest.

OBJECTIVES: Differences in mortality rates previously reported in critically ill patients with coronavirus disease 2019 have increased the need for additional data on mortality and risk factors for death. We conducted this study to describe length of stay, mortality, and risk factors associated with in-hospital mortality in mechanically ventilated patients with coronavirus disease 2019. DESIGN: Observational study. SETTING: Two urban, academic referral hospitals in Indianapolis, Indiana. PATIENTS OR SUBJECTS: Participants were critically ill patients 18 years old and older, admitted with coronavirus disease 2019 between March 1, 2020, and April 27, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes included in-hospital mortality, duration of mechanical ventilation, and length of stay. A total of 242 patients were included with mean age of 59.6 years (sd, 15.5 yr), 41.7% female and 45% African American. Mortality in the overall cohort was 19.8% and 20.5% in the mechanically ventilated subset. Patients who died were older compared with those that survived (deceased: mean age, 72.8 yr [sd, 10.6 yr] vs patients discharged alive: 54.3 yr [sd, 14.8 yr]; p < 0.001 vs still hospitalized: 59.5 yr [sd, 14.4 yr]; p < 0.001) and had more comorbidities compared with those that survived (deceased: 2 [0.5-3] vs survived: 1 [interquartile range, 0-1]; p = 0.001 vs still hospitalized: 1 [interquartile range, 0-2]; p = 0.015). Older age and end-stage renal disease were associated with increased hazard of in-hospital mortality: age 65-74 years (hazard ratio, 3.1 yr; 95% CI, 1.2-7.9 yr), age 75+ (hazard ratio, 4.1 yr; 95% CI, 1.6-10.5 yr), and end-stage renal disease (hazard ratio, 5.9 yr; 95% CI, 1.3-26.9 yr). The overall median duration of mechanical ventilation was 9.3 days (interquartile range, 5.7-13.7 d), and median ICU length of stay in those that died was 8.7 days (interquartile range, 4.0-14.9 d), compared with 9.2 days (interquartile range, 4.0-14.0 d) in those discharged alive, and 12.7 days (interquartile range, 7.2-20.3 d) in those still remaining hospitalized.Conclusions:: We found mortality rates in mechanically ventilated patients with coronavirus disease 2019 to be lower than some previously reported with longer lengths of stay.

Warden Procedure in a 77-Year-Old Man.

Partial anomalous pulmonary venous return is a rare congenital heart defect characterized by 1 or more but not all of the pulmonary veins draining somewhere other than the left atrium, thereby creating a left-to-right shunt. Over time, right-sided volume overload may develop with its subsequent complications. We present a case of isolated partial anomalous pulmonary venous return in an older patient who underwent a Warden procedure at age 77 years, with rapid improvement in right ventricular size and function.

Pharmacological Management of Delirium in the Intensive Care Unit: A Randomized Pragmatic Clinical Trial.

BACKGROUND/OBJECTIVE: Delirium in the intensive care units (ICUs) is prevalent, with both delirium duration and delirium severity associated with adverse outcomes. We designed a pragmatic trial to test the efficacy of a pharmacological management of delirium (PMD) bundle in improving delirium/coma-free days and reducing delirium severity among ICU patients. DESIGN: A randomized pragmatic clinical trial. SETTING: Medical, surgical, and progressive ICUs of three tertiary care hospitals. PARTICIPANTS: A total of 351 critically ill patients. INTERVENTION: A multicomponent PMD bundle consisting of reducing the exposure to 20 definite anticholinergic medications and benzodiazepines and prescribing low-dose haloperidol. MEASUREMENTS: The primary outcomes were delirium/coma-free days, measured through the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU (CAM-ICU), and delirium severity, measured through Delirium Rating Scale-Revised-98 and the CAM-ICU-7. Secondary outcomes were in-hospital and posthospital discharge 30-day mortality, ICU and hospital lengths of stay, and delirium-related hospital complications. RESULTS: We randomized 351 critically ill delirious patients (mean age = 59.3 years [SD = 16.9 years]; 52% female, 42% African Americans) to receive the PMD bundle or usual care. There were no significant differences in median delirium/coma-free days at day 8 (PMD vs usual care = 4 [interquartile range {IQR} = 2-7] days vs 5 [IQR = 1-7] days; P = .888) or at day 30 (PMD vs usual care = 26 [IQR 19-29] days vs 26 [IQR, 14-29] days; P = .991). There were no significant differences for decrease in delirium severity at day 8, but at hospital discharge, the intervention group showed a greater reduction in delirium severity (mean decrease in CAM-ICU-7 score for PMD vs usual care = 3.2 [SD = 3.3] vs 2.5 [SD = 3.2]; P = .046). No differences were observed between groups for ICU and hospital lengths of stay, mortality, and delirium-related hospital complications. Similar results were observed when analyses were limited to patients 65 years or older and 75 years or older. CONCLUSION AND RELEVANCE: Implementing the PMD bundle in the ICU did not reduce delirium duration or severity among critically ill patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00842608. J Am Geriatr Soc 67:1057-1065, 2019.

Deprescribing in the Pharmacologic Management of Delirium: A Randomized Trial in the Intensive Care Unit.

OBJECTIVE: Benzodiazepines and anticholinergics are risk factors for delirium in the intensive care unit (ICU). We tested the impact of a deprescribing intervention on short-term delirium outcomes. DESIGN: Multisite randomized clinical trial. SETTING: ICUs of three large hospitals. PARTICIPANTS: Two hundred adults aged 18 years or older and admitted to an ICU with delirium, according to the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU (CAM-ICU). Participants had a contraindication to haloperidol (seizure disorder or prolonged QT interval) or preference against haloperidol as a treatment for delirium, and were excluded for serious mental illness, stroke, pregnancy, or alcohol withdrawal. Participants were randomized to a deprescribing intervention or usual care. The intervention included electronic alerts combined with pharmacist support to deprescribe anticholinergics and benzodiazepines. MEASUREMENTS: Primary outcomes were delirium duration measured by the CAM-ICU and severity measured by the Delirium Rating Scale Revised-98 (DRS-R-98) and the CAM-ICU-7; secondary outcomes included adverse events and mortality. RESULTS: Participants had a mean age of 61.8 (SD = 14.3) years, 59% were female, and 52% were African American, with no significant differences in baseline characteristics between groups. No differences between groups were identified in the number exposed to anticholinergics (P = .219) or benzodiazepines (P = .566), the median total anticholinergic score (P = .282), or the median total benzodiazepine dose in lorazepam equivalents (P = .501). Neither median delirium/coma-free days (P = .361) nor median change in delirium severity scores (P = .582 for DRS-R-98; P = .333 for CAM-ICU-7) were different between groups. No differences in adverse events or mortality were identified. CONCLUSIONS: When added to state-of-the-art clinical services, this deprescribing intervention had no impact on medication use in ICU participants. Given the age of the population, results of clinical outcomes may not be easily extrapolated to older adults. Nonetheless, improved approaches for deprescribing or preventing anticholinergics and benzodiazepines should be developed to determine the impact on delirium outcomes. J Am Geriatr Soc 67:695-702, 2019.

Long-Acting ß2-Agonists in Asthma: Enantioselective Safety Studies are Needed.

Long-acting ß2-agonists (LABAs) such as formoterol and salmeterol are used for prolonged bronchodilatation in asthma, usually in combination with inhaled corticosteroids (ICSs). Unexplained paradoxical asthma exacerbations and deaths have been associated with LABAs, particularly when used without ICS. LABAs clearly demonstrate effective bronchodilatation and steroid-sparing activity, but long-term treatment can lead to tolerance of their bronchodilator effects. There are also concerns with regard to the effects of LABAs on bronchial hyperresponsiveness (BHR), where long-term use is associated with increased BHR and loss of bronchoprotection. A complicating factor is that formoterol and salmeterol are both chiral compounds, usually administered as 50:50 racemic (rac-) mixtures of two enantiomers. The chiral nature of these compounds has been largely forgotten in the debate regarding LABA safety and effects on BHR, particularly that (S)-enantiomers of ß2-agonists may be deleterious to asthma control. LABAs display enantioselective pharmacokinetics and pharmacodynamics. Biological plausibility of the deleterious effects of ß2-agonists (S)-enantiomers is provided by in vitro and in vivo studies from the short-acting ß2-agonist (SABA) salbutamol. Supportive clinical findings include the fact that patients in emergency departments who demonstrate a blunted response to salbutamol are more likely to benefit from (R)-salbutamol than rac-salbutamol, and resistance to salbutamol appears to be a contributory mechanism in rapid asthma deaths. More effort should therefore be applied to investigating potential enantiospecific effects of LABAs on safety, specifically bronchoprotection. Safety studies directly assessing the effects of LABA (S)-enantiomers on BHR are long overdue.

Multicenter Validation of a Customizable Scoring Tool for Selection of Trainees for a Residency or Fellowship Program. The EAST-IST Study.

RATIONALE: Few data have been published regarding scoring tools for selection of postgraduate medical trainee candidates that have wide applicability. OBJECTIVES: The authors present a novel scoring tool developed to assist postgraduate programs in generating an institution-specific rank list derived from selected elements of the U.S. Electronic Residency Application System (ERAS) application. METHODS: The authors developed and validated an ERAS and interview day scoring tool at five pulmonary and critical care fellowship programs: the ERAS Application Scoring Tool-Interview Scoring Tool. This scoring tool was then tested for intrarater correlation versus subjective rankings of ERAS applications. The process for development of the tool was performed at four other institutions, and it was performed alongside and compared with the "traditional" ranking methods at the five programs and compared with the submitted National Residency Match Program rank list. RESULTS: The ERAS Application Scoring Tool correlated highly with subjective faculty rankings at the primary institution (average Spearman's r = 0.77). The ERAS Application Scoring Tool-Interview Scoring Tool method correlated well with traditional ranking methodology at all five institutions (Spearman's r = 0.54, 0.65, 0.72, 0.77, and 0.84). CONCLUSIONS: This study validates a process for selecting and weighting components of the ERAS application and interview day to create a customizable, institution-specific tool for ranking candidates to postgraduate medical education programs. This scoring system can be used in future studies to compare the outcomes of fellowship training.

The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU.

OBJECTIVES: Delirium severity is independently associated with longer hospital stays, nursing home placement, and death in patients outside the ICU. Delirium severity in the ICU is not routinely measured because the available instruments are difficult to complete in critically ill patients. We designed our study to assess the reliability and validity of a new ICU delirium severity tool, the Confusion Assessment Method for the ICU-7 delirium severity scale. DESIGN: Observational cohort study. SETTING: Medical, surgical, and progressive ICUs of three academic hospitals. PATIENTS: Five hundred eighteen adult (≥ 18 yr) patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients received the Confusion Assessment Method for the ICU, Richmond Agitation-Sedation Scale, and Delirium Rating Scale-Revised-98 assessments. A 7-point scale (0-7) was derived from responses to the Confusion Assessment Method for the ICU and Richmond Agitation-Sedation Scale items. Confusion Assessment Method for the ICU-7 showed high internal consistency (Cronbach's α = 0.85) and good correlation with Delirium Rating Scale-Revised-98 scores (correlation coefficient = 0.64). Known-groups validity was supported by the separation of mechanically ventilated and nonventilated assessments. Median Confusion Assessment Method for the ICU-7 scores demonstrated good predictive validity with higher odds (odds ratio = 1.47; 95% CI = 1.30-1.66) of in-hospital mortality and lower odds (odds ratio = 0.8; 95% CI = 0.72-0.9) of being discharged home after adjusting for age, race, gender, severity of illness, and chronic comorbidities. Higher Confusion Assessment Method for the ICU-7 scores were also associated with increased length of ICU stay (p = 0.001). CONCLUSIONS: Our results suggest that Confusion Assessment Method for the ICU-7 is a valid and reliable delirium severity measure among ICU patients. Further research comparing it to other delirium severity measures, its use in delirium efficacy trials, and real-life implementation is needed to determine its role in research and clinical practice.

Biomarkers of Human Cardiopulmonary Response After Short-Term Exposures to Medical Laser-Generated Particulate Matter From Simulated Procedures: A Pilot Study.

OBJECTIVE: We conducted an exposure chamber study in humans using a simulated clinical procedure lasing porcine tissue to demonstrate evidence of effects of exposure to laser-generated particulate matter (LGPM). METHODS: We measured pre- and post-exposure changes in exhaled nitric oxide (eNO), spirometry, heart rate variability (HRV), and blood markers of inflammation in five volunteers. RESULTS: Change in pre- and post-exposure measurements of eNO and spirometry was unremarkable. Neutrophil and lymphocyte counts increased and fibrinogen levels decreased in four of the five subjects. Measures of HRV showed decreases in the standard deviation of normal between beat intervals and sequential 5-minute intervals. CONCLUSION: These data represent the first evidence of human physiologic response to LGPM exposure. Further exploration of coagulation effects and HRV is warranted.

Relationship Between African-American Race and Delirium in the ICU.

OBJECTIVES: Delirium is a highly prevalent syndrome of acute brain dysfunction among critically ill patients that has been linked to multiple risk factors, such as age, preexisting cognitive impairment, and use of sedatives; but to date, the relationship between race and delirium is unclear. We conducted this study to identify whether African-American race is a risk factor for developing ICU delirium. DESIGN: A prospective cohort study. SETTING: Medical and surgical ICUs of a university-affiliated, safety net hospital in Indianapolis, IN. PATIENTS: A total of 2,087 consecutive admissions with 1,008 African Americans admitted to the ICU services from May 2009 to August 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Incident delirium was defined as first positive Confusion Assessment Method for the ICU result after an initial negative Confusion Assessment Method for the ICU; and prevalent delirium was defined as positive Confusion Assessment Method for the ICU on first Confusion Assessment Method for the ICU assessment. The overall incident delirium rate in African Americans was 8.7% compared with 10.4% in Caucasians (p = 0.26). The prevalent delirium rate was 14% in both African Americans and Caucasians (p = 0.95). Significant age and race interactions were detected for incident delirium (p = 0.02) but not for prevalent delirium (p = 0.3). The hazard ratio for incident delirium for African Americans in the 18-49 years age group compared with Caucasians of similar age was 0.4 (0.1-0.9). The hazard and odds ratios for incident and prevalent delirium in other groups were not different. CONCLUSIONS: African-American race does not confer any additional risk for developing incident or prevalent delirium in the ICU. Instead, younger African Americans tend to have lower rates of incident delirium compared with Caucasians of similar age.

Effectiveness of implementing a wake up and breathe program on sedation and delirium in the ICU.

OBJECTIVES: Mechanically ventilated critically ill patients receive significant amounts of sedatives and analgesics that increase their risk of developing coma and delirium. We evaluated the impact of a "Wake-up and Breathe Protocol" at our local ICU on sedation and delirium. DESIGN: A pre/post implementation study design. SETTING: A 22-bed mixed surgical and medical ICU. PATIENTS: Seven hundred two consecutive mechanically ventilated ICU patients from June 2010 to January 2013. INTERVENTIONS: Implementation of daily paired spontaneous awakening trials (daily sedation vacation plus spontaneous breathing trials) as a quality improvement project. MEASUREMENTS AND MAIN RESULTS: After implementation of our program, there was an increase in the mean Richmond Agitation Sedation Scale scores on weekdays of 0.88 (p < 0.0001) and an increase in the mean Richmond Agitation Sedation Scale scores on weekends of 1.21 (p < 0.0001). After adjusting for age, race, gender, severity of illness, primary diagnosis, and ICU, the incidence and prevalence of delirium did not change post implementation of the protocol (incidence: 23% pre vs 19.6% post; p = 0.40; prevalence: 66.7% pre vs 55.3% post; p = 0.06). The combined prevalence of delirium/coma decreased from 90.8% pre protocol implementation to 85% postimplementation (odds ratio, 0.505; 95% CI, 0.299-0.853; p = 0.01). CONCLUSIONS: Implementing a "Wake Up and Breathe Program" resulted in reduced sedation among critically ill mechanically ventilated patients but did not change the incidence or prevalence of delirium.

Race and documentation of cognitive impairment in hospitalized older adults.

OBJECTIVES: To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium. DESIGN: Secondary data analysis. SETTING: An urban, public hospital and healthcare system. PARTICIPANTS: Hospitalized older adults aged 65 and older admitted to general inpatient medical services evaluated for cognitive impairment (n = 851) and evaluated for delirium (n = 424). MEASUREMENTS: Cognitive impairment and delirium were measured in each participant using the Short Portable Mental Status Questionnaire (SPMSQ) and the Confusion Assessment Method (CAM), respectively, as the reference identification method. Clinical documentation of cognitive impairment and delirium was defined according to the presence of International Classification of Diseases, Ninth Revision (ICD-9), codes from within 1 year before hospitalization through discharge for cognitive impairment or from hospital admission through discharge for delirium. RESULTS: Two hundred ninety-four participants (34%) had cognitive impairment based on SPMSQ performance, and 163 (38%) had delirium based on CAM results. One hundred seventy-one (20%) of those with cognitive impairment had an ICD-9 code for cognitive impairment, whereas 92 (22%) of those with delirium had an ICD-9 code for delirium. After considering age, sex, education, socioeconomic status, chronic comorbidity, and severity of acute illness, of those who screened positive on the SPMSQ, African Americans had a higher adjusted odds ratio (AOR) than non-African Americans for clinical documentation of cognitive impairment (AOR = 1.66, 95% confidence interval (CI) = 0.95-2.89), and of those who screened negative on the SPMSQ, African Americans had higher odds of clinical documentation of cognitive impairment (AOR = 2.10, 95% CI = 1.17-3.78) than non-African Americans. There were no differences in clinical documentation rates of delirium between African Americans and non-African Americans. CONCLUSION: Racial differences in coding for cognitive impairment may exist, resulting in higher documentation of cognitive impairment in African Americans screening positive or negative for cognitive impairment.

S100 calcium binding protein B as a biomarker of delirium duration in the intensive care unit - an exploratory analysis.

BACKGROUND: Currently, there are no valid and reliable biomarkers to identify delirious patients predisposed to longer delirium duration. We investigated the hypothesis that elevated S100 calcium binding protein B (S100ß) levels will be associated with longer delirium duration in critically ill patients. METHODS: A prospective observational cohort study was performed in the medical, surgical, and progressive intensive care units (ICUs) of a tertiary care, university affiliated, and urban hospital. Sixty-three delirious patients were selected for the analysis, with two samples of S100ß collected on days 1 and 8 of enrollment. The main outcome measure was delirium duration. Using the cutoff of <0.1 ng/mL and ≥0.1 ng/mL as normal and abnormal levels of S100ß, respectively, on day 1 and day 8, four exposure groups were created: Group A, normal S100ß levels on day 1 and day 8; Group B, normal S100ß level on day 1 and abnormal S100ß level on day 8; Group C, abnormal S100ß level on day 1 and normal on day 8; and Group D, abnormal S100ß levels on both day 1 and day 8. RESULTS: Patients with abnormal levels of S100ß showed a trend towards higher delirium duration (P=0.076); Group B (standard deviation) (7.0 [3.2] days), Group C (5.5 [6.3] days), and Group D (5.3 [6.0] days), compared to patients in Group A (3.5 [5.4] days). CONCLUSION: This preliminary investigation identified a potentially novel role for S100ß as a biomarker for delirium duration in critically ill patients. This finding may have important implications for refining future delirium management strategies in ICU patients.

Interventions to improve the physical function of ICU survivors: a systematic review.

BACKGROUND: ICU admissions are ever increasing across the United States. Following critical illness, physical functioning (PF) may be impaired for up to 5 years. We performed a systematic review of randomized controlled trials evaluating the efficacy of interventions targeting PF among ICU survivors. The objective of this study was to identify effective interventions that improve long-term PF in ICU survivors. METHODS: MEDLINE, Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence-Based Database (PEDro) were searched between 1990 and 2012. Two reviewers independently evaluated studies for eligibility, critically appraised the included studies, and extracted data into standardized evidence tables. RESULTS: Fourteen studies met the inclusion criteria. Interventions included exercise/physical therapy (PT), parenteral nutrition, nurse-led follow-up, spontaneous awakening trials, absence of sedation during mechanical ventilation, and early tracheotomy. Nine studies failed to demonstrate efficacy on PF of the ICU survivors. However, early physical exercise and PT-based interventions had a positive effect on long-term PF. CONCLUSIONS: The only effective intervention to improve long-term PF in critically ill patients is exercise/PT; its benefit may be greater if started earlier. Further research in this area comparing different interventions and timing is needed.

Clinical decision support system and incidence of delirium in cognitively impaired older adults transferred to intensive care.

BACKGROUND: Elderly patients with cognitive impairment are at increased risk of developing delirium, especially in the intensive care unit. OBJECTIVE: To evaluate the efficacy of a computer-based clinical decision support system that recommends consulting a geriatrician and discontinuing use of urinary catheters, physical restraints, and unnecessary anticholinergic drugs in reducing the incidence of delirium. METHODS: Data for a subgroup of patients enrolled in a large clinical trial who were transferred to the intensive care units of a tertiary-care, urban public hospital in Indianapolis were analyzed. Data were collected on frequency of orders for consultation with a geriatrician; discontinuation of urinary catheterization, physical restraints, or anticholinergic drugs; and the incidence of delirium. RESULTS: The sample consisted of 60 adults with cognitive impairment. Mean age was 74.6 years; 45% were African American, and 52% were women. No differences were detected between the intervention and the control groups in orders for consultation with a geriatrician (33% vs 40%; P = .79) or for discontinuation of urinary catheters (72% vs 76%; P = .99), physical restraints (12% vs 0%; P=.47), or anticholinergic drugs (67% vs 36%; P=.37). The 2 groups did not differ in the incidence of delirium (27% vs 29%; P = .85). CONCLUSION: Use of a computer-based clinical decision support system may not be effective in changing prescribing patterns or in decreasing the incidence of delirium.

Comparison of pulmonary complications after nonmyeloablative and conventional allogeneic hematopoietic cell transplant.

Nonmyeloablative conditioning before allogeneic hematopoietic cell transplant (HCT) is an alternative to conventional conditioning in older patients and those with comorbidities. It is not known whether the decreased tissue injury associated with nonmyeloablative conditioning lowers the risk of pulmonary complications. The medical records of patients who underwent transplantation were reviewed and all pulmonary complications documented. Sixty-two consecutive patients with hematologic malignancies who underwent minimally intensive HCT (subjects) were compared to 48 consecutive patients who received conventional myeloablative allogeneic peripheral blood HCT (controls) over the same period at Indiana University Hospital. Pulmonary complications were categorized according to the type of complication and the time of onset after transplantation. Median follow-up times were similar between groups (P = .70). The study population (minimal intensity recipients) was older (P < .01), and the incidence of chronic graft-versus-host disease (cGVHD) was higher in subjects than controls (P = .02). Sixty-nine percent of subjects and 73% of controls developed pulmonary complications (P = .70). There was a trend in the minimally conditioned patients towards a lower incidence of pulmonary complications in older patients in the early posttransplantation period and a higher incidence of infectious pneumonias and bronchiolitis obliterans syndrome at later time points. The frequency of pulmonary complications seems to be similar after minimally intensive or myeloablative conditioning and allotransplantation. There was no difference in overall mortality or pulmonary-related mortality between the 2 groups.

Delirium in hospitalized patients: implications of current evidence on clinical practice and future avenues for research--a systematic evidence review.

BACKGROUND: Despite the significant burden of delirium among hospitalized adults, critical appraisal of systematic data on delirium diagnosis, pathophysiology, treatment, prevention, and outcomes is lacking. PURPOSE: To provide evidence-based recommendations for delirium care to practitioners, and identify gaps in delirium research. DATA SOURCES: Medline, PubMed, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to April 2011. STUDY SELECTION: All published systematic evidence reviews (SERs) on delirium were evaluated. DATA EXTRACTION: Three reviewers independently extracted the data regarding delirium risk factors, diagnosis, prevention, treatment, and outcomes, and critically appraised each SER as good, fair, or poor using the United States Preventive Services Task Force criteria. DATA SYNTHESIS: Twenty-two SERs graded as good or fair provided the data. Age, cognitive impairment, depression, anticholinergic drugs, and lorazepam use were associated with an increased risk for developing delirium. The Confusion Assessment Method (CAM) is reliable for delirium diagnosis outside of the intensive care unit. Multicomponent nonpharmacological interventions are effective in reducing delirium incidence in elderly medical patients. Low-dose haloperidol has similar efficacy as atypical antipsychotics for treating delirium. Delirium is associated with poor outcomes independent of age, severity of illness, or dementia. CONCLUSION: Delirium is an acute, preventable medical condition with short- and long-term negative effects on a patient's cognitive and functional states.

Comparison and agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in evaluating patients' eligibility for delirium assessment in the ICU.

BACKGROUND: Delirium evaluation in patients in the ICU requires the use of an arousal/sedation assessment tool prior to assessing consciousness. The Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) are well-validated arousal/sedation tools. We sought to assess the concordance of RASS and SAS assessments in determining eligibility of patients in the ICU for delirium screening using the confusion assessment method for the ICU (CAM-ICU). METHODS: We performed a prospective cohort study in the adult medical, surgical, and progressive (step-down) ICUs of a tertiary care, university-affiliated, urban hospital in Indianapolis, Indiana. The cohort included 975 admissions to the ICU between January and October 2009. RESULTS: The outcome measures of interest were the correlation and agreement between RASS and SAS measurements. In 2,469 RASS and SAS paired screens, the rank correlation using the Spearman correlation coefficient was 0.91, and the agreement between the two screening tools for assessing CAM-ICU eligibility as estimated by the κ coefficient was 0.93. Analysis showed that 70.1% of screens were eligible for CAM-ICU assessment using RASS (7.1% sedated [RASS −3 to −1]; 62.6% calm [0]; and 0.4% restless, agitated [+1 to +3]), compared with 72.1% using SAS (5% sedated [SAS 3]; 66.5% calm [4]; and 0.6% anxious, agitated [5, 6]). In the mechanically ventilated subgroup, RASS identified 19.1% CAM-ICU eligible patients compared with 24.6% by SAS. The correlation coefficient in this subgroup was 0.70 and the agreement was 0.81. CONCLUSION: Both SAS and RASS led to similar rates of delirium assessment using the CAM-ICU.

Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial.

BACKGROUND: Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system. OBJECTIVE: Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI. DESIGN: A randomized controlled clinical trial. SETTING: A public hospital in Indianapolis. POPULATION: A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female. INTERVENTION: A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs. MEASUREMENTS: Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs. RESULTS: Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11). CONCLUSION: A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.

Time-motion analysis of health care workers' contact with patients and workers' hand hygiene: open vs closed units.

BACKGROUND: The effects of open (care provided by general medicine teams with a pulmonary intensivist consultant) vs closed (care provided by a dedicated critical care team) intensive care units on health care workers' contact with patients and their hand hygiene is uncertain. OBJECTIVE: To determine if closed intensive care units have fewer visits of patients by health care providers and greater hand-washing compliance among providers than do open units. METHODS: Time-motion analysis was used to observe 2 rooms in a medical intensive care unit at a teaching hospital affiliated with Indiana University School of Medicine, Indianapolis, for 96 hours before and after closure of the unit. The main outcome measures were frequency of health care providers' visits and their hand-washing hygiene compliance rates. RESULTS: Mean number of visits per room per hour by physicians (1.53 in the open unit vs 1.27 in the closed unit; P = .93) and nurses (3.98 in open unit vs 4.14 in closed unit; P = .60) did not differ. No differences were observed in gold-standard hand washing among physicians (0.00% in open unit vs 2.63% in closed unit; P = .11) or nurses (2.50% in open unit vs 3.49% in closed unit; P = .51). However, hand washing decreased significantly in nurses in the closed unit (40.94% in open unit vs 29.84% in closed unit; P = .002). CONCLUSION: Closing the intensive care unit did not decrease the number of contacts between health care providers and patients nor did it increase the providers' compliance with hand hygiene.

FEV1/FVC ratio of 70% misclassifies patients with obstruction at the extremes of age.

BACKGROUND: The American Thoracic Society recommends using the lower limit of normal (LLN) method to diagnose obstructive lung disease. However, few studies have investigated the clinical relevance of these recommendations. We compared the LLN derived from available data sets to a fixed ratio (FEV1/FVC, < 75% or 70%) and also to the FEV1/FVC percent predicted ratio to determine the impact of changing the FEV1/FVC "cutoff" on the spirometric diagnosis of obstructive lung disease. METHODS: FEV1, FVC, FEV1/FVC ratio, age, race, sex, height, and weight were recorded from 1,503 pulmonary function tests. Predicted values were calculated using the Third National Health and Nutrition Examination Study data set (Hankinson), and reference values from studies by Crapo, Knudson, and Morris. In addition, the LLN of the FEV1/FVC ratio was calculated for the Hankinson and Crapo reference values. RESULTS: The number of studies interpreted as obstructed varied from 37% using the Hankinson data set to 55% using the 75% fixed ratio method. Comparing the LLN method vs the 70% fixed ratio method resulted in 7.5% (Hankinson LLN vs 70% fixed) and 6.9% (Crapo LLN vs 70% fixed), which were discordant results. Age was the strongest predictor of discordance, and 16% of subjects > 74 years of age had discordant results comparing Hankinson values to the 70% fixed method. CONCLUSION: At the extremes of age and height, a large number of spirometry test results will be interpreted as showing an obstructive defect if a 70% fixed ratio method is used for interpretation compared with the LLN derived from the Hankinson data set.