Lindroth, Heidi

Abstract Rationale Longer duration and severity of acute brain dysfunction (ABD), including delirium and coma, have been associated with worse clinical outcomes in critically ill adults. Examining ABD trajectories over time may offer deeper insights into understanding its heterogeneity. This study aimed to characterize ABD trajectories and examine its relationship with clinical characteristics and 30-day mortality. Methods We analyzed data from the multicenter BRAIN-ICU and MIND-ICU prospective cohort study, which included adults with acute respiratory failure and/or shock. Delirium presence and severity were determined twice daily for 7 days using the CAM-ICU-7. A score of 0 indicates no delirium, 1-2 indicates subsyndromal delirium, 3-5 indicates mild-to-moderate delirium, and 6-7 indicates severe delirium. Patients with a RASS of -4 or -5, indicating coma, were assigned a CAM-ICU-7 score of 7. We applied group-based trajectory modeling of CAM-ICU-7 to identify ABD severity trajectory patterns and compared demographics, clinical characteristics, and 30-day mortality among trajectory groups. Results The 1035 patients analyzed had a median age of 62 [IQR, 53-72] years, 61% were male, and 91% were White. Overall, patients had a median Charlson Comorbidity Index of 2 (1-4) and SOFA score at enrollment of 6 (4-9). 731 patients (70.6%) had delirium at some point during the study. Five ABD severity trajectories were identified as the optimal model fit based on global fit indices and clinical interpretability: T1 was associated with mild and persistent ABD, while T2-T5 were characterized by severe ABD early during critical illness with different resolution patterns (Figure). Trajectory membership varied by patient clinical characteristics. T1 had lighter levels of sedation (median RASS score: -2) in the 24 hours surrounding ICU admission than T2-T5 (median RASS scores: -3, -3, -4, and -3, respectively) (p<.001). At enrollment, T1 and T2 had lower modified SOFA scores (median scores: 6) compared to T5 (median score: 7) (p<.001). Trajectory membership independently predicted 30-day mortality, with T5 having the highest 30-day mortality and T2, which had the fastest resolution of ABD, the lowest (p<.001). Conclusions We identified five trajectories of ABD severity over the first week of a patient’s ICU stay. These trajectories were differentially associated with mortality and clinical characteristics, suggesting trajectory-based approaches may enable more nuanced risk stratification and support the tailoring of interventions and clinical trial designs to specific ABD trajectory patterns. Future work should validate these trajectories in independent cohorts, explore whether they modify treatment effects, and determine if they represent distinct mechanistic pathways. This abstract is funded by: NIH/NIA

Purpose: Delirium is a serious underrecognized health condition in hospitalized older adults. The current qualitative study used dimensional analysis to increase understanding of the clinical reasoning processes used by acute care nurses to assess for delirium. Method: Ten focus groups with experienced medical, surgical, and intensive care nurses ( N = 39) from quaternary, community, and academic medical centers discussed their application of clinical reasoning processes to assess/detect delirium symptoms. Transcripts were inductively analyzed. Trustworthiness was checked with a subset of participants ( n = 12). Results: Findings illustrate how nurses apply clinical reasoning to recognize and respond to delirium symptoms and navigate clinical and social structures to maintain patient safety. Clinical context and social structures are important conditions influencing nurse reasoning and judgment. Conclusion: Further process improvement and research efforts should explore strategies to enhance interdisciplinary shared knowledge within a supportive environment to improve the detection and care to lessen the severity and duration of delirium for vulnerable patients.

Background Global efforts to raise delirium awareness have been made over the past years, such as the formation of the iDelirium group and the institution, in 2017, of the annual World Delirium Awareness Day (WDAD) in March. In 2023, our group and researchers from around the world conducted a global one-day point prevalence study of delirium on WDAD. These strategies appear to improve delirium recognition and management. Objective To assess participants’ perceived impact of participating in the WDAD 2023 one-day point prevalence study and to gather feedback on the survey process to inform future campaigns. Methods An online survey was administered to multiple national and clinical collaborators from 44 countries participating in the one-day global point delirium prevalence study on WDAD 2023. Using SurveyMonkey®, the survey was distributed via a snowball system, with participants’ consent implied through their involvement. The survey, developed iteratively to balance time and detail, consisted of six core questions, including closed and open formats. Data were collected from September 9th to October 9th, 2023, and qualitative and quantitative analyses were performed using Excel®. Quantitative data underwent statistical analysis using IBM® SPSS Statistics28. Results 49 out of 53 (93.45%) healthcare professionals responded to the survey: 71.43% reported increased awareness, and responses were almost equally divided between those who initiated projects (46.94%) and those who did not (53.06%). Most participants (93.88%) did not find the WDAD 2023 one-day point prevalence study in March burdensome, and all expressed interest in future participation. The WDAD 2023 one-day point prevalence study highlighted diverse projects, primarily focused on delirium awareness and education. The survey found suggestions for future improvements emphasizing more efficient, digital, and engaging research methods and a clear need for educational resources, particularly in ICU delirium. Conclusions Our survey finds that participation in WDAD 2023 one-day point prevalence study boosted delirium visibility, leading to ongoing awareness, interest in future studies, and practice changes that benefit patients and the healthcare system. Further evidence-based research is needed to assess the impact of these campaigns on delirium recognition and management.

IMPORTANCE: Accurate and reliable sedation assessment is crucial to improving patient outcomes in the ICU. OBJECTIVE: To evaluate the inter-rater agreement and reliability of Richmond Agitation Sedation Scale (RASS) assessments between bedside nurses and trained investigators in patients receiving mechanical ventilation in the ICU. DESIGN, SETTING, AND PARTICIPANTS: An assessor triad, comprising an ICU nurse providing direct patient care and two trained investigators, simultaneously performed RASS assessments during 79 encounters with 62 unique patients receiving mechanical ventilation at two ICUs at a tertiary care academic hospital in Colorado. A total of 58 nurses participated in the study. MAIN OUTCOMES AND MEASURES: The inter-rater reliability of RASS assessments was evaluated with the intraclass correlation coefficient (ICC) and weighted kappa (κ), and inter-rater agreement was evaluated with percentage agreement and Bland-Altman analysis. RESULTS: Acute respiratory failure (55%) and altered mental status (21%) were the most common reasons for mechanical ventilation. Most patients were receiving one (interquartile range, 0.5–2) continuous sedative during the assessment. The inter-rater reliability of RASS assessments between the nurses and investigators (ICC, 0.728–0.779; weighted κ, 0.62–0.63) was lower than between the two investigators (ICC, 0.891; weighted κ, 0.80). The assessor triad agreed on the same RASS values in only 35% of observations. The average differences in RASS were greater between the investigators and nurses, ranging from –0.658 to –0.544, compared with 0.114 between the two investigators. Compared with the mean of the two investigators, RASS values recorded by nurses were more likely to be higher (52% of observations), indicating a lighter sedation level. In 16% of observations, at least one assessor commented on uncertainty or ambiguity with the RASS. CONCLUSIONS AND RELEVANCE: The inter-rater reliability of RASS assessments was high. However, we observed variations in the degree of agreement by assessor category. Further studies are necessary to explore how factors such as assessor characteristics, ICU environment, and patient conditions influence the inter-rater agreement of the RASS in contemporary ICU practices.

Objectives: The delirium course of critically ill adults can be classified into trajectories based on the severity and duration of delirium as shown by a recent study. It is unknown whether these trajectories and associated outcomes are reproducible. We aimed to define delirium severity trajectories using the Intensive Care Delirium Screening Checklist (ICDSC) and delirium duration and evaluate the association of trajectory membership with clinical characteristics and 30-day post-discharge mortality. Design: Population-based retrospective cohort. Setting: Fourteen medical-surgical ICUs in Alberta, Canada from January 1, 2014, to December 21, 2019. Patients: We included adult patients (≥ 18 yr old) with an ICU length of stay of greater than or equal to 24 hours, an ICDSC score indicating delirium (≥ 4), and 30-day follow-up data were included. Group-based trajectory modeling identified trajectories over a 7-day period with SAS v9.4 (SAS Institute, Cary, NC). Interventions: None. Measurements and Main Results: Demographic (age, sex) and clinical data (2 × d ICDSC score, comorbidities, illness severity, admission reason, procedures, length of stay, in-hospital, and 30-d post-discharge mortality) were captured from electronic medical records. In total, 21,071 patients were included, with a median age of 59 years (interquartile range, 46–70 yr), 59% male (n = 12,547), and 3% died at 30 days (n = 541). The five-trajectory model was selected. These trajectories followed previously defined patterns: 1) Mild-Brief (19.4%); 2); Severe-Rapid Recovers (18.5%); 3) Severe-Slow Recovers (31%); 4) Mild-Accelerating (14.1%); and 5) Severe-Nonrecovers (16.9%). Trajectory membership was not significantly associated with 30-day post-discharge mortality; however, clinically relevant trends were observed. Conclusions: The current study substantiates the proof-of-concept model of five delirium severity trajectories. Trajectory membership did not predict 30-day post-discharge mortality. Further research is needed to understand the associations between trajectory membership, biological-based biomarkers, and patient-relevant outcomes.

Background Family participation in the delivery of nonpharmacological measures has shown in past studies to prevent 17-75% of incident delirium. A scalable and sustainable method to partner with family (i.e., care partners) and support their delivery of nonpharmacologic measures is needed. Objectives To test the feasibility, acceptability, and usability of iPREPARED in a pilot randomized controlled clinical trial (RCT). iPREPARED is a mobile health technology co-designed with patients and care partners containing resources on nonpharmacological interventions to prevent delirium. Methods Hospitalized adults ( > 65 years) with > 1 delirium risk factor and a care partner (family or friend > 18yo) willing to participate were enrolled. The primary outcomes were feasibility, acceptability, and usability. Descriptive statistics are reported. Results In total, 23 dyads completed the study (median age 72 years (IQR 64, 79), 60% male, and 100% Caucasian). Dyads reported that iPREPARED was acceptable, with moderate usability. Recruitment in the emergency department was feasible whereas recruitment once hospitalized and admitted was more difficult. Conclusion The study design was feasible. iPREPARED was acceptable and usable as an intervention.

Abstract Rationale: Critical illness survivors often experience anxiety, depression, and post-traumatic stress disorder (PTSD) due to traumatic experiences, sedation, and delirium. Early interventions of psychological support may help mitigate mental health deficits post-ICU. Memory of the ICU stay may play a key role in addressing trauma and facilitating therapeutic engagement. Therefore, we sought to determine the relationship between ICU memory recollection, in-ICU delirium, and mental health outcomes at 1-month follow-up in a critical illness recovery center. Methods: We analyzed data collected at 1-month follow-up in a critical illness recovery center seeing adults who had ICU stays of >4 days with sepsis, respiratory failure, and/or delirium. Patients were asked, “Do you remember your experience in the ICU, and if so, can you describe your most impactful memories?” and we qualitatively coded responses for A) presence/absence of memories and B) type of memories described. We analyzed unadjusted associations between demographic, clinical, and mental health measures (anxiety, depression, and PTSD) and memory recollection using chi-square and Wilcoxon rank-sum tests. Results: Among 196 patients seen at 1-month follow-up, 96 (49%) reported memories of their ICU stay. Of these, 44 (46%) described support they received in the ICU (e.g., feeling “safe and watched” by ICU staff, spouse at bedside), 36 (38%) recalled delusions and/or hallucinations (e.g., being kidnapped), 35 (37%) remembered specific treatments (e.g., cardioversion), and 33 (34%) described symptoms (e.g., pain, constipation). Baseline characteristics and critical illness features are shown in the Table. Patients who reported no memories of their ICU stay were more frequently admitted with neurological diagnoses, whereas those who reported memories were more often admitted with trauma or burns (p<0.001). Those without memories had more delirium days than those reporting memories (p=0.02). Although PTSD and anxiety symptoms at 1-month follow-up were not associated with memories, patients who remembered their ICU stay had fewer depression symptoms (p=0.04). Conclusions: One month after their critical illness, half of survivors recalled their ICU experience, with memories ranging from supportive interactions to distressing experiences. In unadjusted analyses, memory recollection was associated with fewer depressive symptoms during follow-up, but a larger study is needed to determine whether this association persists after adjusting for potential confounders. Memories of the ICU may provide a therapeutic foundation for interventions targeting depression after critical illness, such as exposure therapy or ICU diaries, which may improve mental health outcomes in critical illness survivors.

Abstract Rationale: ICU nurses can experience high levels of burnout and job dissatisfaction due to stressors associated with high-stakes patient care, uncertain outcomes, and constant exposure to death. Witnessing patient recovery and/or disability status in the weeks or months after hospital discharge through reconnection with survivors of critical illness and their families may offer emotional and professional benefits to ICU nurses. However, the impact of connecting with patients’ post-ICU outcomes on nursing clinical practice and job satisfaction has not been well explored. This study aimed to investigate pragmatic perspectives from ICU nurses related to their insights on long-term patient outcomes after critical illness with a goal of identifying key mechanisms that may be associated with impacts on clinical practice and job satisfaction. Methods: A web-based investigator-designed survey was distributed to ICU nurses with endorsement from the American Association of Critical-Care Nurses for completion via their website and annual conference. Survey items included quantitative and open-ended prompts to examine the impact of reconnecting with ICU survivors on clinical practice and job satisfaction. Thematic analysis was performed on free-text responses. Results: Fifty-four ICU nurses (76% female) participated in the survey (June 2023-May 2024), with a median age of 41 years and a median of 7 years of critical care experience. Among them, 89% reported that reconnecting with survivors positively impacted their job satisfaction, and 78% felt that reconnecting influenced their clinical practice. Thematic analysis revealed three themes: Empathy and Human Connection – Nurses felt validated and fulfilled knowing their care positively impacted patients’ lives, reinforcing the meaning of their work. These interactions fostered greater empathy, reminding nurses of the real-life impact of their care.Validation of Effort and Accomplishment – Nurses reported a stronger sense of accomplishment seeing the positive outcomes of their work. Reconnecting with survivors reaffirmed the importance of their roles, strengthening nurses’ sense of purpose and commitment.Positive Emotional Impact and Job Satisfaction – Interactions with survivors provided emotional uplift, enhancing job satisfaction and reminding nurses of the rewarding aspects of their roles. Gratitude and progress from survivors motivated nurses, helping them manage the emotional challenges of ICU work. Conclusion: Reconnecting with ICU survivors and their families may have positive impacts on job satisfaction and clinical practice by providing emotional rewards, reinforcing nurses’ professional purpose, and validating their contributions to patient recovery. Embedding structured, low-cost re-engagement activities with critical illness survivors could offer valuable benefits to the ICU nurse workforce.

Abstract Background The prevalence of delirium in intensive care units (ICUs) is high and has a major impact on patient outcomes. Aim To describe delirium assessment instruments, prevalence, interventions and barriers in delirium management in adult and paediatric ICUs; and to explore the association between delirium prevalence and reported interventions and barriers at unit level. Study Design A secondary analysis of the cross‐sectional World Delirium Awareness Day Delirium Survey on 15 March 2023. This was a prospective study to assess the one‐day point delirium prevalence, practices and quality improvement efforts across healthcare systems. Data was analysed descriptively and using multiple linear regression. Results Data of 1612 assessments in 123 ICUs from three German‐speaking countries were analysed. The most frequently used delirium assessment instrument was the Intensive Care Delirium Screening Checklist (43.9%, n = 54). The prevalence of delirium at 8 AM was 18.6% and at 8 PM 20.4% from the 94 ICUs included in the regression analyses. Prevalence for adult and paediatric and mixed ICUs are comparable. Main reported over all unit‐level interventions were ‘pain management’ (95.9%, n = 118), ‘mobilization’ (94.3%, n = 116) and ‘verbal re‐orientation’ (84.6%, n = 104). Main reported over all unit‐level barriers were ‘shortage of staff’ (53.7%, n = 66) and ‘patients who are difficult to assess’ (44.7%, n = 55). Interventions such as ‘avoidance of bladder tubes/catheters’ in all ICUs, ‘use of ear plugs and/or sleep glasses’ in adult ICUs and ‘mobilization’ in paediatric and mixed ICUs were associated with reduced delirium prevalence. Across all ICUs, as well as in both adult and paediatric ICUs, ‘lack of appropriate scores for delirium assessment’ was identified as a significant barrier. Conclusions One fifth of assessed ICU patients suffer from delirium. Several reported unit‐level interventions and barriers may have an impact on delirium prevalence, suggesting an approach for future studies and clinical practice. Relevance to Clinical Practice In clinical practice, unit‐level ‘avoidance of bladder tubes/catheters’, ‘use of ear plugs and/or sleep glasses’ and ‘mobilization’ may be used as delirium prevention and treatment interventions.