E Wesley Ely

Vanderbilt University, Нашвилл, Michigan, United States

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Publications (277)1727.06 Total impact

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    ABSTRACT: Delirium is frequently missed in older emergency department (ED) patients. Brief (<2 minutes) delirium assessments have been validated for the ED, but some ED health care providers may consider them to be cumbersome. The Richmond Agitation Sedation Scale (RASS) is an observational scale that quantifies level of consciousness and takes less than 10 seconds to perform. The authors sought to explore the diagnostic accuracy of the RASS for delirium in older ED patients. This was a preplanned analysis of a prospective observational study designed to validate brief delirium assessments for the ED. The study was conducted at an academic ED and enrolled patients who were 65 years or older. Patients who were non-English-speaking, deaf, blind, comatose or had end-stage dementia were excluded. A research assistant (RA) and a physician performed the RASS at the time of enrollment. Within 3 hours, a consultation-liaison psychiatrist performed his or her comprehensive reference standard assessment for delirium using Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) criteria. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (CIs) were calculated. Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the consult-liaison psychiatrist reference rater. When performed by the RA, a RASS other than 0 (RASS > 0 or < 0) was 84.0% sensitive (95% CI = 73.8% to 94.2%) and 87.6% specific (95% CI = 84.2% to 91.1%) for delirium. When performed by physician, a RASS other than 0 was 82.0% sensitive (95% CI = 71.4% to 92.6%) and 85.1% specific (95% CI = 81.4% to 88.8%) for delirium. Using a RASS > +1 or < -1 as the cutoff, the specificity improved to approximately 99% for both raters at the expense of sensitivity; the sensitivities were 22.0% (95% CI = 10.5% to 33.5%) and 16.0% (95% CI = 5.8% to 25.2%) in the RAs and physician raters, respectively. The positive likelihood ratio was 19.6 (95% CI = 6.5 to 59.1) when performed by the RA and 57.0 (95% CI = 7.3 to 445.9) when performed by the physician, indicating that a RASS > +1 or < -1 strongly increased the likelihood of delirium. The weighted kappa was 0.63, indicating moderate interobserver reliability. In older ED patients, a RASS other than 0 has very good sensitivity and specificity for delirium as diagnosed by a psychiatrist. A RASS > +1 or < -1 is nearly diagnostic for delirium, given the very high positive likelihood ratio. © 2015 by the Society for Academic Emergency Medicine.
    Academic Emergency Medicine 06/2015; 22(7). DOI:10.1111/acem.12706 · 2.20 Impact Factor
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    ABSTRACT: Approximately 1 million individuals experience a mild traumatic brain injury (TBI) and cost the United States nearly $17 billion each year. Many trauma survivors with mild TBI have debilitating and long-term physical, emotional, and cognitive impairments that are unrecognized at trauma centers. Early intervention studies are needed to address these impairments, especially cognitive deficits in executive functioning. Goal management training (GMT) is a structured cognitive rehabilitation program that has been found to improve executive functioning in patients with moderate to severe TBI. The current study adapted the GMT program for telephone delivery in order to improve the accessibility of rehabilitation services in a patient population with multiple barriers to care and significant yet unrecognized cognitive impairment. The primary objective of this study is to examine the efficacy of telephone-based GMT for improving executive functioning, functional status, and psychological health in trauma survivors with mild TBI. This study is a three-group randomized controlled trial being conducted at a Level I trauma center. Ninety trauma survivors with mild TBI and cognitive deficits in executive functioning will be randomized to receive telephone-based GMT, telephone-based education, or usual care. GMT and education programs will be delivered by a physical therapist. The first in-person session is 1 h and the remaining six telephone sessions are 30 min. A battery of well-established cognitive tests will be conducted and validated questionnaires will be collected that measure executive functioning, functional status, and depressive and posttraumatic stress disorder symptoms at 6 weeks, 4 months, and 7 months following hospital discharge. This study supports a telephone-delivery approach to rehabilitation services in order to broaden the availability of evidence-based cognitive strategies. This trial was registered with Clinicaltrials.gov on 10 October 2012, registration number: NCT01714531 .
    Trials 06/2015; 16(1):244. DOI:10.1186/s13063-015-0775-1 · 2.12 Impact Factor
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    ABSTRACT: Immunosuppressed states may predispose patients to development of acute brain injury during times of critical illness. Lymphopenia is a non-specific yet commonly used bedside marker of immunosuppressed states. We examined whether lymphopenia would predict development of acute brain dysfunction (delirium and/or coma) in 518 patients enrolled in the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study in medical and surgical ICUs of a tertiary care, university-based medical center. Utilizing proportional odds logistic regression and Cox proportional hazards survival analysis, we assessed the relationship between pre-enrollment lymphocytes and subsequent cognitive outcomes including delirium- and coma-free days (DCFDs) and 30-day mortality. There were no statistically significant associations between lymphocytes and DCFDs (p = 0.17); additionally, the relationship between lymphocytes and mortality was not statistically significant (p = 0.71). Among 259 patients without history of cancer or diabetes, there was no statistically significant association between lymphocytes and DCFDs (p = 0.07). lymphopenia, a commonly used bedside marker of immunosuppression, does not appear to be a marker of risk for acute brain injury (delirium/coma) or 30-day mortality in general medical/surgical ICU patients.
    PLoS ONE 05/2015; 10(5):e0126216. DOI:10.1371/journal.pone.0126216 · 3.23 Impact Factor
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    ABSTRACT: The incidence of delirium in ventilated patients is estimated at up to 82%, and it is associated with longer intensive care and hospital stays, and long-term cognitive impairment and mortality. The pathophysiology of delirium has been linked with inflammation and neuronal apoptosis. Simvastatin has pleiotropic properties; it penetrates the brain and, as well as reducing cholesterol, reduces inflammation when used at clinically relevant doses over the short term. This is a single centre randomised, controlled trial which aims to test the hypothesis that treatment with simvastatin will modify delirium incidence and outcomes. The ongoing study will include 142 adults admitted to the Watford General Hospital Intensive Care Unit who require mechanical ventilation in the first 72 hours of admission. The primary outcome is the number of delirium- and coma-free days in the first 14 days. Secondary outcomes include incidence of delirium, delirium- and coma-free days in the first 28 days, days in delirium and in coma at 14 and 28 days, number of ventilator-free days at 28 days, length of critical care and hospital stay, mortality, cognitive decline and healthcare resource use. Informed consent will be taken from patient's consultee before randomisation to receive either simvastatin (80 mg) or placebo once daily. Daily data will be recorded until day 28 after randomisation or until discharge from the ICU if sooner. Surviving patients will be followed up on at six months from discharge. Plasma and urine samples will be taken to investigate the biological effect of simvastatin on systemic markers of inflammation, as related to the number of delirium- and coma-free days, and the potential of cholinesterase activity and beta-amyloid as a predictor of the risk of delirium and long-term cognitive impairment. This trial will test the efficacy of simvastatin on reducing delirium in the critically ill. If patients receiving the statin show a reduced number of days in delirium compared with the placebo group, the inflammatory theory implicated in the pathogenesis of delirium will be strengthened. The trial was registered with the International Standard Randomised Controlled Trial Registry ( ISRCTN89079989 ) on 26 March 2013.
    Trials 05/2015; 16(1):218. DOI:10.1186/s13063-015-0731-0 · 2.12 Impact Factor
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    ABSTRACT: The Mini-Mental State Examination (MMSE) is a common cognitive screening test, but its utility in identifying impairments in survivors of acute respiratory failure is unclear. The purpose of this study was to evaluate MMSE performance versus a concurrently-administered detailed neuropsychological test battery in survivors of acute respiratory failure. This cross-sectional analysis used data from the ARDSNet Long Term Outcomes Study (ALTOS) and Awakening and Breathing Controlled Trial (ABC). Participants were 242 survivors of acute respiratory failure. The MMSE and detailed neuropsychological tests were administered at 6 and 12 months post-hospital discharge for ALTOS, and at hospital discharge, 3 and 12 months for ABC. Overall cognitive impairment identified by the MMSE (score <24) was compared to impairments identified by the neuropsychological tests. We also matched orientation, registration, attention, memory and language domains on the MMSE to the corresponding neuropsychological test. Pairwise correlations, sensitivity, specificity, positive and negative predictive value, and agreement were assessed. Agreement between MMSE and neuropsychological tests for overall cognitive impairment was fair (42%-80%). Specificity was excellent ≥93%, but sensitivity was poor (19-37%). Correlations between MMSE domains and corresponding neuropsychological tests were weak to moderate (6-month: r = 0.11-0.28; 12-month: r = 0.09-0.34). The highest correlation between the MMSE and neuropsychological domains was for attention at 6 months (r = 0.28) and language at 12 months (r = 0.34). In acute respiratory failure survivors, the MMSE has poor sensitivity in detecting cognitive impairment compared with concurrently-administered detailed neuropsychological tests. MMSE results in this population should be interpreted with caution.
    Critical care (London, England) 05/2015; 19(1):220. DOI:10.1186/s13054-015-0934-5
  • E Wesley Ely
    The Linacre quarterly 05/2015; 82(2):112-5. DOI:10.1179/0024363915Z.000000000118
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    ABSTRACT: Coordinating efforts across disciplines in the intensive care unit is a key component of quality improvement (QI) efforts. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are considered key components of guidelines, yet unfortunately are often not done or coordinated properly. To determine if a pharmacist-driven awakening and breathing coordination (ABC) QI program would improve compliance (ie, process measures) as compared with the previous protocol, which did not involve pharmacists. The QI program included pharmacist-led education, daily discussion on rounds, and weekly performance reports to staff. Using a pre-QI versus during-QI versus post-QI intervention design, we compared data from 500 control ventilator-days (pre-QI period) versus 580 prospective ventilator-days (during-QI period). We then evaluated the sustainability of the QI program in 216 ventilator-days in the post-QI period. SAT safety screens were performed on only 20% pre-QI patient-days versus 97% of during-QI patient-days (P < 0.001) and 100% of post-QI patient-days (P = 0.25). The rates of passing the SAT safety screen in pre-QI and during-QI periods were 63% versus 78% (P = 0.03) and 81% in the post-QI period (P = 0.86). The rates of SATs among eligible patients on continuous infusions were only 53% in the pre-QI versus 85% in the during-QI (P = 0.0001) and 87% in the post-QI (P = 1) periods. In this QI initiative, a pharmacist-driven, interdisciplinary ABC protocol significantly improved process measures compliance, comparing the pre-QI versus during-QI rates of screening, performing, and coordinating SAT and SBTs, and these results were sustained in the 8-month follow-up period post-QI program. © The Author(s) 2015.
    Annals of Pharmacotherapy 04/2015; 49(8). DOI:10.1177/1060028015582050 · 2.92 Impact Factor
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    ABSTRACT: Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes. We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described. We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioural change ,was also associated with reduced mortality. Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.
    Critical care (London, England) 04/2015; 19(1):157. DOI:10.1186/s13054-015-0886-9
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    ABSTRACT: The purpose of the study is to determine if pharmacologic approaches are effective in prevention and treatment of delirium in critically ill patients. We performed a systematic search to identify publications (from January 1980 to September 2014) that evaluated the pharmacologic interventions to treat or prevent delirium in intensive care unit (ICU) patients. From 2646 citations, 15 studies on prevention (6729 patients) and 7 studies on treatment (1784 patients) were selected and analyzed. Among studies that evaluated surgical patients, the pharmacologic interventions were associated with a reduction in delirium prevalence, ICU length of stay, and duration of mechanical ventilation, but with high heterogeneity (respectively, I(2) = 81%, P = .0013; I(2) = 97%, P < .001; and I(2) = 97%). Considering treatment studies, only 1 demonstrated a significant decrease in ICU length of stay using dexmedetomidine compared to haloperidol (Relative Risk, 0.62 [1.29-0.06]; I(2) = 97%), and only 1 found a shorter time to resolution of delirium using quetiapine (1.0 [confidence interval, 0.5-3.0] vs 4.5 [confidence interval, 2.0-7.0] days; P = .001). The use of antipsychotics for surgical ICU patients and dexmedetomidine for mechanically ventilated patients as a preventive strategy may reduce the prevalence of delirium in the ICU. None of the studied agents that were used for delirium treatment improved major clinical outcome, including mortality. Copyright © 2015. Published by Elsevier Inc.
    Journal of Critical Care 04/2015; 30(4). DOI:10.1016/j.jcrc.2015.04.005 · 2.19 Impact Factor
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    ABSTRACT: To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness. We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living, instrumental activities of daily living, and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations. We identified 19 studies evaluating disability outcomes in critically ill patients who were 65 years and older. Descriptive epidemiologic data on disability after critical illness. Newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less severe cognitive impairment were also highly prevalent. Factors related to the acute critical illness, ICU practices, such as heavy sedation, physical restraints, and immobility, as well as aging physiology, and coexisting geriatric conditions can combine to result in these poor outcomes. Older adults who survive critical illness have physical and cognitive declines resulting in disability at greater rates than hospitalized, noncritically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.
    Critical Care Medicine 03/2015; 43(6). DOI:10.1097/CCM.0000000000000924 · 6.15 Impact Factor
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    ABSTRACT: Poor cognitive function is associated with negative consequences across settings of care, but research instruments are arduous for routine clinical implementation. This study examined the association between impaired arousal, as measured using an ultra-brief screen, and risk of 2 adverse clinical outcomes: hospital length of stay and discharge to a skilled nursing facility (SNF). A secondary data analysis was conducted using 2 separate groups of medical ward patients: a Veterans Affairs medical center in the northeast (N = 1487, between 2010 and 2012) 60 years and older and a large tertiary care, university-based medical center (N = 669, between 2007 and 2013) 65 years and older in the southeastern United States. The impact of impaired arousal, defined by the Richmond Agitation Sedation Scale as anything other than "awake and alert," was determined using Cox Proportional Hazard Regression for time to hospital discharge and logistic regression for discharge to a SNF. Hazard ratios (HRs) and odds ratios (OR) with their 95% confidence intervals (CI) are reported, respectively. Both models were adjusted age, sex, and dementia. The 2156 total patients included in these groups had a mean age of 76 years, of whom 16.4% in group 1 and 28.5% in group 2 had impaired arousal. In the first group, patients with normal arousal spent an average of 5.9 days (standard deviation 6.2) in the hospital, while those with impaired arousal spent 8.5 days (9.2). On any given day, patients with impaired arousal had 27% lower chance of being discharged (adjusted HR 0.73 (95% CI 0.63-0.84). In the second group, individuals with normal arousal spent 3.8 (4.1) days in the hospital compared with 4.7 (4.6) for those with impaired arousal; indicating a 21% lower chance of being discharged [adjusted HR 0.79 (95% CI 0.66-0.95). With regard to risk of discharge to SNF, those with impaired arousal in group 1 had a 65% higher risk than those without impaired arousal [adjusted OR 1.65 (95% CI 1.21-2.25)], and those in group 2 had a nonsignificant 27% higher risk [adjusted OR 1.27 (0.80-2.03)]. Because of the quality improvement nature, this analysis did not control for comorbidities, which is a significant limitation. In this study of over 2000 older hospitalized patients, the simple observation of an abnormal arousal level may be an independent predictor of a longer hospital stay and discharge to SNF. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of the American Medical Directors Association 03/2015; 16(7). DOI:10.1016/j.jamda.2015.01.093 · 4.78 Impact Factor
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    ABSTRACT: We undertook this pilot prospective cohort investigation to examine the feasibility of functional magnetic resonance imaging (fMRI) assessments in survivors of critical illness and to analyze potential associations between delirium and brain activation patterns observed during a working memory task (N-back) at hospital discharge and 3-month follow-up. At hospital discharge and 3 months later, fMRI assessed subjects' functional activity during an N-back task. Multiple linear regression was used to examine associations between duration of delirium and brain activity, and elastic net regression was used to assess the relationship between brain activation patterns at 3 months and cognitive outcomes at 12 months. Of 47 patients who underwent fMRI at discharge, 38 (80%) completed the protocol; of 37 who underwent fMRI at 3 months, 34 (91%) completed the protocol. At discharge, the mean (SD) percentage of correct responses on the most challenging version (the N2 version) of the N-back task was 70.4 (23.2; range of 20-100) compared with 76 (23.4; range of 33-100) at 3 months. No association was observed between delirium duration in the hospital and brain region activity in any brain region at discharge or 3 months after adjusting for relevant covariates (P values across all 11 brain regions of interest were >.25). Our data support the feasibility of using fMRI in survivors of critical illness at 3-month follow-up but not at discharge. In this small study, delirium was not associated with distinct or abnormal brain activation patterns, although overall performance on a cognitive task of working memory was poorer than observed in other cohorts of individuals with medically related executive dysfunction, mild cognitive impairment, and mild traumatic brain injury. Copyright © 2015. Published by Elsevier Inc.
    Journal of Critical Care 01/2015; 30(3). DOI:10.1016/j.jcrc.2015.01.017 · 2.19 Impact Factor
  • E Wesley Ely
    Annals of internal medicine 01/2015; 162(2):152-153. DOI:10.7326/M14-1691 · 16.10 Impact Factor
  • American Journal of Respiratory and Critical Care Medicine 01/2015; 191(1):10-1. DOI:10.1164/rccm.201412-2179ED · 11.99 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 12/2014; 9(12). DOI:10.1002/jhm.2276 · 2.08 Impact Factor
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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. DOI:10.1097/CCM.0000000000000660 · 6.15 Impact Factor
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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; 31(3). DOI:10.1016/j.iccn.2014.10.002
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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; 191(3). DOI:10.1164/rccm.201407-1394OC · 11.99 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; DOI:10.1016/j.apmr.2014.08.005 · 2.44 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; 21(8). DOI:10.1111/acem.12436 · 2.20 Impact Factor

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18k Citations
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Institutions

  • 1999–2015
    • Vanderbilt University
      • • Department of Medicine
      • • Center for Health Services Research
      • • Division of Allergy, Pulmonary and Critical Care
      • • Department of Internal Medicine
      Нашвилл, Michigan, United States
  • 2011
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States
  • 2009
    • Hospital Clínico Universidad de Chile
      CiudadSantiago, Santiago, Chile
    • Middle Tennessee Medical Center
      Murfreesboro, Tennessee, United States
  • 2007
    • Trevecca Nazarene University
      Nashville, Tennessee, United States
  • 2001–2003
    • Johns Hopkins University
      • Department of Medicine
      Baltimore, Maryland, 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
  • 1995–1999
    • Wake Forest University
      • Department of Internal Medicine
      Winston-Salem, North Carolina, United States
  • 1996–1998
    • Wake Forest School of Medicine
      • Department of Internal Medicine
      Winston-Salem, North Carolina, United States