Relationship Between Delirium and Ventilatory Outcomes in the Medical Intensive Care Unit.

BACKGROUND: Delirium is a common neuropsychiatric diagnosis in intensive care units and often leads to extended hospital stays and an increased rate of complications. Delirium can be classified as hypoactive, hyperactive, or mixed. Hyperactive delirium is often accompanied by agitation, which is a predictive factor for unplanned extubation. Hypoactive delirium does not include outward agitation; its incidence and relationship to ventilatory outcomes, specifically unplanned extubation and duration of mechanical ventilation, are relatively unexplored. OBJECTIVE: To determine the occurrence rate of each delirium type in the first 7 days after intensive care unit admission and explore the relationship between delirium type and ventilatory outcomes. METHODS: This was a retrospective cohort study that enrolled adult patients consecutively admitted to a medical intensive care unit over 12 months. Data were abstracted on patient demographic variables, daily clinical variables (morning and evening delirium, coma, and sedation scores), and outcome variables (unplanned extubation, length of stay, and duration of mechanical ventilation). RESULTS: We enrolled 171 patients in the study. Hypoactive delirium occurred in up to 44% of patients. Of 25 instances of unplanned extubation, up to 74% of patients had hypoactive delirium. Delirium was not a predictor of unplanned extubation; smoking history, chronic obstructive pulmonary disease, and failed breathing trials best predicted unplanned extubation (odds ratios = 3.2, 5.2, and 12.6, respectively; P < .05). CONCLUSIONS: Hypoactive delirium is common among intensive care unit patients and may precede unplanned extubation. Patient history and comorbidities remain the strongest predictors of unplanned extubation.

One Team's Experience with Integrating Flexible Visitation in the Medical Intensive Care Unit.

Integration of flexible visitation into a large health system requires concentrated effort. Evaluating impact on patient, family, and staff outcomes is important to facilitate changes and ensure visiting policy success. The medical intensive care unit staff participated in a collaborative quality improvement effort to encourage flexible visitation. The integration of flexible visitation spanned an 18-month period, timed to accompany a transition to a new setting with rooms designed to support visitor presence. This article details these efforts, outcomes, and important gaps for future work evaluating integration of flexible visitation in critical care.

Risk Factors for Falls Among Hospitalized Acute Post-Ischemic Stroke Patients.

BACKGROUND: Falls remain an important benchmarking indicator for hospitals. Research identifies factors associated with falls among hospitalized patients in general. Similarly, the stroke literature outlines fall risk factors in the inpatient rehabilitation and community setting. PURPOSE: The aim of this study was to identify prevalence and risk factors for falls among acute, hospitalized AIS patients within an urban public healthcare system. Secondary aims were to identify activities present at the time of the fall and outcomes associated with falling. METHODS: This is a retrospective case-control study. Data were abstracted and merged from hospital stroke and fall registries and matched with medical records from 2013 to 2015 among all adult patients admitted for AIS. RESULTS: The study included 856 patients with AIS, with 2.3% experiencing a fall during the acute care hospitalization period. Falls among patients with AIS accounted for 1.4% of all hospitalized adult falls. Bivariate analysis indicate that a higher proportion of falls occurred among male patients when compared with female patients (75% male; χ = 3.964, P < .05) and among patients with a history of previous myocardial infarction or renal insufficiency (χ = 5.260, P < .05; χ = 11.116, P < .001, respectively). Multivariate analyses identify previous myocardial infarction (OR, 2.5; 95% confidence interval, 1.0-6.3; P = .04) and renal insufficiency (odds ratio, 4.2; 95% confidence interval, 1.5-12.2; P = .008) as strongest predictors of falls. The occurrence of a fall resulted in increased hospital length of stay (7.1 vs 4.0 days, P < .000) and slightly decreased functional outcome at discharge. Most falls occurred during the day shift while toileting, despite implementation and adherence to fall prevention programs. CONCLUSIONS: Fall rates among hospitalized patients with AIS are low, which may be reflective of increased vigilance among providers and widespread integration of fall prevention strategies. Consistent with the fall literature among other populations, the occurrence of a fall in the inpatient setting can substantially increase length of stay.

The role of standardized protocols in unplanned extubations in a medical intensive care unit.

BACKGROUND: Many patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors. OBJECTIVE: To identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols. METHODS: A prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed. RESULTS: Weaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group. CONCLUSIONS: Weaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group.