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Effectiveness of the CAM-ICU in Diagnosing Delirium in ICU Patients: 

Effectiveness of the CAM-ICU in Diagnosing Delirium in ICU Patients Bethany Perkins Rob Romance Lauren Welshonse Sara Zimbelman Creighton University School of Nursing

Problem Statement: 

Problem Statement Delirium is under-diagnosed in the intensive care unit (ICU) patients Delirium can present differently in each patient Difficult to standardize and implement a screening tool

PICO Question: 

PICO Question Does use of the Confusion Assessment Method for the intensive care unit (CAM-ICU) lead to more accurate and effective diagnoses of delirium in ICU patients than clinician and nurse judgment?

Significance of ICU Delirium: 

Significance of ICU Delirium Incidence of delirium in ICU patients is 30-83% 1,2 Delirium undiagnosed in 66-84% of patients in the ICU 3 Delirium associated with prolonged hospital lengths of stay and a threefold increase in risk of mortality in ICU patients 4 Delayed treatment for ICU delirium is associated with three times higher mortality rates than immediate treatment 5 ICU delirium positively associated with long-term cognitive impairment 6 Total annual cost of ICU delirium to the U.S. healthcare system estimated to total $1.5–$4.7 billion 7

Care Management Outcomes: 

Care Management Outcomes Clinical outcomes More accurate and effective diagnosis of delirium in ICU patients 2,8,9,10 Decrease in long-term cognitive impairment following delirium 2 Quality outcomes Decreased mortality associated with delirium 2,9,10 Increased quality of life after discharge from the ICU 2 Cost outcomes Decreased length of stay and readmission rate 2,9,10

Research Summary: 

Research Summary Sample Sample size ranged from 46-250 participants Included men and women, except one study which only included men 8 Ages ranged from 18-92 years old All participants were patients in an ICU and received intensive nursing care Language barriers were an exclusion in all studies Level of Evidence Level IV evidence: non-experimental design 11 Quality of Evidence Moderately well controlled studies 11

Research Results: 

Research Results The CAM-ICU was shown to yield more accurate and effective diagnoses of delirium in ICU patients than clinician and nurse judgment The CAM-ICU was validated for diagnoses of delirium in patients in the ICU, including older adults, patients with suspected dementia, and the critically ill 2 Use of CAM-ICU by ICU nurses had a greater sensitivity in diagnosing delirium than clinician impression of the patient 9,10 Nurses were able to effectively use the tool to diagnose delirium and had a high level of compliance with the program 8

Potential Impact of CAM-ICU: 

Potential Impact of CAM-ICU The impact of implementing CAM-ICU relies on effectively identifying and treating delirium Clinical outcomes Regular screening of patients with CAM-ICU can lead to early diagnosis and allow for treatment of delirium Quality outcomes Early treatment of delirium has been linked with lower mortality rates in patients with delirium 5 Cost outcomes Treatment has the potential to decrease patients ’ length of stay as well as associated costs

Future Research Recommendations: 

Future Research Recommendations Determine if use of CAM-ICU leads to better patient outcomes 10 Validate CAM-ICU for use in traumatic brain injury patients 8 Investigate best practices for CAM-ICU implementation and education in ICUs 8 Replicate results in multiple-center studies with more representative samples Investigate treatment options for ICU delirium Evaluate effects of delirium on patient quality of life after discharge

References: 

References 1 Ouimet, S., Kavanagh, B., Gottfried, S., & Skrobik, Y. (2007). Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine , 33(1), 66-73. doi: 10.1007/s00134-006-0399-8 2 Ely, E.W., Inouye, S.K., Bernard, G.R., Gordon, S., Francis, J., May, L., … Dittus, R. (2001). Delirium in mechanically ventilated patients validity and reliability of the confusion assessment method for the ICU. American Medical Association , 286, 2703-2710. doi:10.1001/jama.286.21.2703 3 Pandharipande, P., Cotton, B., Shintani, A., Thompson, J., Costabile, S., Truman Pun, B., … Ely, E. (2007). Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intensive Care Medicine , 33(10), 1726-1731. doi: 10.1007/s00134-007-0687-y 4 Ely, E., Shintani, A., Truman, B., Speroff, T., Gordon, S., Harrell, F., … Dittus, R. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA: The Journal Of The American Medical Association , 291(14), 1753-1762. doi: 10.1001/jama.291.14.1753 5 Heymann, A., Radtke, F., Schiemann, A., Lütz, A., MacGuill, M., Wernecke, K., & Spies, C. (2010). Delayed treatment of delirium increases mortality rate in intensive care unit patients. The Journal Of International Medical Research , 38(5), 1584-1595. Retrieved from http://www.jimronline.net 6 Girard, T., Jackson, J., Pandharipande, P., Pun, B., Thompson, J., Shintani, A., … Ely, E. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine , 38(7), 1513-1520. doi: 10.1097/CCM.0b013e3181e47be1

References continued: 

References continued 7 Milbrandt, E., Deppen, S., Harrison, P., Shintani, A., Speroff, T., Stiles, R., … Ely, E. (2004). Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine , 32(4), 955-962. doi: 10.1097/01.CCM.0000119429.16055.92 8 Soja, S., Pandharipande, P., Fleming, S., Cotton, B., Miller, L, Weaver, S., … Ely, E. (2008). Implementation, reliability testing, and compliance monitoring of the confusion assessment method for the intensive care unit in trauma patients. Intensive Care Medicine , 34 , 1263-1268. doi: 10.1007/s00134-008-1031-x 9 van Eijk, M., van Marum, R., Klijn, I. A., de Wit, N., Kesecioglu, J., & Slooter, A. J. (2009). Comparison of delirium assessment tools in a mixed intensive care unit. Critical Care Medicine, 37 (6), 1881-1885. doi: 10.1097/CCM.0b013e3181a00118 10 Spronk, P., Riekerk, B., Hofhuis, J., & Rommes, J. (2009). Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Medicine , 35, 1276–1280. doi: 10.1007/s00134-009-1466-8 11 LoBiondo-Wood, G., & Haber, J. (2010). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice . St. Louis, MO: Elsevier. 12 Melnyck, B.M. & Fineout-Overholt, E. (2005). Evidence-based practice in healthcare. [Schematic]. Philadelphia: Lippincott. Retrieved from http://consultgerirn.org/evidence-based_practice