E Wesley Ely

Vanderbilt University, Nashville, Michigan, United States

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Publications (238)1354.28 Total impact

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    ABSTRACT: 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. A pre/post implementation study design. A 22-bed mixed surgical and medical ICU. Seven hundred two consecutive mechanically ventilated ICU patients from June 2010 to January 2013. Implementation of daily paired spontaneous awakening trials (daily sedation vacation plus spontaneous breathing trials) as a quality improvement project. 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). 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.
    Critical care medicine. 12/2014; 42(12):e791-5.
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    ABSTRACT: Delirium may lead to adverse outcomes in patients with serious conditions, but is often under-diagnosed due to inadequate screening. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is an established method for assessing delirium in the ICU. The validity and reliability of the Japanese version of the CAM-ICU has not, however, been verified, and we undertook this study to verify these parameters. CAM-ICU validity and reliability were assessed in two Japanese ICUs. Using the evaluation of the DMS-IV-TR in the psychiatrists group as the standard criteria for delirium diagnosis, we compared the evaluation of the Japanese version of the CAM-ICU between the research nurses group and the staff nurses group. According to DSM-IV-TR criteria, the prevalence of delirium was 22.0%, and according to CAM-ICU delirium was found in 22.0% with Research Nurses and 19.5% with Staff Nurses. CAM-ICU sensitivity ratings were 83% and 78%, while their specificity ratings were 95% and 97%, respectively. The Kappa inter-rater reliability was good (κ=0.85), and Cronbach's alpha coefficient was 0.69 (95% CI: 0.57-0.79). Mean rating time for the CAM-ICU was 2.5-2.8minutes for Research Nurses and Staff Nurses, respectively. The Japanese version of the CAM-ICU has comparable validity and reliability as a delirium assessment tool in surgical patients in two Japanese ICUs. With training, CAM-ICU can be incorporated into daily clinical practice. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Intensive and Critical Care Nursing. 11/2014;
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    ABSTRACT: Rationale: The Centers for Disease Control and Prevention (CDC) introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs. Objectives: To assess the preventability of VAEs. Methods: We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance amongst 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining 8 units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, SOFA score, and comorbidity index. Measurements and Main Results: We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator-day but significant decreases in VAE risk per episode of mechanical ventilation (OR 0.63, 95% CI 0.42-0.97) and infection-related ventilator-associated complications (OR 0.35, 95% CI 0.17-0.71) but not pneumonias (OR 0.51, 95% CI 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates. Conclusions: Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01583413.
    American Journal of Respiratory and Critical Care Medicine 11/2014; · 11.04 Impact Factor
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    ABSTRACT: OBJECTIVES Impaired arousal signifies underlying brain dysfunction, but its clinical significance outside the intensive care unit remains unclear. We sought to determine if impaired arousal at initial presentation was associated with higher 6-month mortality and if this relationship existed in the absence of delirium.DESIGNProspective cohort study.SETTINGAn emergency department located within an academic, tertiary care hospital.PARTICIPANTSA total of 1084 noncomatose patients who were aged 65 years or older.MEASUREMENTSThe Richmond Agitation-Sedation Scale (RASS) is a 10-second arousal scale; a score of 0 indicates normal arousal. Cox proportional hazard regression was performed adjusting for patient characteristics, admission status, and psychoactive medication administration. To determine if impaired arousal in the absence of delirium was associated with 6-month mortality, Cox proportional hazard regression was performed in a subset of 406 patients who received a psychiatric assessment; the inverse weighted propensity score method was used to minimize residual confounding. Hazard ratios (HR) with their 95% confidence intervals (95% CI) were reported.RESULTSPatients with impaired arousal were 73% more likely to die within 6 months (HR: 1.73, 95% CI: 1.21-2.49). Even in the absence of delirium, patients with an abnormal RASS were more likely to die within 6 months (HR: 2.20, 95% CI: 1.10-4.41).CONCLUSION Impaired arousal at initial presentation is an independent predictor of death within 6 months in a diverse group of acutely ill older patients, even in the absence of delirium. Routine RASS assessment of arousal during clinical care may be warranted as it correlates with prognosis. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine
    Journal of Hospital Medicine 10/2014; · 1.40 Impact Factor
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    ABSTRACT: To determine whether delirium during the hospital stay predicted health-related quality of life (HRQOL) at 1-year following injury in trauma intensive care unit (ICU) survivors without intracranial hemorrhage. We also examined the association between depressive and post-traumatic stress disorder (PTSD) symptoms and each of the HRQOL domains at 1-year follow-up.
    Archives of Physical Medicine and Rehabilitation 08/2014; · 2.36 Impact Factor
  • Jin H. Han, John F. Schnelle, E. Wesley Ely
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    ABSTRACT: Background Altered mental status is a common chief complaint among older emergency department (ED) patients. Patients with this chief complaint are likely delirious, but to the authors' knowledge, this relationship has not been well characterized. Additionally, health care providers frequently ascribe “altered mental status” to other causes, such as dementia, psychosis, or depression.Objectives The objective was to determine the relationship between altered mental status as a chief complaint and delirium.Methods This was a secondary analysis of a cross-sectional study designed to validate three brief delirium assessments, conducted from July 2009 to March 2012. English-speaking patients who were 65 years or older and in the ED for <12 hours were included. Patients who were comatose or nonverbal or unable to follow simple commands prior to the acute illness were excluded. Chief complaints were obtained from the ED nurse triage assessment. The reference standard for delirium was a comprehensive psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivity, specificity, positive likelihood ratio (LR), and negative LR with their 95% confidence intervals (CIs) were calculated using the psychiatrist's assessment as the reference standard.ResultsA total of 406 patients were enrolled. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, 57 (14.0%) were nonwhite race, and 50 (12.3%) had delirium. Twenty-three (5.7%) of the cohort had chief complaints of altered mental status. The presence of this chief complaint was 38.0% sensitive (95% CI = 25.9% to 51.9%) and 98.9% specific (95% CI = 97.2% to 99.6%). The negative LR was 0.63 (95% CI = 0.50 to 0.78), and the positive LR was 33.82 (95% CI = 11.99 to 95.38).Conclusions The absence of a chief complaint of altered mental status should not reassure the clinician that delirium is absent. This syndrome will be missed unless it is actively looked for using a validated delirium assessment. However, patients with this chief complaint are highly likely to be delirious, and no additional delirium assessment is necessary.ResumenIntroducciónEl estado mental alterado (EMA) es un motivo de consulta principal frecuente en pacientes mayores que consultan al servicio de urgencias (SU). Este motivo de consulta principal en estos pacientes corresponde con más frecuencia a delirium, pero según el conocimiento de los autores, esta relación no ha sido bien caracterizada. Además, los sanitarios frecuentemente relacionan EMA a otras causas, como la demencia, la psicosis o la depresión.ObjetivosEl objetivo fue determinar la relación entre EMA como motivo de consulta principal y el delirium.MetodologíaAnálisis secundario de un estudio transversal diseñado para validar tres valoraciones breves de delirium, llevado a cabo de julio de 2009 a marzo de 2012. Se incluyeron los pacientes de habla inglesa que tenían 65 años o más de edad y que estuvieron menos de 12 horas en el SU. Se excluyeron los pacientes en coma o que tenían demencia en estadio terminal. Los motivos de consulta principales se obtuvieron de la valoración del triaje de enfermería del SU. El estándar de referencia de delirium fue una valoración psiquiátrica global usando los criterios revisados DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, cuartra edición). Se calculó la sensibilidad, la especificidad, la razón de probabilidad positiva y la razón de probabilidad negativa con sus intervalos de confianza al 95% usando la valoración del psiquiatra como estándar de referencia.ResultadosSe incluyeron un total de 406 pacientes. La mediana de edad fue de 73,5 años (rango intercuartílico: 69 a 80 años), 202 (50%) fueron mujeres, 57 (14%) de raza no blanca y 50 (12,3%) tuvieron delirium. Veintitrés pacientes (5,7%) de la cohorte tuvieron como motivo de consulta principal EMA. La presencia de este motivo de consulta principal tuvo una sensibilidad de un 38,0% (IC 95% = 25,9% a 51,9%) y una especificidad de un 98,9% (IC 95%= 97,2% a 99,6%). La razón de probabilidad negativa fue 0,63 (IC 95% = 0,50 a 0,78) y la razón de probabilidad positiva fue 33,82 (IC 95% = 11,99 a 95,38).ConclusionesLa ausencia de un motivo de consulta de EMA no debería hacer pensara al clínico que el delirium está ausente. El diagnóstico de este síndrome se perderá a menos que se busque activamente usando un valoración validada de delirium. Sin embargo, los pacientes con EMA como motivo de consulta principal es más probable que padezcan delirium y que no sea necesaria una valoración de delirium adicional.
    Academic Emergency Medicine 08/2014; · 2.20 Impact Factor
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    ABSTRACT: Many patients, due to a combination of illness and sedatives, spend a considerable amount of time in a comatose state that can include time in burst suppression. We sought to determine if burst suppression measured by processed electroencephalography during coma in sedative-exposed patients is a predictor of post-coma delirium during critical illness.
    Critical care medicine. 07/2014;
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    ABSTRACT: To determine the psychometric properties of the Italian version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a clinical assessment tool to detect delirium among Intensive Care Unit patients.
    Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses 07/2014;
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    ABSTRACT: “Brain Disorders in Critical Illness”, edited by Robert Stevens, Tarek Sharshar and Wes Ely, offers an overview of critical illness brain dysfunction (delirium, coma, encephalopathy), a major problem in intensive care with potentially debilitating long-term consequences. Chapters on epidemiology, outcomes, relevant behavioral neurology and biological mechanisms of acute brain dysfunction are written by an interdiscplinary panel of leading experts in the field.
    07/2014; Cambridge University Press., ISBN: 9781107029194
  • S Jean Hsieh, E Wesley Ely, Michelle N Gong
    Annals of the American Thoracic Society. 06/2014; 11(5):852-853.
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    ABSTRACT: Since statins have pleiotropic effects on inflammation and coagulation that may interrupt delirium pathogenesis, we tested the hypotheses that statin exposure is associated with reduced delirium during critical illness, whereas discontinuation of statin therapy is associated with increased delirium. Multicenter, prospective cohort study. Medical and surgical ICUs in two large tertiary care hospitals in the United States. Patients with acute respiratory failure or shock. None. We measured statin exposure prior to hospitalization and daily during the ICU stay, and we assessed patients for delirium twice daily using the Confusion Assessment Method for the ICU. Of 763 patients included, whose median (interquartile range) age was 61 years (51-70 yr) and Acute Physiology and Chronic Health Evaluation II was 25 (19-31), 257 (34%) were prehospital statin users and 197 (26%) were ICU statin users. Overall, delirium developed in 588 patients (77%). After adjusting for covariates, ICU statin use was associated with reduced delirium (p < 0.01). This association was modified by sepsis and study day; for example, statin use was associated with reduced delirium among patients with sepsis on study day 1 (odds ratio, 0.22; 95% CI, 0.10-0.49) but not among patients without sepsis on day 1 (odds ratio, 0.92; 95% CI, 0.46-1.84) or among those with sepsis later, for example, on day 13 (odds ratio, 0.70; 95% CI, 0.35-1.41). Prehospital statin use was not associated with delirium (odds ratio, 0.86; 95% CI, 0.44-1.66; p = 0.18), yet the longer a prehospital statin user's statin was held in the ICU, the higher the odds of delirium (overall p < 0.001 with the odds ratio depending on sepsis status and study day due to significant interactions). In critically ill patients, ICU statin use was associated with reduced delirium, especially early during sepsis; discontinuation of a previously used statin was associated with increased delirium.
    Critical care medicine 05/2014; · 6.37 Impact Factor
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    ABSTRACT: Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations of age and duration of delirium with mental health and functional disabilities in this group. In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist-Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795. We enrolled 821 patients with a median age of 61 years (IQR 51-71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive-affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes. Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care. National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.
    The lancet. Respiratory medicine. 05/2014; 2(5):369-79.
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    ABSTRACT: Rationale: Existing studies of risk factors for physical impairments in acute lung injury (ALI) survivors were potentially limited by single-center design or relatively small sample size. Objectives: To evaluate risk factors for 3 measures of physical impairments commonly experienced by ALI survivors in the first year after hospitalization. Methods: A prospective, longitudinal study of 6- and 12-month physical outcomes (muscle strength, 6-minute walk distance, and SF-36 Physical Function score) for 203 ALI survivors enrolled from 12 hospitals participating in the ARDS Network randomized trials. Multivariable regression analyses evaluated the independent association of critical illness-related variables and intensive care interventions with impairments in each physical outcome measure, after adjusting for patient demographics, comorbidities, and baseline functional status. Measurements and Main Results: At 6- and 12-months, respectively, mean (±SD) values for strength (presented as proportion of maximum strength score evaluated using manual muscle testing) was 92% (±8%) and 93% (±9%), 6-minute walk distance (as percent-predicted) was 64% (±22%) and 67% (±26%), and SF-36 Physical Function score (as percent-predicted) was 61% (±36%) and 67% (±37%). After accounting for patient baseline status, there was significant association and statistical interaction of mean daily dose of corticosteroids and ICU length of stay with impairments in physical outcomes. Conclusions: Patients had substantial impairments, from predicted values, for 6-minute walk distance and SF-36 Physical Function outcome measures. Minimizing corticosteroid dose and implementing existing evidence-based methods to reduce duration of ICU stay and associated patient immobilization may be important interventions for improving ALI survivors' physical outcomes.
    American Journal of Respiratory and Critical Care Medicine 04/2014; · 11.04 Impact Factor
  • Paula L Watson, Beth A Malow, E Wesley Ely
    Critical care medicine 04/2014; 42(4):e313-4. · 6.37 Impact Factor
  • Eduard E Vasilevskis, E Wesley Ely
    The Neurohospitalist. 04/2014; 4(2):58-60.
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    ABSTRACT: To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools. The authors used a survey to address reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information, and diagnostic process, completed via web or telephone interview according to respondent preference. Participants were authors of 39 studies included in three recent systematic reviews of delirium detection instruments in hospitalized patients. Authors from 85% (N = 33) of the 39 eligible studies responded to the survey. The median number of raters per study was 2.5 (interquartile range: 2-3); 79% were physicians. The raters' median duration of clinical experience with delirium diagnosis was 7 years (interquartile range: 4-10), with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (N = 21) and 45% (N = 15) of studies, respectively, with 33% (N = 11) using both and 27% (N = 9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% of studies (N = 23) used all available information for delirium diagnosis, whereas 15% excluded such patients. Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels, and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results.
    The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 03/2014; · 3.35 Impact Factor
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    ABSTRACT: To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium. Secondary data analysis. An urban, public hospital and healthcare system. 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). 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. 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. 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.
    Journal of the American Geriatrics Society 02/2014; · 4.22 Impact Factor
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    ABSTRACT: : End-stage heart failure patients are being supported with continuous flow left ventricular assist devices (CF-LVAD) in increasing numbers. The severe physiologic and pharmacologic derangements associated with end-stage heart failure therapies predispose these patients to delirium. During a delirious episode, a patient may inadvertently disconnect CF-LVAD equipment, which may have dangerous consequences. Unfortunately, it is not yet routine to use readily available clinical monitoring tools to allow early detection of delirium in this high-risk population. The authors present a case of acute hyperactive delirium leading to pump power disconnection and cardiopulmonary arrest occurring 7 days after CF-LVAD implantation. The case highlights the need for delirium awareness in the cardiovascular intensive care unit and the unique challenges associated with resuscitation of CF-LVAD patients. The authors propose that cardiovascular intensive care unit patients undergo at least twice daily delirium monitoring and provide a novel resuscitation algorithm for patients who have CF-LVADs.
    The American Journal of the Medical Sciences 02/2014; · 1.33 Impact Factor
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    ABSTRACT: Objectives In the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (
    Academic Emergency Medicine 02/2014; 21(2). · 2.20 Impact Factor

Publication Stats

8k Citations
1,354.28 Total Impact Points


  • 2000–2014
    • Vanderbilt University
      • • Department of Internal Medicine
      • • Department of Anesthesiology
      • • Center for Health Services Research
      • • Department of Medicine
      • • Department of Biostatistics
      • • Division of Allergy, Pulmonary and Critical Care
      Nashville, Michigan, United States
  • 2013
    • Northwestern University
      Evanston, Illinois, United States
    • Regenstrief Institute, Inc.
      Indianapolis, Indiana, United States
  • 2012
    • University of Nebraska at Omaha
      • College of Nursing
      Omaha, NE, United States
    • Masaryk University
      • Neurologická klinika
      Brno, South Moravian Region, Czech Republic
  • 2011
    • Imperial College London
      • Section of Anaesthetics, Pain Medicine, and Intensive Care (APMIC)
      London, ENG, United Kingdom
  • 2010
    • Prince of Wales Hospital and Community Health Services
      Sydney, New South Wales, Australia
  • 2009
    • Hospital Clínico Universidad de Chile
      CiudadSantiago, Santiago, Chile
    • Middle Tennessee Medical Center
      Murfreesboro, Tennessee, United States
    • Brigham and Women's Hospital
      • Division of Pulmonary and Critical Care Medicine
      Boston, MA, United States
  • 2007
    • Brigham Young University - Provo Main Campus
      • Department of Psychology
      Provo, UT, United States
    • Baylor Health Care System
      Dallas, Texas, United States
  • 2005
    • Brown University
      • Division of Infectious Diseases
      Providence, RI, United States
  • 2004–2005
    • Yale University
      • Department of Internal Medicine
      New Haven, CT, United States
    • University of Pittsburgh
      • Department of Critical Care Medicine
      Pittsburgh, PA, United States
  • 2002
    • Emory University
      • Division of Pulmonary, Allergy and Critical Care Medicine
      Atlanta, GA, United States
    • University of Minnesota Twin Cities
      • Department of Medicine
      Minneapolis, MN, United States
  • 1994–1999
    • Wake Forest School of Medicine
      • Department of Internal Medicine
      Winston-Salem, NC, United States