E Wesley Ely

Vanderbilt University, Нашвилл, Michigan, United States

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Publications (299)2080.44 Total impact

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    ABSTRACT: Delirium is common in mechanically ventilated patients and is associated with cognitive impairment lasting at least 1 year after hospital discharge. Preclinical and observational studies suggest that the use of statins might reduce delirium in intensive care. We assessed whether the pleiotropic effects of statins can reduce delirium in intensive care and decrease subsequent cognitive impairment in a randomised controlled trial.
    No preview · Article · Jan 2016 · The Lancet Respiratory Medicine
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    ABSTRACT: When robust clinical trials are lacking, clinicians are often forced to extrapolate safe and effective evidence-based interventions from one patient care setting to another. This article is about such an extrapolation from the intensive care unit (ICU) to the long-term acute care hospital (LTACH) setting. Chronic critical illness is an emerging, disabling, costly, and yet relatively silent epidemic that is central to both of these settings. The number of chronically critically ill patients requiring prolonged mechanical ventilation is expected to reach unprecedented levels over the next decade. Despite the prevalence, numerous distressing symptoms, and exceptionally poor outcomes associated with chronic critical illness, to date there is very limited scientific evidence available to guide the care and management of this exceptionally vulnerable population, particularly in LTACHs. Recent studies conducted in the traditional ICU setting suggest interprofessional, multicomponent strategies aimed at effectively assessing, preventing, and managing pain, agitation, delirium, and weakness, such as the ABCDEF bundle, may play an important role in the recovery of the chronically critically ill. This article reviews what is known about the chronically critically ill, provide readers with some important historical perspectives on the ABCDEF bundle, and address some controversies and practical implications of adopting the ABCDEF bundle into the everyday care of patients requiring prolonged mechanical ventilation in the LTACH setting. We believe developing new and better ways of addressing both the science and organizational aspects of managing the common and distressing symptoms associated with chronic critical illness and prolonged mechanical ventilation will ultimately improve the quality of life for the many patients and families admitted to LTACHs annually.
    No preview · Article · Jan 2016 · Seminars in Respiratory and Critical Care Medicine
  • Timothy D. Girard · Robert S. Dittus · E. Wesley Ely
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    ABSTRACT: A growing body of literature has shown that survivors of critical illness often struggle with cognitive impairment that persists months to years after hospital discharge. We describe the epidemiology of this form of cognitive impairment-which we refer to as critical illness brain injury-and review the history and maturation of the investigation of this previously unrecognized, yet common problem. We then review the characteristics of critical illness brain injury, which can vary in severity and typically affects multiple domains of cognition. Finally, we examine known risk factors for critical illness brain injury and, based on these data, suggest approaches to patient management.
    No preview · Article · Jan 2016 · Annual Review of Medicine
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    ABSTRACT: Rationale: The incidence and risk factors of posttraumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience has not been reported in a mixed Veteran and civilian cohort. Objectives: To describe the incidence and risk factors for PTSD related to critical illness and the ICU experience in veterans and civilians. Methods: This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness following respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without pre-existing PTSD (i.e. PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3- and 12-months post-hospitalization. Measurements and main results: Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in 1-8% of patients at either follow-up time points, whether assessed by PTSD Checklist-Event Specific Version score (PCL-S score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, pre-existing PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was pre-existing depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48). Conclusions: This study found around one in ten ICU survivors experienced ICU-related PTSD (i.e. PTSD anchored to their critical illness) in the year after hospitalization. Pre-existing PTSD and depression were strongly associated with ICU-related PTSD.
    No preview · Article · Jan 2016 · American Journal of Respiratory and Critical Care Medicine

  • No preview · Article · Nov 2015 · Critical care medicine

  • No preview · Article · Nov 2015 · Critical Care Medicine
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    ABSTRACT: Objective: To characterize fentanyl population pharmacokinetics in patients with critical illness and identify patient characteristics associated with altered fentanyl concentrations. Design: Prospective cohort study. Setting: Medical and surgical ICUs in a large tertiary care hospital in the United States. Patients: Patients with acute respiratory failure and/or shock who received fentanyl during the first 5 days of their ICU stay. Measurements and main results: We collected clinical and hourly drug administration data and measured fentanyl concentrations in plasma collected once daily for up to 5 days after enrollment. Among 337 patients, the mean duration of infusion was 58 hours at a median rate of 100 μg/hr. Using a nonlinear mixed-effects model implemented by NONMEM, we found that fentanyl pharmacokinetics were best described by a two-compartment model in which weight, severe liver disease, and congestive heart failure most affected fentanyl concentrations. For a patient population with a mean weight of 92 kg and no history of severe liver disease or congestive heart failure, the final model, which performed well in repeated 10-fold cross-validation, estimated total clearance, intercompartmental clearance (Q), and volumes of distribution for the central (V1) and peripheral compartments (V2) to be 35 L/hr (95% CI, 32-39 L/hr), 55 L/hr (95% CI, 42-68 L/hr), 203 L (95% CI, 140-266 L), and 523 L (95% CI, 428-618 L), respectively. Severity of illness was marginally associated with fentanyl pharmacokinetics but did not improve the model fit after liver and heart diseases were included. Conclusions: In this study, fentanyl pharmacokinetics during critical illness were strongly influenced by severe liver disease, congestive heart failure, and weight, factors that should be considered when dosing fentanyl in the ICU. Future studies are needed to determine if data-driven fentanyl dosing algorithms can improve outcomes for ICU patients.
    No preview · Article · Oct 2015 · Critical care medicine
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    ABSTRACT: Objectives: The Sequential Organ Failure Assessment and other severity of illness scales rely on the Glasgow Coma Scale to measure acute neurologic dysfunction, but the Glasgow Coma Scale is unavailable or inconsistently applied in some institutions. The objective of this study was to assess the validity of a modified Sequential Organ Failure Assessment that uses the Richmond Agitation-Sedation Scale instead of Glasgow Coma Scale. Design: Prospective cohort study. Setting: Medical and surgical ICUs within a large, tertiary care hospital. Patients: Critically ill medical/surgical ICU patients. Interventions: We calculated daily Sequential Organ Failure Assessment scores by using electronic medical record-derived data. By using bedside nurse-recorded Glasgow Coma Scale and Richmond Agitation-Sedation Scale measures, we calculated neurologic Sequential Organ Failure Assessment scores using the original Glasgow Coma Scale-based approach and a novel Richmond Agitation-Sedation Scale-based approach, converting the 10-point Richmond Agitation-Sedation Scale to a 4-point neurologic Sequential Organ Failure Assessment score. We assessed construct validity of Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment by analyzing correlations with established severity of illness constructs (Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale-based Sequential Organ Failure Assessment) and predictive validity by using logistic regression to determine whether Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment predicts ICU, hospital, and 1-year mortality. We assessed discriminative performance with c-statistics. Main results: Among 513 patients (5,199 patient-days), Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment was strongly correlated with Acute Physiology and Chronic Health Evaluation II acute physiology score at enrollment (r = 0.583; 95% CI, 0.518-0.642) and daily Glasgow Coma Scale-based Sequential Organ Failure Assessment scores (r = 0.963; 95% CI, 0.956-0.968). Mean Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment scores predicted ICU mortality (areas under the curve = 0.814)-as did mean Glasgow Coma Scale-based Sequential Organ Failure Assessment (0.799)-as well as hospital and 1-year mortality. Admission Sequential Organ Failure Assessment scores, whether using Richmond Agitation-Sedation Scale or Glasgow Coma Scale, were less accurate predictors of mortality; areas under the curves for ICU mortality for Richmond Agitation-Sedation Scale-based and Glasgow Coma Scale-based Sequential Organ Failure Assessment, for example, were 0.622 and 0.608, respectively. Conclusion: A modified Sequential Organ Failure Assessment score that uses bedside Richmond Agitation-Sedation Scale when Glasgow Coma Scale data are not available is a valid means of assessing daily severity of illness in the ICU and may be valuable for risk-adjustment and benchmarking purposes.
    No preview · Article · Oct 2015 · Critical care medicine

  • No preview · Article · Jul 2015
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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.
    No preview · Article · Jun 2015 · Academic Emergency Medicine
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    ABSTRACT: Background: 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. Methods/design: 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. Discussion: This study supports a telephone-delivery approach to rehabilitation services in order to broaden the availability of evidence-based cognitive strategies.
    Full-text · Article · Jun 2015 · Trials
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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.
    Full-text · Article · May 2015 · PLoS ONE
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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.
    Full-text · Article · May 2015 · Trials
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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.
    Full-text · Article · May 2015 · Critical care (London, England)
  • E Wesley Ely

    No preview · Article · May 2015 · The Linacre quarterly
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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.
    No preview · Article · Apr 2015 · Annals of Pharmacotherapy
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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.
    Full-text · Article · Apr 2015 · Critical care (London, England)
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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.
    Full-text · Article · Apr 2015 · Journal of Critical Care
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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.
    No preview · Article · Mar 2015 · Critical Care Medicine
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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.
    No preview · Article · Mar 2015 · Journal of the American Medical Directors Association

Publication Stats

21k Citations
2,080.44 Total Impact Points


  • 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
  • 2012
    • Charité Universitätsmedizin Berlin
      • Department of Anesthesiology and Operative Intensive Care Medicine
      Berlin, Land Berlin, Germany
  • 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
  • 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
  • 1991-2001
    • Wake Forest University
      • School of Medicine
      Winston-Salem, North Carolina, United States
  • 1996-1998
    • Wake Forest School of Medicine
      • Department of Internal Medicine
      Winston-Salem, North Carolina, United States