Better Trading Strategies For Investors And Traders

Information in this article cannot be perceived as a call for investing or buying/selling of any asset on the exchange. All situations, discussed in the article, are provided with the purpose of getting acquainted with the functionality and advantages of the ATAS platform. Reversal trading is a trading system, the aim of which is to identify the price reversal and the end of the current trend. This strategy is considered to be the most complex and risky one, since it is difficult to identify true price reversals. First, it is necessary to identify the range, within which the price has stayed for some time. The price range is limited by the resistance and support levels.

strategies for trading

Trend trades are often open over several days so they may incur more overnight risks than other strategies. However, this can be mitigated by placing stop-loss orders. Some trades will be held overnight, incurring additional risks, but this can be mitigated by placing a stop-loss order on your positions. This style of trading requires less time commitment than other trading strategies. This is because there is only a need to study charts at their opening and closing times. Depending on the type of news, trading positions may be open over several days.

Grid trading is a breakout trading technique that attempts to capitalize on a new trend as it takes shape. Unlike other breakout trading strategies, however, grid trading eliminates the need to know what direction the trend will take. News traders rely on economic calendars and indexes such as the consumer confidence index to anticipate when a change will occur and in what direction price will move.

Technical traders believe all information about a given security is contained in its price and that it moves in trends. For example, a simple trading strategy may be amoving averagecrossover whereby a short-term moving average crosses above or below a long-term moving average. Here we will extend this investigation to other financial markets and for new trading strategies.

More Choices More Ways To Invest How You Want

Mobileye, an Israeli company that Intel bought for about $15 billion five years ago, could be valued at more than $50 billion during its U.S. initial public offering in mid-2022, sources told Reuters. Put-call parity is an important concept in options pricing which shows how the prices of puts, calls, and the underlying asset must be consistent with trading strategy one another. This equation establishes a relationship between the price of a call and put option which have the same underlying asset. This fits in with the investor’s prediction and provides high payoffs when the price is low. The diagram also shows that the bear put’s payoff shown by the orange line decreases steadily with the rise in price.

strategies for trading

Getting in early is part of the game, but getting in too early can be reckless. More experienced traders will often wait for confirmation of the breakout before acting on a hunch. Trend trading doesn’t require traders to know what will happen next—only to understand what is happening right now.

If it does, proceed to trade the strategy in ademo account in real time. If it’s profitable over the course of two months or more in a simulated environment, proceed with day trading the strategy with real capital. A strategy doesn’t need to win all the time to be profitable. However, they make more on their winners than they lose on their losers.

Uncle Sam will also want a cut of your profits, no matter how slim. Remember that you’ll have to pay taxes on any short-term gains—or any investments you hold for one year or less—at the marginal rate. This page which contains Currency Risk our free trading strategies might give you input on how to start trading. Trading is not easy, and certainly much more demanding than long-term investing. Among prop traders long/short and pairs trading are popular.

Bitcoin And Crypto Trading Strategies:

Specifically, this means how pricing and trading volumes have changed over time. You trade based on trend lines and price movement, metrics that make use of charts and graphs. If the share price has shown volatility that leads you to expect future losses, you might sell.

Where is the average calculated in each time window of size . In general, exhibits a power-law dependence with exponent , i.e. Tuesday’s gains will help Intel add $17 billion to its market capitalization.

Eric’s work focuses on the human impact of abstract issues, emphasizing analytical journalism that helps readers more fully understand their world and their money. He has reported from more than a dozen countries, with datelines that include Sao Paolo, Brazil; Phnom Penh, Cambodia; and Athens, Greece. A former attorney, before becoming a journalist Eric worked in securities litigation and white collar criminal defense with a pro bono specialty in human trafficking issues. He graduated from the University of Michigan Law School and can be found any given Saturday in the fall cheering on his Wolverines.

Cut Losses With Limit Orders

Many of the offers appearing on this site are from advertisers from which this website receives compensation for being listed here. This compensation may impact how and where products appear on this site . These offers do not represent all available deposit, investment, loan or credit products. Any historical returns, expected returns, or probability projections may not reflect actual future performance.

An increase in a stock’s volume is often a harbinger of a price jump, either up or down. Decide what type of orders you’ll use to enter and exit trades. When you place a market order, it’s executed at the best price available at the time—thus, no price guarantee. Make a wish list of stocks you’d like to trade and keep yourself informed about the selected companies and general markets. While trading offers scalability and huge profit potential, consider the time spent and risk of ruin.

  • The price target is whatever figure translates into “you’ve made money on this deal.”FadingFading involves shorting stocks after rapid moves upward.
  • Varying time periods (long, medium, and short-term) correspond to different trading strategies.
  • Emotions have no place in any successful strategy (and can destroy your dream!).

Investors are looking for markets where the price action is moving constantly to capitalize on fluctuations in small increments. A popular advice in this regard is to set a risk limit at each trade. For instance, traders tend to set a 1% limit on their trades, meaning they won’t risk more than 1% of their account on a single trade.

However, with enough confidence in their trading system, the trend trader should be able to stay disciplined and follow their rules. However, it’s equally important to know when your system has stopped working. This usually occurs Credit note due to a fundamental market change, therefore it’s important to cut your losses short and let your profits run when trend trading. Markets need energy to move and this comes from information flow such as news releases.

Rotation Strategies Free Momentum Strategies:

Given the aggressiveness of this method, it is crucial to concentrate as much as possible so as not to suffer from losses. Indeed, the trader using scalping positions himself on a multitude of sales and purchases. Each of these positions taken separately yields very little. It is also referred to as black-box trading or trading via robots. It is enough for the trader to put in place a certain number of rules and conditions for the computer program to follow his preferences to the letter. When traders buy stock, they also need to think about their exit strategy.

Position Trading

Adam received his master’s in economics from The New School for Social Research and his Ph.D. from the University of Wisconsin-Madison in sociology. He is a CFA charterholder as well as holding FINRA Series 7 & 63 licenses. He currently researches and teaches at the Hebrew University in Jerusalem. A countertrend strategy targets corrections in a trending security’s price action to make money. A sell signal is a condition or measurable level at which an investor is alerted to sell a specified investment and can have an impact on performance. Today’s high refers to a security’s intraday high trading price or the highest price at which a stock traded during the course of the day.

Although there is a lot of confusion between ‘style’ and ‘strategy’, there are some important differences that every trader should know. There are four high-level trading strategies that every trader should know. This strategy describes when a trader uses technical analysis to define a trend, and only enters trades in the direction of the pre-determined trend. A day trader can make use of local and international markets and can open and close many positions within the day, including taking advantage of 24/7forex market hours.

Mutual Funds And Mutual Fund Investing

If you’re just starting out in forex, day-trading strategies that demand quick action and require you to manage multiple trades at a time may not be ideal learning environments. Instead, opt for a more straightforward, long-term strategy that will give you the time you need to learn technical analysis, practice smart money management, and reflect on your performance. Breakout trading is used by active index investors to take a position within a trend’s early stages. Generally speaking, this strategy can be the starting point for major price moves, expansions in volatility, and when managed properly, can offer limited downside risk. A breakout is a price moving outside a defined support or resistance level with increased volume. Here, a breakout trader will enter a long position on an index after the price breaks above resistance or enters a short position after the price breaks below support.

Pairs trading is finding the correlated pair of instruments where the valuation relationship has gone out of whack, buying under-priced instruments and the selling the overpriced ones. The aim is to make a profit irrespective of market conditions such as downtrends, uptrends and so on. Successful traders often track their profits and losses, which helps to maintain their consistency and discipline across all trades. Consult our article on creating atrading plan template that could help to improve your trade performance. End-of-day trading can be a good way to start trading, as there is no need to enter multiple positions.

Proven Currency Trading Strategies: How To Profit In The Forex Market, + Website By

Finally, if price breaks through this established range, it may be a sign that a new trend is about to take shape. Range traders are less interested in anticipating breakouts and more interested in markets that oscillate between support and resistance levels without trending in one direction for an extended period. Even when a market is trending, there are bound to be small price fluctuations that go against the prevailing trend direction. For this reason, trend trading favors a long-term approach known as position trading. For obvious reasons, trend traders favor trending markets or those that swing between overbought and oversold thresholds with relative predictability.

This strategy, one of the most common forms of active investing, is based on publicly available information. For example, if the weather looks bad in a coffee-growing region, a trading the newsstrategy might short Starbucks shares in anticipation of higher coffee prices. News traders strive to act on publicly available information more quickly than the rest of the market or to anticipate an event’s effect that other traders are not anticipating. Arguably every investor is a news trader to one degree or another. Trading involves a high amount of risk and can cause beginner traders to quickly lose tens of thousands of dollars.

Author: Rich Dvorak

Momo Stock Scanner

Know the proper amount of stock to buy—for the risk of the trade, your risk tolerance, and relative to your account capital—before placing a trade. The Cup and Handle is a great trading pattern, as it is easy to spot, scan for, and we have definite criteria that we can look to find high-quality trades. See the Cup and Handle Swing Trading Strategy article and video for more on how to trade that pattern.

  • I was using the free Finviz screener long before I started using Trade Ideas.
  • Also, institutions use their proprietary artificial intelligence based algorithms, and I use this stock scanner for over ten years now.
  • For example, if the S&P 500 just fell 40% from its high, not many stocks are going to be near a high (90% criteria).
  • That’s why Zacks is our choice as the best free option for a stock screener.
  • In this particular example, you could remove your 1,000,000 volume filter and replace it with a $10,000,000 dollar volume filter.

Penny stock traders need another stock scanner than fundamental analysts. If you need 10 years of historical data for 650+ financial metrics that you can analyze and compare with a mouse click and crunch in MS Excel, then you need Stock Rover. Hammerstone is also a powerful tool for traders solely focusing on news.

How To Find Undervalued Stocks

Everything saves to your portfolio, and you can use the screener for up to 100 portfolios, and up to 100 screener presets. Traders also have access to a live trading room, real-time streaming trade ideas, and simultaneous charts. Trade Ideas connects directly to online brokerage firms such as TD Ameritrade, E-Trade, and Alpaca to allow traders to move between simulated trading and real-world trading. All but some of its more advanced features are available on the free plan.

The conditions and results of the Scan examples should not be construed as a recommendation to buy or sell any security. To apply the condition to any time frame, click the TimeFrame dropdown to choose the desired bar interval. The checkmark activates the Scan menu from which conditions can be selected or created. You now have the List of Options from the Scanned list of stocks .

With scanner, all you need to do is type in your conditions and select the group , you want to scan, provide a name for the scan and then click on Scan And Save. The Yahoo Finance stock screener is very basic, but what it lacks in its depth of technical and fundamental criteria to be filtered, it gains with simplicity. Alongside ease of use, the swing trade scanner free stock screener includes free streaming quotes, ESG data filters, and results include columns of popular Yahoo Finance fundamental data. Also, in addition to a traditional results list, results can be viewed as a heatmap. Scanning for new stock trades does not have to be a time consuming activity if you know the right websites to go to.

Use Your Stock Screener Effectively

This site and all information therein is provided for informational and educational purposes only and should not be construed as investment advice. The author and/or publisher may hold positions in the stocks, futures or industries discussed here. You should not rely solely on this Information in making any investment.

how to scan stocks

Use the stock screener results as a starting point — not the final verdict. Real-time MT4 snapshots and trade status on your phone mean you’re always up-to-date. And the cloud-based platform means you’ll never have lost data or configurations. Cryptocurrencies can fluctuate widely in prices and are, therefore, not appropriate for all investors. Trading cryptocurrencies is not supervised by any EU regulatory framework. The entry-level Silver plan costs $9.99 per month, providing users with the opportunity to begin testing the EasyScan stock screener’s capabilities.

Quickly find investment opportunities using our predefined and custom technical scans. Both kinds of scans search our entire database of tens of thousands of ticker symbols, returning only those that meet your exact technical criteria. Predefined scans are available to all users, and screen for commonly-requested criteria. Custom technical scans put Extra and Pro members in the driver’s seat, empowering them to scan based on their own custom technical criteria. StockFetcher takes some getting used to, but once you get the hang of it, it’s one of the most powerful stock screeners available. With StockFetcher, you can select from pre-existing stock screens or create your own.

Best Stock Screeners

Focus on trading the stocks at the bottom and top of the list. These are the stocks with the biggest changes from the open, both to the upside and downside. Go through some of the ones at the top and bottom of the list, and watch for trade setups. For ideas on how to enter and exit day trades, see How to Day Trade Stocks with a Trend Strategy. When I started day trading full-time, back in 2005, I would sometimes look at the top % and $ gainers/losers list available on many financial websites.

how to scan stocks

For instance, users can access a stock’s chart simply by hovering over the stock symbol in the screener. But their real claim to fame is the way they have stacked its screener with many useful tools and features. Its Elite screener is a powerful research tool with access to real-time data, advanced charts, pre-market data, customized filters, and data export capabilities. Enter your criteria in the search fields provided on the blank stock-scanning screen. You can search for stocks with the highest-paying dividends.

Percentage Gainers Screener

RSI Stock Screener – RSI Screener find oversold and overbought stocks and stocks with RSI increasing or decreasing. The premium version is more expensive than Stock Rover. Click here Super profitability to get free access to Hammerstone for 14 days. Read the in-depth Finviz Review to learn more about all features. Stock Rover Premium opens a whole new world of investment analysis.

They got a whole bunch of examples here and, by the way, they’ve got tons of them. These come already with the program and then if you want more, they got a great forums a section here where people participate and people will post other formulas in there. So let’s just take one here, you might like to, as you can Finance see here, gap up on volume. Stochastic Screener – Stochastic oscillator is another great technical indicator to find stocks that are oversold or overbought. This is one of the most popular indicator used by swing traders. MACD Crossover Stocks – find stocks that are making a MACD crossover on the daily chart.

Stock Screener App

I call the trading strategy the Truncated Price Swing. Here are the charts from the top and bottom stocks on the list, PDD and DKS (the yellow area is pre-market). The list has been sorted by Change from Open, as this is the price movement day traders care about. Since we are two hours into the session, the Relative Volume has been bumped up to Over 2 and Current Volume to Over 2M. Commodity and historical index data provided by Pinnacle Data Corporation. Unless otherwise indicated, all data is delayed by 15 minutes.

The high of day momentum scanner is my go-to scanner when premarket activity is light and I don’t have much to watch. This scanner will pull up stocks that are hitting a new intra-day high on high relative volume. Using stock scanners I can choose the specific type of stocks I want to see. I can make complex scanners to look for specific chart patterns or I can use simple scanners to look for broad matches such as stocks that just reported earnings in the last 24hrs.

The criteria used in this ranking includes depth of filter criteria, selection of both fundamental and technical filters, ease of use, and extra functionality. The pattern scanner scans for various technical indicators and stock chart patterns for finding trade setups. Traders can use our stock screener to find breakout, momentum, and trending stocks as well as stocks that are currently trading at a bargain.

If a stock is up 10%, then 8%, then 6%, that stock is falling quickly. If you want to limit the exchanges you trade, you can select which exchanges to include in the Exchange option. Everyone trades their own way, but be careful about basing ideas or strategies on one only one stock/move. The stock had just dropped significantly to a new swing low, and had just started to turn higher.

Author: Michael Sheetz

What Criteria Should Be Used To Analyze The Impact Of Healthcare Reform On Insurance Coverage Like Health System, Patient Outcomes, And Financing Success Or Failure?

What Criteria Should Be Used To Analyze The Impact Of Healthcare Reform On Insurance Coverage Like Health System, Patient Outcomes, And Financing Success Or Failure?
Support Your Responses With Academic Resources.C

Patient Is A 24-Year-Old Female Administrative Assistant Who Comes To The Emergency Department With A Chief Complaint Of Severe Right-Sided Headache. She States That This Is The Sixth Time In The Last 2 Months She Has Had This Headache

Patient Is A 24-Year-Old Female Administrative Assistant Who Comes To The Emergency Department With A Chief Complaint Of Severe Right-Sided Headache. She States That This Is The Sixth Time In The Last 2 Months She Has Had This Headache. She Says The Headaches Last 2-3 Days And Have Impacted Her Ability To Concentrate At Work. She Complains Of Nausea And Has Vomited Three Times In The Last 3 Hours. She States, “The Light Hurts My Eyes.” She Rates Her Pain As A 10/10 At This Time. Ibuprofen And Acetaminophen Ease Her Symptoms Somewhat But Do Not Totally Relieve Them. No Other Current Complaints.
Explain The Neurological And Musculoskeletal Pathophysiologic Process That Would Account For The Patient Presenting These Symptoms.

SHERMAN “RED” YODER

Each Student Is Responsible For Completing The Case Study Below. Answers May Be In Bullet Or Short Answer Format, But Follow APA Guidelines For Writing Mechanics Including Grammar, And Syntax. Students Must Provide Citations In APA For 2 References Used To Help Answer The Questions. A Reference List In APA Format Should Be Included In The Assignment Submission As Well.

Case Study

For this case study you will use the case study listed below and answer all of the questions. Please keep in mind that while these questions do not need to be answered in paper format, they should be written in a professional manner that fully answers the questions, and provides citations and references in APA where appropriate.

SHERMAN “RED” YODER

I understand you want to hear my story; well I’m not much for talking, but I can give you the highlights. There’s a lot that’s happened over my 80 years. From the top. My name is Sherman Yoder, but I answer to “Red.” No one around here even remembers my real name. I was born in this house in the downstairs bedroom. Mom had already delivered six kids and there was no way I was waiting for Dad to finish feeding the hogs and get Mom to town before I come out. Mom used to love to tell that story.

Dad bought this farmhouse and the first hundred acres right before he went off to WWI. The folks saw good times and bad in this ol’ place and so have I. All my brothers and sisters left the land as soon as they could. I was the only one of the lot to care about this place and want to carry on what Dad started. I really haven’t gone far from this spot in my entire life. The one time I got it in my head to try something different; I wound up in Korea with an Army uniform on. I was glad to get back to this place after that stint and here I’ve been ever since.

Married the neighbor girl Bessie when I got back. Her dad wasn’t so sure that it would work out since she was 8 years younger than me and she intended to go off to the state college. We sure did prove him wrong; we celebrated our 50th anniversary the week before Bessie died. The ladies at the church had the hall all decorated up and we brought Bessie home from the hospital for the afternoon. She was bound and determined to live for that day; no way did she want her friends to go to that much work for her to not show up. I couldn’t believe it when the ladies had to prepare for the reception after we buried Bessie in that same hall one week later. We had such a good life together. That was 10 years ago.

I don’t do much of the farm work anymore. Our son Jon takes care of the crops and the few animals we have. I still go out to the hen house every morning to collect the eggs. I’m a little stiff in the morning, but I get loosened up enough to walk out to gather some fresh eggs to go with my bacon for breakfast. I get in to town at least once a week; on Monday morning me and my buddies meet at the VFW for our coffee and donut break. I get caught up on all the town gossip and we laugh and bellyache about what’s going on in the world.

Three weeks ago I celebrated my 80th birthday. My daughter in law, Judy, organized a big “to do” at the church after the Sunday service with cake and ice cream and all the fixins’ for my party. I had a big piece of cake but skipped the ice cream. Doc Baker was there and I knew he would scold me about too much sugar. Six months ago he told me I had diabetes and I started taking a pill for it, but a few weeks ago he put me on insulin. I figure I should be able to eat what I want; come on, I’m not going to live forever, and it was my favorite cake, German chocolate. I ate it in the kitchen so the Doc wouldn’t see me; wouldn’t you know, his office nurse Helen came in the kitchen with a load of dishes just as I was putting the last bite in my mouth. She just winked at me and smiled.

After the party I went out to the mall with Jon and the grandkids. I’m not one for shopping much, but I needed a new ink cartridge for my printer and the computer store is the one place I like to look around in. Too bad we parked clear on the other end of the mall so the kids could go by their favorite stores for Grandpa to buy them a little something. Jon got real mad at me when I asked if I could sit and rest for a while, so I just kept walking. I guess my new shoes were a little tight; I didn’t feel anything but when I got home there was some blood on my sock, and then I saw a sore on my big toe. It must not be too bad since it’s not hurting except when I try to put my shoes on.

I showed the sore to Jon and Judy the other day and Judy said she would call the doctor to see what she should put on it. Jon gets so irritated when I need extra help; I hope I can just continue to soak my foot in hot water to clean it out. Judy was a nursing assistant out at the old folk’s home for many years; I’m hoping she will be able to help me with this. I like the idea of the home nurses coming out here as long as my VA benefits pay for it. That way they can see that I’m doing just fine living here on my own.

I was searching on the Internet for the best way to treat this sore; there are so many sites that talk about foot sores if you’re a diabetic. Some of those pictures are pretty scary; I can’t sleep at night thinking about what could happen if this doesn’t heal. Of course I haven’t slept through the night for years. Even the couple of beers I have at night when I’m on the computer don’t seem to be helping anymore. Judy sometimes gives the kids Benadryl to help them sleep so I’ve been taking a couple when I go to bed; they seem to help me sleep a little better.

As a matter of fact, I need to wrap this up now. I promised Jack, my grandson in college, that I’d Skype him in a few minutes. He just started the agronomy program at the university. I love to hear about what he’s learning and give him encouragement to come back to the farm.
CASE STUDY QUESTIONS:

  1. How might his diagnoses impact his current quality of life?
  2. What is the pertinent medical history for this client?
  3. Discuss what you know about access to health care in the aging population. Describe how this patient compares to the information you listed.
  4. For the main medical concern, what are special considerations for the geriatric population regarding treatment of this illness or condition?
  5. What do you think would be the top priority nursing diagnosis related to his physical health for the care of this individual? Please write out the whole diagnosis and provide rationale as to why it is a priority.
  6. Describe the client’s current living situation. What about this situation is pertinent to the client’s current state of health?
  7. What is the social support system of this client? Does it seem to be sufficient, or would additional resources be needed? Provide your rationale for either answer.
  8. What psychosocial nursing diagnosis would you consider to be the top priority for this patient? Write out the entire diagnosis and provide your rationale for why this is the top priority.
  9. State one social concern this client is facing. Is this a common social concern among the aging population?
  10. What community resources would you recommend to help meet the needs of this client?

SHERMAN “RED” YODER

Each Student Is Responsible For Completing The Case Study Below. Answers May Be In Bullet Or Short Answer Format, But Follow APA Guidelines For Writing Mechanics Including Grammar, And Syntax. Students Must Provide Citations In APA For 2 References Used To Help Answer The Questions. A Reference List In APA Format Should Be Included In The Assignment Submission As Well.

Case Study

For this case study you will use the case study listed below and answer all of the questions. Please keep in mind that while these questions do not need to be answered in paper format, they should be written in a professional manner that fully answers the questions, and provides citations and references in APA where appropriate.

SHERMAN “RED” YODER

I understand you want to hear my story; well I’m not much for talking, but I can give you the highlights. There’s a lot that’s happened over my 80 years. From the top. My name is Sherman Yoder, but I answer to “Red.” No one around here even remembers my real name. I was born in this house in the downstairs bedroom. Mom had already delivered six kids and there was no way I was waiting for Dad to finish feeding the hogs and get Mom to town before I come out. Mom used to love to tell that story.

Dad bought this farmhouse and the first hundred acres right before he went off to WWI. The folks saw good times and bad in this ol’ place and so have I. All my brothers and sisters left the land as soon as they could. I was the only one of the lot to care about this place and want to carry on what Dad started. I really haven’t gone far from this spot in my entire life. The one time I got it in my head to try something different; I wound up in Korea with an Army uniform on. I was glad to get back to this place after that stint and here I’ve been ever since.

Married the neighbor girl Bessie when I got back. Her dad wasn’t so sure that it would work out since she was 8 years younger than me and she intended to go off to the state college. We sure did prove him wrong; we celebrated our 50th anniversary the week before Bessie died. The ladies at the church had the hall all decorated up and we brought Bessie home from the hospital for the afternoon. She was bound and determined to live for that day; no way did she want her friends to go to that much work for her to not show up. I couldn’t believe it when the ladies had to prepare for the reception after we buried Bessie in that same hall one week later. We had such a good life together. That was 10 years ago.

I don’t do much of the farm work anymore. Our son Jon takes care of the crops and the few animals we have. I still go out to the hen house every morning to collect the eggs. I’m a little stiff in the morning, but I get loosened up enough to walk out to gather some fresh eggs to go with my bacon for breakfast. I get in to town at least once a week; on Monday morning me and my buddies meet at the VFW for our coffee and donut break. I get caught up on all the town gossip and we laugh and bellyache about what’s going on in the world.

Three weeks ago I celebrated my 80th birthday. My daughter in law, Judy, organized a big “to do” at the church after the Sunday service with cake and ice cream and all the fixins’ for my party. I had a big piece of cake but skipped the ice cream. Doc Baker was there and I knew he would scold me about too much sugar. Six months ago he told me I had diabetes and I started taking a pill for it, but a few weeks ago he put me on insulin. I figure I should be able to eat what I want; come on, I’m not going to live forever, and it was my favorite cake, German chocolate. I ate it in the kitchen so the Doc wouldn’t see me; wouldn’t you know, his office nurse Helen came in the kitchen with a load of dishes just as I was putting the last bite in my mouth. She just winked at me and smiled.

After the party I went out to the mall with Jon and the grandkids. I’m not one for shopping much, but I needed a new ink cartridge for my printer and the computer store is the one place I like to look around in. Too bad we parked clear on the other end of the mall so the kids could go by their favorite stores for Grandpa to buy them a little something. Jon got real mad at me when I asked if I could sit and rest for a while, so I just kept walking. I guess my new shoes were a little tight; I didn’t feel anything but when I got home there was some blood on my sock, and then I saw a sore on my big toe. It must not be too bad since it’s not hurting except when I try to put my shoes on.

I showed the sore to Jon and Judy the other day and Judy said she would call the doctor to see what she should put on it. Jon gets so irritated when I need extra help; I hope I can just continue to soak my foot in hot water to clean it out. Judy was a nursing assistant out at the old folk’s home for many years; I’m hoping she will be able to help me with this. I like the idea of the home nurses coming out here as long as my VA benefits pay for it. That way they can see that I’m doing just fine living here on my own.

I was searching on the Internet for the best way to treat this sore; there are so many sites that talk about foot sores if you’re a diabetic. Some of those pictures are pretty scary; I can’t sleep at night thinking about what could happen if this doesn’t heal. Of course I haven’t slept through the night for years. Even the couple of beers I have at night when I’m on the computer don’t seem to be helping anymore. Judy sometimes gives the kids Benadryl to help them sleep so I’ve been taking a couple when I go to bed; they seem to help me sleep a little better.

As a matter of fact, I need to wrap this up now. I promised Jack, my grandson in college, that I’d Skype him in a few minutes. He just started the agronomy program at the university. I love to hear about what he’s learning and give him encouragement to come back to the farm.
CASE STUDY QUESTIONS:

  1. How might his diagnoses impact his current quality of life?
  2. What is the pertinent medical history for this client?
  3. Discuss what you know about access to health care in the aging population. Describe how this patient compares to the information you listed.
  4. For the main medical concern, what are special considerations for the geriatric population regarding treatment of this illness or condition?
  5. What do you think would be the top priority nursing diagnosis related to his physical health for the care of this individual? Please write out the whole diagnosis and provide rationale as to why it is a priority.
  6. Describe the client’s current living situation. What about this situation is pertinent to the client’s current state of health?
  7. What is the social support system of this client? Does it seem to be sufficient, or would additional resources be needed? Provide your rationale for either answer.
  8. What psychosocial nursing diagnosis would you consider to be the top priority for this patient? Write out the entire diagnosis and provide your rationale for why this is the top priority.
  9. State one social concern this client is facing. Is this a common social concern among the aging population?
  10. What community resources would you recommend to help meet the needs of this client?

QUESTION: Give An Example Of Reliability And Validity From Article Below.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

Delirium In Trauma Patients: Prevalence And Predictors Kathryn T. Von Rueden, RN, MS, CNS-BC Breighanna Wallizer, RN, MS, CCRN, AG-ACNP Paul Thurman, RN, MS, ACNPC, CCNS Karen McQuillan, RN, MS, CNS-BC, CCRN

BACKGROUND Delirium Is Associated With Increased Mortality, Morbidity, Hospital Costs, And Postdischarge Cognitive Dysfunction. Most Research Focuses On Nontrauma Patients Receiving Mechanical Ventilation In The Intensive Care Unit. OBJECTIVES To Determine The Prevalence And Predictors Of Delirium In Trauma Patients Residing In Intensive And Intermediate Care Units Of An Academic Medical Center.

 

METHODS

Trauma Patients Were Screened For Delirium By Using The Confusion Assessment Method For The Intensive Care Unit. Exclusion Criteria Included Documented Brain Injury, History Of Psychosis Or Cognitive Impairment, Not Speaking English, And Hearing Or Vision Loss. RESULTS Of The 215 Study Patients, 24% Were Positive For Delirium; 36% Of Patients In The Intensive Care Unit And 11% Of Patients In The Intermediate Care Unit. Delirium-Positive Patients Were Older (Mean Age, 53.4 Years) Than Patients Who Were Not (Mean Age, 44 Years; P = .004). Although Mechanical Ventilation (Odds Ratio, 4.73, P = .004) Was The Strongest Independent Risk Factor For Delirium, 12% Of Delirium-Positive Patients Were Not Receiving Mechanical Ventilation. Other Predictors Of Delirium Were Use Of Antipsychotic Medications, Higher Scores On The Acute Physiology And Chronic Health Evaluation III, And Lower Scores On The Richmond Agitation-Sedation Scale.

 

CONCLUSIONS

Patients In Both The Intermediate And Intensive Care Units, Whether Mechanical Ventilation Was Used Or Not, Were Positive For Delirium. Delirium Prevention Protocols May Benet Trauma Patients Regardless Of Their Inpatient Location.

In The Past 2 Decades, Delirium Has Been An Increasing Focus Of Research In Critically Ill Patients Receiving Mechanical Ventilation. Acute Delirium, More Recently Referred To As Acute Brain Dysfunction, Has Been Reported In Up To 60% To 80% Of Critically Ill Patients Undergoing Mechanical Ventilation1-3 And Is Often Undiagnosed In Hospitalized Patients.4,5

 

Delirium Has A Marked Impact On Patients’ Outcomes. It Is Associated With Increased Mortality,2-4,6,7 Length Of Stay,2,8,9 And Rate Of Postdischarge Cognitive Dysfunction And Institutionalization.10-13 Delirium Leads To An Additional 17.5 Million Inpatient Days, With More Than $5 Billion In Medicare Charges Annually. Predictors Of Delirium Include Preexisting Medical Conditions, Conditions Associated With Acute Illness, As Well As Iatrogenic And Environmental Factors.14,15 Preexisting Or Nonmodiable Risk Factors For Delirium At The Time Of Hospital Admission Include Advanced Age (> 65 Years), Alcohol Use, Brain Trauma, Dementia, Hypertension, Smoking, Depression, Chronic Illnesses, And Male Sex.14,15 Illness-Related Factors Include Hypoxia, Sepsis, Metabolic And Electrolyte Disturbances, Respiratory And Cardiac Failure, And Immobility.3,14,16 Iatrogenic Factors Include Opioid, Sedative, And Antipsychotic Medications; Physical And Chemical Restraints; And Nutritional Deciencies.9,10,14-17 A Recent Systematic Review Suggested That Age, Dementia, Coma, Scores On The Acute Physiology And Chronic Health Evaluation (APACHE) II, Previous Delirium, Emergency Surgery And Trauma, Mechanical Ventilation, And Metabolic Acidosis Were Well Supported By Evidence To Contribute To Development Of Delirium.15

Incidence, Risk Factors, And Predictors Of Acute Delirium Are Widely Reported In Critically Ill Medical And Surgical Patients Receiving Mechanical Ventilation, But Less Is Known About Acute Delirium In Trauma Patients, Particularly Those Who Require Mechanical Ventilation. Studies Of Delirium In Trauma Patients Have Been Retrospective In Nature,18,19 Have Included Only Patients Undergoing Mechanical Ventilation,5,17,20 Or Have Had Limited Sample Sizes.5,17,20,21 The Objective Of This Prospective, Observational Study Was To Determine The Prevalence Of Delirium In Trauma Patients Who Reside In Intermediate Care Units (IMCs) Or In Intensive Care Units (ICUs). Secondary Aims Were To Explore And Dene Characteristics And Predictors Of Delirium In Trauma Patients.

 

Methods

The Investigation Was Approved By The Institutional Review Board With A Waiver Of Informed Consent As A Noninterventional, Observational Point Prevalence Study. This Cross-Sectional Descriptive Study Was Conducted At A Large, Urban Academic Trauma Center And Included Patients From 3 Trauma IMCs And ICUs. Data Were Collected During The Day Shift (Between 7 AM And 7 PM) On 13 Different Days For Several Months. Prevalence, Presence Of Delirium In Patients On The Data Collection Days, Was Used Because The Incidence Of Delirium Could Not Be Determined As Delirium Was Not Routinely Assessed. The Trauma Center’s Daily Patient Census Was Used To Identify Potential Study Participants On Each Data Collection Day. Eligible Patients Met The Following Inclusion Criteria: 18 Years Or Older, English Speaking, No Diagnosed Traumatic Brain Injury, And A Score Of At Least 8 On The Glasgow Coma Scale At The Time Of Data Collection. Exclusion Criteria Were Nontrauma Admissions, Hospital Readmissions, Known History Of Psychosis Or Cognitive Impairment, Brain Injury Documented On Computed Tomography (CT) Of The Brain, Signicant Hearing Or Vision Loss, And A Level Of Arousal Less Than -3 As Dened By The Richmond Agitation-Sedation Scale (RASS). Because Mild Traumatic Brain Injury Is Difcult To Diagnose And Not Readily Detectable With Brain CT,22 These Patients Could Not Be Excluded On The Basis Of A Known Brain Injury. Other Patients Were Excluded If They Had Previously Been Included In The Study Or Were Scheduled For Surgery Or Hospital Discharge On The Screening And Data Collection Days. The Data Collected From Medical Records Of Eligible Patients Included Mechanism Of Injury; Demographics Such As Medical History, Age, And Sex; Criteria For Mild Traumatic Brain Injury; Past Use Of Illicit Drugs Or Alcohol; Results Of Admission Toxicology And Blood Alcohol Screenings; Use Of Medications Known To Affect Delirium; Illness Severity As Measured By APACHE III Score; And Presence Of Sepsis. Criteria For Evaluating Potential Mild Traumatic Brain Injury Included At Least 2 Of The Following: Loss Of Consciousness For More Than 30 Minutes At The Scene, Amnesia At Or Near The Time Of The Event, And Score Of 13 To 14 On The Glasgow Coma Scale On Admission.22 Medications Administered To Patients At The Time Of Data Collection That May Inuence Results Of The Confusion Assessment Method For The Intensive Care Unit (CAMICU) And Delirium Were Classied As Sedatives (Propofol, Dexmedetomidine), Antipsychotic Agents (Haloperidol, Ziprasidone), Benzodiazepines (Lorazepam, Diazepam, Midazolam), And Narcotics (Fentanyl, Hydromorphone, Oxycodone). APACHE III Score Was Used Rather Than APACHE II Score To Quantify Illness Severity Because The APACHE III Was Developed From A More Contemporary Database23,24 And Assigns Points For Age Ranges Younger Than The APACHE II Score Does. APACHE III Has Been Validated In Trauma Patients.25 Eligible Patients Were Assessed With The CAM-ICU To Detect Delirium. This Well-Validated Tool Evaluates For Acute Onset Of Changes Or Fluctuations In Mental Status, Inattention, And Either Disorganized Thinking Or An Altered Level Of Consciousness.26 Published Directions For Scoring The CAM-ICU Are Available.27 Because

The Institution Did Not Use A Formal Delirium Assessment And Prevention Protocol At The Time Of The Study, A Team Of 7 Nurses Was Trained To Use The CAM-ICU. Training, Overseen By An Expert Clinical Nurse Specialist, Was Conducted Via Video And Live Demonstrations That Used Standardized Scenarios With Return Demonstrations On Patients. This Team Also Collected All Of The Data From The Medical Records.

Statistical Analysis

Bivariate Analysis With R2 Test, T Test, And Correlation Examined The Association Between The Outcome Variables Of Delirium And Each Factor. Variables Showing A Signicant (P < .20) Bivariate Relationship To Delirium Were Included In The Nal Logistic Regression To Predict Delirium. Logistic Regression With A Sample Size Of 215 Observations Achieved 84% Power At A .05 Signifcance Level And Medium Effect Size (R = 0.3).

Results Of The 800 Patients Screened, 215 Met Eligibility Requirements For Inclusion. Many Patients Were Excluded Because Of A Large Number Of Nontrauma Admissions, Readmissions, And Patients With Radiographically Documented Traumatic Brain Injuries During The Data Collection Period. Overall Delirium Prevalence In This Sample Of Trauma Patients In Both The ICUs And IMCs Was 23.7% (N = 51). Patients’ Characteristics Were Classified Into Categories Related To Prehospitalization Variables (Table 1),

Table 1 Prehospitalization Characteristics Of Patients And Relationships To Acute Delirium

Variable Male Female Mechanism Of Injury Vehicle Penetration Sports Crushing Falling Tobacco Use Hypertension Vascular Disease Depression Past Illicit Drug Use Past Alcohol Use

P

.63

.34

.38 .46 .52 .62 .76 .22

R2

0.2

4.5

3.1 1.6 1.3 1.0 0.5 3.1

Total (N = 215)  164 (76.3) 51 (23.7)

89 (41.4) 47 (21.9) 6 (2.8) 9 (4.2) 64 (29.8) 77 (35.8) 61 (28.4) 19 (8.8) 19 (8.8) 52 (24.2) 49 (22.8)

No Delirium (N = 164)  124 (75.6) 40 (24.4)

68 (41.5) 39 (23.8) 6 (3.7) 7 (4.3) 44 (26.8) 60 (36.6) 44 (26.8) 13 (7.9) 14 (8.5) 38 (23.2) 33 (20.1)

Delirium (N = 51) 40 (78.4) 11 (21.6)

21 (41.2) 8 (15.7) 0 (0) 2 (3.9) 20 (39.2) 17 (33.3) 17 (33.3) 6 (11.8) 5 (9.8) 14 (27.5) 16 (31.4)

No. (%) Of Patients

 

Admission Variables (Table 2), And Inpatient Variables From The Day Of Data Collection (Table 3). Prehospitalization Variables Included Age, Mechanism Of Injury, Preexisting Comorbid Conditions, And History Of Tobacco, Illicit Drug, And Alcohol Use. The Mean Sample Age Was 46.3 Years (SD, 14.9 Years; Range, 18-95 Years). Signicant Differences Were Found In Age Between Those Who Screened Positive For Delirium (Mean, 53.4 Years; SD, 20.0 Years) And Those Who Did Not (Mean, 44.1 Years; SD, 19.6 Years; T = 2.95, P = .004). In Patients Aged 65 Years And Older, 35% Had Delirium Compared With 21% Of Patients Less Than 65 Years Old, But The Difference Was Not Signicant (R2 = 3.4, P = .06). No Other Signicant Relationships Were Found Between Prehospitalization Variables And Delirium (Table 1). Admission Variables Included Routinely Collected Blood Alcohol Level, Results Of Drug Toxicology Screening, And Signs And Symptoms Of Mild Brain Injury (Table 2). None Of These Variables Demonstrated A Relationship With A Positive Nding On The CAM-ICU.

Inpatient Variables From The Day Of Delirium Assessment Included Illness Severity, Patient Location, RASS Score, Sepsis Or Infection Diagnosis, Use Of Mechanical Ventilation, And Administration Of Medications Known To Be Associated With Acute Delirium (Table 3). Of The 215 Eligible Patients, 113 Were In The ICUs And 102 Were In The IMCs. ICU Patients Had A Higher Prevalence Of Delirium Than IMC Patients, With 36% Of ICU Patients Screening Positive For Delirium Versus 11% Of Patients In The IMC (R2 = 18.7, P < .001). Lower RASS Score Was Related To Delirium (T = -5.58, P < .001). Of Those Testing Positive For Delirium, 40 Patients (78%) Had A RASS Score Of -1, -2, Or -3. Higher Severity Of Illness Was Associated With Delirium. Mean APACHE III Score Was 38.9 (SD, 15.7) In CAM-ICU-Positive Patients Compared With 26.4 (SD, 13.3) In CAM-ICU-Negative Patients (T = 5.75, P < .001). Patients Who Screened Positive For Delirium Differed Signicantly From Patients Who Did Not In The Use Of Mechanical Ventilation And Medications (Table 3). Delirium Was Present In 51% Of Those Requiring Mechanical

Table 2 Admission Variables And Relationships To Acute Delirium

Variable Blood Alcohol Level > 0.08 Mg/DL Toxicology Screening Positive Mild Brain Injury

P .83 .41 .09

R2 0.4 1.8 4.8

Total (N = 215)  55 (25.6) 64 (29.8) 37 (17.2)

No Delirium (N = 164)  41 (25.0) 49 (29.9) 27 (16.5)

Delirium (N = 51) 14 (27.5) 15 (29.4) 10 (19.6)

No. (%) Of Patients

D I I I Bl (T Bl 2) Di I I Bl I I I Bl F H D Fd Li I

Table 3 Inpatient Variables On The Day Of Delirium Assessment

Variables APACHE III Score, Mean (SD) RASS Score, Mean (SD) Location, No. (%) Of Patients ICU IMC Mechanical Ventilation, No. (%) Of Patients Sepsis/Infection, No. (%) Of Patients Benzodiazepines, No. (%) Of Patients Antipsychotics, No. (%) Of Patients Narcotics, No. (%) Of Patients Sedatives, No. (%) Of Patients

P < .001 < .001 < .001

< .001 .26 .43 .001 .54 < .001

Total (N = 215)  29.3 (14.9)  -0.39 (0.95)

113 (52.6) 102 (47.4)  48 (22.3)  31 (14.4)  66 (30.7)  32 (14.9) 197 (91.6) 17 (7.9)

No Delirium (N = 164)  26.4 (13.3) -0.13 (0.56)

72/113 (63.7) 91/102 (89.2) 22 (13.4) 21 (12.8) 48 (29.3) 17 (10.4) 150 (91.5) 6 (3.7)

Delirium (N = 51) 38.9 (15.7) -1.22 (1.40)

41/113 (36.3) 11/102 (10.8) 26 (51.0) 10 (19.6) 18 (35.3) 15 (29.4) 47 (92.2) 12 (21.6)

Statistic T = 5.75 T = -5.58 R2 = 18.7

R2 = 33.4 R2 = 1.3 R2 = 0.6 R2 = 11.0 R2 = 0.4 R2 = 19.9

Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; ICU, Intensive Care Unit; IMC, Intermediate Care Unit; RASS, Richmond Agitation-Sedation Scale.

44  CriticalCareNurse Vol 37, No. 1, FEBRUARY 2017 Www.Ccnonline.Org

Our Findings Provide Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not.

Ventilation (R2 = 33.8, P < .001). The Patients Screening Positive For Delirium Had Greater Use Of Antipsychotic Agents (29% Vs 10.4%, R2 = 11.0, P = .001) As Well As The Use Of Sedative Medications On The Day Of Screening (21.6% Vs 3.7%, R2 = 19.9, P < .001). The Use Of Benzodiazepines And Narcotics Did Not Differ Between Patients Who Screened Positive For Delirium And Patients Who Were Negative For Delirium On The Day Of Data Collection. Six Variables Showed At Least Small Correlations With Delirium: Age (R = 0.17, P = .003), Sedative Use (R = 0.29, P < .001), Mechanical Ventilation (R = 0.38, P < .001), Antipsychotic Medication Administration (R = 0.23, P = .001), APACHE III Score (R = 0.29, P < .001), And RASS Score (R = -0.492, P < .001). The Best Model Included These 6 Variables, Signicantly Predicting Delirium (P < .001), Explaining 51.9% Of Variance (Cox And Snell R2 = 0.34; Nagelkerke R2 = 0.52). Table 4 Shows The Results Of Logistic Regression. Four Factors Predictive Of Delirium Were Mechanical Ventilation, Use Of Antipsychotic Agents, Higher APACHE III Score, And Lower RASS Score.

Discussion In Our Study, 24% Of Trauma Patients Screened With The CAM-ICU Tested Positive For Delirium In Both ICUs And IMCs, With Delirium Affecting More ICU Patients (36%). We Suspect That The Overall Lower Prevalence Of Delirium In Our Study Compared With Previous Studies May Be Due To Several Factors. One Factor Was The Small Numbers Of Patients With Preexisting Comorbid Conditions Such As Hypertension, Vascular Disease, And Pulmonary Disease. These Small Numbers Were Most Likely Due To The Younger Mean Age Of This Trauma Population Compared With Other Studies Of Critically Ill Patients. Although The Mean Age Of This Sample Was Younger Than The Mean Age In Other Investigations, Older Age Was Signicant For Higher Prevalence Of Delirium And Was Included In The Predictive Model. Similar To Other Studies Of Delirium In Trauma Patients,17,20,28 The Age Of Our Trauma Patients And Those Patients Testing Positive For Delirium Were Younger Than The Ages Reported In The General ICU Population.1-3,9 These Ndings Are Important Because Younger Patients Are Not Usually Considered To Be At High Risk For Delirium.

This Nding Underscores The Need For Delirium-Prevention Strategies In Hospitalized Trauma Patients, Regardless Of The Patients’ Age. Detrimental Effects Of Delirium Such As Increased Risk Of Death, Dementia, And Cognitive Dysfunction Following Discharge From The Hospital7,11,14,29,30 Underscores The Signicance Of Delirium Prevention Across The Age Span. Admission Variables Identied By Others To Be Related To Delirium Development Include Positive Results Of A Toxicology Screening, Elevated Blood Alcohol Content (> 0.08 G/DL), And Abnormal Score On The Glasgow Coma Scale (≤ 14). Unlike Studies Based On The National Trauma Databank19 And A Trauma Registry,18 Positive Blood Alcohol On Admission And History Of Alcohol Use Were Not Associated With Or Predictive Of Delirium In This Study Of Trauma Patients And In A Large Systematic Review.15 In Addition, Other Previously Reported Risk Factors Such As Positive Results Of Drug Toxicology Screening On Admission19,21 And Abnormal Score On The Glasgow Coma Scale21 Were Not Related To Delirium In Our Sample. Inpatient Variables Associated With Delirium Include Mechanical Ventilation And Administration Of Sedatives And Analgesics.9,10,15,17 Our Ndings Provide Additional Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not, Although The Prevalence Of Delirium In Our Sample Of Trauma Patients Receiving Mechanical Ventilation Was Lower Than Reported In Other Studies. This Lower Prevalence May Be Due To The Younger Age Of Trauma Patients And Fewer Comorbid Conditions That Would Predispose Individuals To Respiratory Dysfunction Or Failure. However, A Number Of The Study Patients In The ICU In Whom Mechanical Ventilation Was Not Being Used Thi  Di D Th Df D Li I Ti

Table 4 Multivariate Analysis Of Delirium Predictors In Trauma Patients

Variable Age Sedative Mechanical Ventilation Psychotropic Agent APACHE III Score RASS Score

Adjusted Odds Ratio (95% CI) 1.017 (0.993-1.042) 1.235 (0.296-5.163) 4.726 (1.628-13.716) 3.850 (1.280-11.579) 1.057 (1.020-1.095) 0.311 (0.188-0.516)

P .17 .77 .004 .02 .002 < .001 Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; RASS, Richmond Agitation-Sedation Scale.

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Tested Positive For Delirium On The Day Of Screening. Thomason And Colleagues31 Similarly Reported That 48% Of Medical ICU Patients Who Were Not Receiving Mechanical Ventilation Experienced At Least 1 Episode Of Delirium. An Important Nding Of This Investigation Was That Patients Who Tested Positive For Delirium Were Not Limited To Those Residing In The ICU. Of The Trauma IMC Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients. This Finding Is Noteworthy Because Most Studies Have Focused More Exclusively On Critically Ill Patients Who Require Mechanical Ventilation. These Results Suggest That Implementation Of Delirium Assessment And Prevention Strategies May Benet Trauma Patients Who Are Not Receiving Mechanical Ventilation Or Are Not In The ICU. Interestingly, Half Of The Patients Receiving Antipsychotic (Ziprasidone, Haloperidol) Or Sedative (Dexmedetomidine, Propofol) Medications Tested Positive For Delirium. At The Time Of This Study, Use Of Ziprasidone, Dexmedetomidine, And Haloperidol Was The Common Practice In Our Trauma Center For Treating Agitation Or Suspected Delirium. The High Percentage Of Patients Receiving These Medications Also May Have Been Related To Deliberate Attempts To Avoid Benzodiazepines And Narcotics To Facilitate More Rapid Liberation From Mechanical Ventilation, Practices Consistent With The Current Pain, Agitation, And Delirium Guidelines.32 Zall And Colleagues15 Identied Dexmedetomidine To Be Associated With Reduced Delirium Occurrence. This Same Review And Our Analysis Did Not Nd The Use Of Narcotics Or Benzodiazepines To Be Signicantly Associated With Delirium On The Day Of Data Collection, Although These Agents Have Been Reported To Be Risk Factors For The Development Of Delirium.9,10,17 The Use Of These Medications Can Result In A Lower RASS Score, Which We Found To Be Predictive Of Delirium. A RASS Score Of -1 To -3 Was Identied In 75% Of The Studied Patients. Delirium Is Often Underrecognized In This Subset Of Patients.1,5,11 Higher Illness Severity Has Been Associated With Delirium.10,14,15,18 Our Ndings Were Consistent With Results Of These Other Studies. In Our Sample, Higher APACHE III Scores Were Also Predictive Of Delirium. Mild Brain Injury Is Not Easily Detectable By Brain CT And May Go Undiagnosed.22,33 Thus, Patients With Normal Ndings On A Brain CT Scan But Signs And Symptoms Of A Possible Mild Brain Injury Were Included In Data Collection

To Ascertain If Delirium Is Related To Mild Brain Injury. In Trauma Patients Who Are CAM-ICU Positive, Differentiating Physiological Dysfunction Associated With Mild Traumatic Brain Injury And Cognitive Decits Related To Delirium Is Important To Guide Appropriate Interventions. Potentially Because Of The Limited Sample Size, No Signicant Relationship Was Detected Between Mild Brain Injury And Delirium. Further Exploration Of This Population Of Patients Is Warranted As Previous Studies Have Shown A Positive Relationship Between These 2 Variables.13 Limitations Of This Study Merit Further Exploration. Delirium Was Not Routinely Assessed In The ICUs And IMCs Of The Trauma Center At The Time Of This Investigation, Necessitating Collection Of Data On Point Prevalence; Thus The True Incidence Of Delirium Is Not Known, And We Were Inhibited From Being Able To Monitor Changes Over Time. We Were Unable To Differentiate Those Patients Who Were Receiving Antipsychotic Therapy For Suspected Delirium From Patients Receiving It For The Prevention Or Management Of Agitation. Although We Explored A Wide Variety Of Variables, It Is Possible That Other Factors Such As Use Of Isolation For Antibiotic-Resistant Infections, ICU Stay Before IMC Admission, As Well As The Types And Quantities Of Deliriogenic Medications Received Before The Data Collection Day Could Also Contribute To The Development Of Delirium. Finally, This Study Was Not Designed To Evaluate Long-Term Effects Of Delirium. Although We Know From Other Studies That Episodes Of Acute Delirium Are Detrimental To Long-Term Health Outcomes, We Were Unable To Draw Conclusions Specically Related To Our Younger Trauma Patients. This Topic Is A Potential Area For Study In Trauma Patients. Other Foci For Future Research Include Investigating The Impact Of A Delirium Prevention Initiative In Patients Who Are Not Receiving Mechanical Ventilation Or Who Have Mild Traumatic Brain Injury. Studies Related To The Prevention Of Delirium In The Trauma Population Are Limited. Education Regarding Delirium Before Implementing A Screening Program May Be Effective In Preventing Delirium.32,34 Use Of Validated Assessment Tools For Pain, Agitation, And Delirium In Conjunction With Delirium-Prevention Strategies Is Of The Trauma Intermediate Care Unit Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients.

Other Nonpharmacological Strategies That Are Within The Nursing Scope Of Practice Include Interventions Such As Music Or Light Therapy, Use Of Earplugs, And Sleep Promotion.37,38 Thus, Through Independent Interventions, Nurses Are Able To Directly Inuence The Outcomes Of Trauma Patients And Others Who Are At Risk For Delirium Developing, By Reducing The Occurrence Of Acute Delirium And Therefore Its Untoward Effects On Length Of Stay, Mortality, Long-Term Cognitive Function, And Cost Of Care.39

Conclusions

In This Study, Delirium Was Detected In Nearly 24% Of Hospitalized Trauma Patients. Use Of Mechanical Ventilation And Psychotropic Medications, Higher APACHE III Score, And Lower RASS Score Were Independent Predictors Of Delirium. Although The Presence Of Delirium In The Current Investigation Was Lower Than Reported In Other Studies Of Critically Ill Patients, Our Subset Of Trauma Patients Was Younger, Had Fewer Comorbid Conditions, And Included Patients Not Receiving Mechanical Ventilation And IMC Patients. Importantly, Delirium Was Present In Both The IMC Patients And The Patients Not Receiving Mechanical Ventilation. These Ndings Suggest That Delirium Assessment And Incorporation Of Delirium-P Revention Strategies Into The Routine Management Of All Hospitalized Trauma Patients May Be Benecial. Considering The Unfavorable Effects That Delirium Has On Patients And Their Postdischarge Outcomes, Nurses’ Attention To Prevention Strategies Is Crucial.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

Delirium In Trauma Patients: Prevalence And Predictors Kathryn T. Von Rueden, RN, MS, CNS-BC Breighanna Wallizer, RN, MS, CCRN, AG-ACNP Paul Thurman, RN, MS, ACNPC, CCNS Karen McQuillan, RN, MS, CNS-BC, CCRN

BACKGROUND Delirium Is Associated With Increased Mortality, Morbidity, Hospital Costs, And Postdischarge Cognitive Dysfunction. Most Research Focuses On Nontrauma Patients Receiving Mechanical Ventilation In The Intensive Care Unit. OBJECTIVES To Determine The Prevalence And Predictors Of Delirium In Trauma Patients Residing In Intensive And Intermediate Care Units Of An Academic Medical Center.

 

METHODS

Trauma Patients Were Screened For Delirium By Using The Confusion Assessment Method For The Intensive Care Unit. Exclusion Criteria Included Documented Brain Injury, History Of Psychosis Or Cognitive Impairment, Not Speaking English, And Hearing Or Vision Loss. RESULTS Of The 215 Study Patients, 24% Were Positive For Delirium; 36% Of Patients In The Intensive Care Unit And 11% Of Patients In The Intermediate Care Unit. Delirium-Positive Patients Were Older (Mean Age, 53.4 Years) Than Patients Who Were Not (Mean Age, 44 Years; P = .004). Although Mechanical Ventilation (Odds Ratio, 4.73, P = .004) Was The Strongest Independent Risk Factor For Delirium, 12% Of Delirium-Positive Patients Were Not Receiving Mechanical Ventilation. Other Predictors Of Delirium Were Use Of Antipsychotic Medications, Higher Scores On The Acute Physiology And Chronic Health Evaluation III, And Lower Scores On The Richmond Agitation-Sedation Scale.

 

CONCLUSIONS

Patients In Both The Intermediate And Intensive Care Units, Whether Mechanical Ventilation Was Used Or Not, Were Positive For Delirium. Delirium Prevention Protocols May Benet Trauma Patients Regardless Of Their Inpatient Location.

In The Past 2 Decades, Delirium Has Been An Increasing Focus Of Research In Critically Ill Patients Receiving Mechanical Ventilation. Acute Delirium, More Recently Referred To As Acute Brain Dysfunction, Has Been Reported In Up To 60% To 80% Of Critically Ill Patients Undergoing Mechanical Ventilation1-3 And Is Often Undiagnosed In Hospitalized Patients.4,5

 

Delirium Has A Marked Impact On Patients’ Outcomes. It Is Associated With Increased Mortality,2-4,6,7 Length Of Stay,2,8,9 And Rate Of Postdischarge Cognitive Dysfunction And Institutionalization.10-13 Delirium Leads To An Additional 17.5 Million Inpatient Days, With More Than $5 Billion In Medicare Charges Annually. Predictors Of Delirium Include Preexisting Medical Conditions, Conditions Associated With Acute Illness, As Well As Iatrogenic And Environmental Factors.14,15 Preexisting Or Nonmodiable Risk Factors For Delirium At The Time Of Hospital Admission Include Advanced Age (> 65 Years), Alcohol Use, Brain Trauma, Dementia, Hypertension, Smoking, Depression, Chronic Illnesses, And Male Sex.14,15 Illness-Related Factors Include Hypoxia, Sepsis, Metabolic And Electrolyte Disturbances, Respiratory And Cardiac Failure, And Immobility.3,14,16 Iatrogenic Factors Include Opioid, Sedative, And Antipsychotic Medications; Physical And Chemical Restraints; And Nutritional Deciencies.9,10,14-17 A Recent Systematic Review Suggested That Age, Dementia, Coma, Scores On The Acute Physiology And Chronic Health Evaluation (APACHE) II, Previous Delirium, Emergency Surgery And Trauma, Mechanical Ventilation, And Metabolic Acidosis Were Well Supported By Evidence To Contribute To Development Of Delirium.15

Incidence, Risk Factors, And Predictors Of Acute Delirium Are Widely Reported In Critically Ill Medical And Surgical Patients Receiving Mechanical Ventilation, But Less Is Known About Acute Delirium In Trauma Patients, Particularly Those Who Require Mechanical Ventilation. Studies Of Delirium In Trauma Patients Have Been Retrospective In Nature,18,19 Have Included Only Patients Undergoing Mechanical Ventilation,5,17,20 Or Have Had Limited Sample Sizes.5,17,20,21 The Objective Of This Prospective, Observational Study Was To Determine The Prevalence Of Delirium In Trauma Patients Who Reside In Intermediate Care Units (IMCs) Or In Intensive Care Units (ICUs). Secondary Aims Were To Explore And Dene Characteristics And Predictors Of Delirium In Trauma Patients.

 

Methods

The Investigation Was Approved By The Institutional Review Board With A Waiver Of Informed Consent As A Noninterventional, Observational Point Prevalence Study. This Cross-Sectional Descriptive Study Was Conducted At A Large, Urban Academic Trauma Center And Included Patients From 3 Trauma IMCs And ICUs. Data Were Collected During The Day Shift (Between 7 AM And 7 PM) On 13 Different Days For Several Months. Prevalence, Presence Of Delirium In Patients On The Data Collection Days, Was Used Because The Incidence Of Delirium Could Not Be Determined As Delirium Was Not Routinely Assessed. The Trauma Center’s Daily Patient Census Was Used To Identify Potential Study Participants On Each Data Collection Day. Eligible Patients Met The Following Inclusion Criteria: 18 Years Or Older, English Speaking, No Diagnosed Traumatic Brain Injury, And A Score Of At Least 8 On The Glasgow Coma Scale At The Time Of Data Collection. Exclusion Criteria Were Nontrauma Admissions, Hospital Readmissions, Known History Of Psychosis Or Cognitive Impairment, Brain Injury Documented On Computed Tomography (CT) Of The Brain, Signicant Hearing Or Vision Loss, And A Level Of Arousal Less Than -3 As Dened By The Richmond Agitation-Sedation Scale (RASS). Because Mild Traumatic Brain Injury Is Difcult To Diagnose And Not Readily Detectable With Brain CT,22 These Patients Could Not Be Excluded On The Basis Of A Known Brain Injury. Other Patients Were Excluded If They Had Previously Been Included In The Study Or Were Scheduled For Surgery Or Hospital Discharge On The Screening And Data Collection Days. The Data Collected From Medical Records Of Eligible Patients Included Mechanism Of Injury; Demographics Such As Medical History, Age, And Sex; Criteria For Mild Traumatic Brain Injury; Past Use Of Illicit Drugs Or Alcohol; Results Of Admission Toxicology And Blood Alcohol Screenings; Use Of Medications Known To Affect Delirium; Illness Severity As Measured By APACHE III Score; And Presence Of Sepsis. Criteria For Evaluating Potential Mild Traumatic Brain Injury Included At Least 2 Of The Following: Loss Of Consciousness For More Than 30 Minutes At The Scene, Amnesia At Or Near The Time Of The Event, And Score Of 13 To 14 On The Glasgow Coma Scale On Admission.22 Medications Administered To Patients At The Time Of Data Collection That May Inuence Results Of The Confusion Assessment Method For The Intensive Care Unit (CAMICU) And Delirium Were Classied As Sedatives (Propofol, Dexmedetomidine), Antipsychotic Agents (Haloperidol, Ziprasidone), Benzodiazepines (Lorazepam, Diazepam, Midazolam), And Narcotics (Fentanyl, Hydromorphone, Oxycodone). APACHE III Score Was Used Rather Than APACHE II Score To Quantify Illness Severity Because The APACHE III Was Developed From A More Contemporary Database23,24 And Assigns Points For Age Ranges Younger Than The APACHE II Score Does. APACHE III Has Been Validated In Trauma Patients.25 Eligible Patients Were Assessed With The CAM-ICU To Detect Delirium. This Well-Validated Tool Evaluates For Acute Onset Of Changes Or Fluctuations In Mental Status, Inattention, And Either Disorganized Thinking Or An Altered Level Of Consciousness.26 Published Directions For Scoring The CAM-ICU Are Available.27 Because

The Institution Did Not Use A Formal Delirium Assessment And Prevention Protocol At The Time Of The Study, A Team Of 7 Nurses Was Trained To Use The CAM-ICU. Training, Overseen By An Expert Clinical Nurse Specialist, Was Conducted Via Video And Live Demonstrations That Used Standardized Scenarios With Return Demonstrations On Patients. This Team Also Collected All Of The Data From The Medical Records.

Statistical Analysis

Bivariate Analysis With R2 Test, T Test, And Correlation Examined The Association Between The Outcome Variables Of Delirium And Each Factor. Variables Showing A Signicant (P < .20) Bivariate Relationship To Delirium Were Included In The Nal Logistic Regression To Predict Delirium. Logistic Regression With A Sample Size Of 215 Observations Achieved 84% Power At A .05 Signifcance Level And Medium Effect Size (R = 0.3).

Results Of The 800 Patients Screened, 215 Met Eligibility Requirements For Inclusion. Many Patients Were Excluded Because Of A Large Number Of Nontrauma Admissions, Readmissions, And Patients With Radiographically Documented Traumatic Brain Injuries During The Data Collection Period. Overall Delirium Prevalence In This Sample Of Trauma Patients In Both The ICUs And IMCs Was 23.7% (N = 51). Patients’ Characteristics Were Classified Into Categories Related To Prehospitalization Variables (Table 1),

Table 1 Prehospitalization Characteristics Of Patients And Relationships To Acute Delirium

Variable Male Female Mechanism Of Injury Vehicle Penetration Sports Crushing Falling Tobacco Use Hypertension Vascular Disease Depression Past Illicit Drug Use Past Alcohol Use

P

.63

.34

.38 .46 .52 .62 .76 .22

R2

0.2

4.5

3.1 1.6 1.3 1.0 0.5 3.1

Total (N = 215)  164 (76.3) 51 (23.7)

89 (41.4) 47 (21.9) 6 (2.8) 9 (4.2) 64 (29.8) 77 (35.8) 61 (28.4) 19 (8.8) 19 (8.8) 52 (24.2) 49 (22.8)

No Delirium (N = 164)  124 (75.6) 40 (24.4)

68 (41.5) 39 (23.8) 6 (3.7) 7 (4.3) 44 (26.8) 60 (36.6) 44 (26.8) 13 (7.9) 14 (8.5) 38 (23.2) 33 (20.1)

Delirium (N = 51) 40 (78.4) 11 (21.6)

21 (41.2) 8 (15.7) 0 (0) 2 (3.9) 20 (39.2) 17 (33.3) 17 (33.3) 6 (11.8) 5 (9.8) 14 (27.5) 16 (31.4)

No. (%) Of Patients

 

Admission Variables (Table 2), And Inpatient Variables From The Day Of Data Collection (Table 3). Prehospitalization Variables Included Age, Mechanism Of Injury, Preexisting Comorbid Conditions, And History Of Tobacco, Illicit Drug, And Alcohol Use. The Mean Sample Age Was 46.3 Years (SD, 14.9 Years; Range, 18-95 Years). Signicant Differences Were Found In Age Between Those Who Screened Positive For Delirium (Mean, 53.4 Years; SD, 20.0 Years) And Those Who Did Not (Mean, 44.1 Years; SD, 19.6 Years; T = 2.95, P = .004). In Patients Aged 65 Years And Older, 35% Had Delirium Compared With 21% Of Patients Less Than 65 Years Old, But The Difference Was Not Signicant (R2 = 3.4, P = .06). No Other Signicant Relationships Were Found Between Prehospitalization Variables And Delirium (Table 1). Admission Variables Included Routinely Collected Blood Alcohol Level, Results Of Drug Toxicology Screening, And Signs And Symptoms Of Mild Brain Injury (Table 2). None Of These Variables Demonstrated A Relationship With A Positive Nding On The CAM-ICU.

Inpatient Variables From The Day Of Delirium Assessment Included Illness Severity, Patient Location, RASS Score, Sepsis Or Infection Diagnosis, Use Of Mechanical Ventilation, And Administration Of Medications Known To Be Associated With Acute Delirium (Table 3). Of The 215 Eligible Patients, 113 Were In The ICUs And 102 Were In The IMCs. ICU Patients Had A Higher Prevalence Of Delirium Than IMC Patients, With 36% Of ICU Patients Screening Positive For Delirium Versus 11% Of Patients In The IMC (R2 = 18.7, P < .001). Lower RASS Score Was Related To Delirium (T = -5.58, P < .001). Of Those Testing Positive For Delirium, 40 Patients (78%) Had A RASS Score Of -1, -2, Or -3. Higher Severity Of Illness Was Associated With Delirium. Mean APACHE III Score Was 38.9 (SD, 15.7) In CAM-ICU-Positive Patients Compared With 26.4 (SD, 13.3) In CAM-ICU-Negative Patients (T = 5.75, P < .001). Patients Who Screened Positive For Delirium Differed Signicantly From Patients Who Did Not In The Use Of Mechanical Ventilation And Medications (Table 3). Delirium Was Present In 51% Of Those Requiring Mechanical

Table 2 Admission Variables And Relationships To Acute Delirium

Variable Blood Alcohol Level > 0.08 Mg/DL Toxicology Screening Positive Mild Brain Injury

P .83 .41 .09

R2 0.4 1.8 4.8

Total (N = 215)  55 (25.6) 64 (29.8) 37 (17.2)

No Delirium (N = 164)  41 (25.0) 49 (29.9) 27 (16.5)

Delirium (N = 51) 14 (27.5) 15 (29.4) 10 (19.6)

No. (%) Of Patients

D I I I Bl (T Bl 2) Di I I Bl I I I Bl F H D Fd Li I

Table 3 Inpatient Variables On The Day Of Delirium Assessment

Variables APACHE III Score, Mean (SD) RASS Score, Mean (SD) Location, No. (%) Of Patients ICU IMC Mechanical Ventilation, No. (%) Of Patients Sepsis/Infection, No. (%) Of Patients Benzodiazepines, No. (%) Of Patients Antipsychotics, No. (%) Of Patients Narcotics, No. (%) Of Patients Sedatives, No. (%) Of Patients

P < .001 < .001 < .001

< .001 .26 .43 .001 .54 < .001

Total (N = 215)  29.3 (14.9)  -0.39 (0.95)

113 (52.6) 102 (47.4)  48 (22.3)  31 (14.4)  66 (30.7)  32 (14.9) 197 (91.6) 17 (7.9)

No Delirium (N = 164)  26.4 (13.3) -0.13 (0.56)

72/113 (63.7) 91/102 (89.2) 22 (13.4) 21 (12.8) 48 (29.3) 17 (10.4) 150 (91.5) 6 (3.7)

Delirium (N = 51) 38.9 (15.7) -1.22 (1.40)

41/113 (36.3) 11/102 (10.8) 26 (51.0) 10 (19.6) 18 (35.3) 15 (29.4) 47 (92.2) 12 (21.6)

Statistic T = 5.75 T = -5.58 R2 = 18.7

R2 = 33.4 R2 = 1.3 R2 = 0.6 R2 = 11.0 R2 = 0.4 R2 = 19.9

Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; ICU, Intensive Care Unit; IMC, Intermediate Care Unit; RASS, Richmond Agitation-Sedation Scale.

44  CriticalCareNurse Vol 37, No. 1, FEBRUARY 2017 Www.Ccnonline.Org

Our Findings Provide Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not.

Ventilation (R2 = 33.8, P < .001). The Patients Screening Positive For Delirium Had Greater Use Of Antipsychotic Agents (29% Vs 10.4%, R2 = 11.0, P = .001) As Well As The Use Of Sedative Medications On The Day Of Screening (21.6% Vs 3.7%, R2 = 19.9, P < .001). The Use Of Benzodiazepines And Narcotics Did Not Differ Between Patients Who Screened Positive For Delirium And Patients Who Were Negative For Delirium On The Day Of Data Collection. Six Variables Showed At Least Small Correlations With Delirium: Age (R = 0.17, P = .003), Sedative Use (R = 0.29, P < .001), Mechanical Ventilation (R = 0.38, P < .001), Antipsychotic Medication Administration (R = 0.23, P = .001), APACHE III Score (R = 0.29, P < .001), And RASS Score (R = -0.492, P < .001). The Best Model Included These 6 Variables, Signicantly Predicting Delirium (P < .001), Explaining 51.9% Of Variance (Cox And Snell R2 = 0.34; Nagelkerke R2 = 0.52). Table 4 Shows The Results Of Logistic Regression. Four Factors Predictive Of Delirium Were Mechanical Ventilation, Use Of Antipsychotic Agents, Higher APACHE III Score, And Lower RASS Score.

Discussion In Our Study, 24% Of Trauma Patients Screened With The CAM-ICU Tested Positive For Delirium In Both ICUs And IMCs, With Delirium Affecting More ICU Patients (36%). We Suspect That The Overall Lower Prevalence Of Delirium In Our Study Compared With Previous Studies May Be Due To Several Factors. One Factor Was The Small Numbers Of Patients With Preexisting Comorbid Conditions Such As Hypertension, Vascular Disease, And Pulmonary Disease. These Small Numbers Were Most Likely Due To The Younger Mean Age Of This Trauma Population Compared With Other Studies Of Critically Ill Patients. Although The Mean Age Of This Sample Was Younger Than The Mean Age In Other Investigations, Older Age Was Signicant For Higher Prevalence Of Delirium And Was Included In The Predictive Model. Similar To Other Studies Of Delirium In Trauma Patients,17,20,28 The Age Of Our Trauma Patients And Those Patients Testing Positive For Delirium Were Younger Than The Ages Reported In The General ICU Population.1-3,9 These Ndings Are Important Because Younger Patients Are Not Usually Considered To Be At High Risk For Delirium.

This Nding Underscores The Need For Delirium-Prevention Strategies In Hospitalized Trauma Patients, Regardless Of The Patients’ Age. Detrimental Effects Of Delirium Such As Increased Risk Of Death, Dementia, And Cognitive Dysfunction Following Discharge From The Hospital7,11,14,29,30 Underscores The Signicance Of Delirium Prevention Across The Age Span. Admission Variables Identied By Others To Be Related To Delirium Development Include Positive Results Of A Toxicology Screening, Elevated Blood Alcohol Content (> 0.08 G/DL), And Abnormal Score On The Glasgow Coma Scale (≤ 14). Unlike Studies Based On The National Trauma Databank19 And A Trauma Registry,18 Positive Blood Alcohol On Admission And History Of Alcohol Use Were Not Associated With Or Predictive Of Delirium In This Study Of Trauma Patients And In A Large Systematic Review.15 In Addition, Other Previously Reported Risk Factors Such As Positive Results Of Drug Toxicology Screening On Admission19,21 And Abnormal Score On The Glasgow Coma Scale21 Were Not Related To Delirium In Our Sample. Inpatient Variables Associated With Delirium Include Mechanical Ventilation And Administration Of Sedatives And Analgesics.9,10,15,17 Our Ndings Provide Additional Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not, Although The Prevalence Of Delirium In Our Sample Of Trauma Patients Receiving Mechanical Ventilation Was Lower Than Reported In Other Studies. This Lower Prevalence May Be Due To The Younger Age Of Trauma Patients And Fewer Comorbid Conditions That Would Predispose Individuals To Respiratory Dysfunction Or Failure. However, A Number Of The Study Patients In The ICU In Whom Mechanical Ventilation Was Not Being Used Thi  Di D Th Df D Li I Ti

Table 4 Multivariate Analysis Of Delirium Predictors In Trauma Patients

Variable Age Sedative Mechanical Ventilation Psychotropic Agent APACHE III Score RASS Score

Adjusted Odds Ratio (95% CI) 1.017 (0.993-1.042) 1.235 (0.296-5.163) 4.726 (1.628-13.716) 3.850 (1.280-11.579) 1.057 (1.020-1.095) 0.311 (0.188-0.516)

P .17 .77 .004 .02 .002 < .001 Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; RASS, Richmond Agitation-Sedation Scale.

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Tested Positive For Delirium On The Day Of Screening. Thomason And Colleagues31 Similarly Reported That 48% Of Medical ICU Patients Who Were Not Receiving Mechanical Ventilation Experienced At Least 1 Episode Of Delirium. An Important Nding Of This Investigation Was That Patients Who Tested Positive For Delirium Were Not Limited To Those Residing In The ICU. Of The Trauma IMC Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients. This Finding Is Noteworthy Because Most Studies Have Focused More Exclusively On Critically Ill Patients Who Require Mechanical Ventilation. These Results Suggest That Implementation Of Delirium Assessment And Prevention Strategies May Benet Trauma Patients Who Are Not Receiving Mechanical Ventilation Or Are Not In The ICU. Interestingly, Half Of The Patients Receiving Antipsychotic (Ziprasidone, Haloperidol) Or Sedative (Dexmedetomidine, Propofol) Medications Tested Positive For Delirium. At The Time Of This Study, Use Of Ziprasidone, Dexmedetomidine, And Haloperidol Was The Common Practice In Our Trauma Center For Treating Agitation Or Suspected Delirium. The High Percentage Of Patients Receiving These Medications Also May Have Been Related To Deliberate Attempts To Avoid Benzodiazepines And Narcotics To Facilitate More Rapid Liberation From Mechanical Ventilation, Practices Consistent With The Current Pain, Agitation, And Delirium Guidelines.32 Zall And Colleagues15 Identied Dexmedetomidine To Be Associated With Reduced Delirium Occurrence. This Same Review And Our Analysis Did Not Nd The Use Of Narcotics Or Benzodiazepines To Be Signicantly Associated With Delirium On The Day Of Data Collection, Although These Agents Have Been Reported To Be Risk Factors For The Development Of Delirium.9,10,17 The Use Of These Medications Can Result In A Lower RASS Score, Which We Found To Be Predictive Of Delirium. A RASS Score Of -1 To -3 Was Identied In 75% Of The Studied Patients. Delirium Is Often Underrecognized In This Subset Of Patients.1,5,11 Higher Illness Severity Has Been Associated With Delirium.10,14,15,18 Our Ndings Were Consistent With Results Of These Other Studies. In Our Sample, Higher APACHE III Scores Were Also Predictive Of Delirium. Mild Brain Injury Is Not Easily Detectable By Brain CT And May Go Undiagnosed.22,33 Thus, Patients With Normal Ndings On A Brain CT Scan But Signs And Symptoms Of A Possible Mild Brain Injury Were Included In Data Collection

To Ascertain If Delirium Is Related To Mild Brain Injury. In Trauma Patients Who Are CAM-ICU Positive, Differentiating Physiological Dysfunction Associated With Mild Traumatic Brain Injury And Cognitive Decits Related To Delirium Is Important To Guide Appropriate Interventions. Potentially Because Of The Limited Sample Size, No Signicant Relationship Was Detected Between Mild Brain Injury And Delirium. Further Exploration Of This Population Of Patients Is Warranted As Previous Studies Have Shown A Positive Relationship Between These 2 Variables.13 Limitations Of This Study Merit Further Exploration. Delirium Was Not Routinely Assessed In The ICUs And IMCs Of The Trauma Center At The Time Of This Investigation, Necessitating Collection Of Data On Point Prevalence; Thus The True Incidence Of Delirium Is Not Known, And We Were Inhibited From Being Able To Monitor Changes Over Time. We Were Unable To Differentiate Those Patients Who Were Receiving Antipsychotic Therapy For Suspected Delirium From Patients Receiving It For The Prevention Or Management Of Agitation. Although We Explored A Wide Variety Of Variables, It Is Possible That Other Factors Such As Use Of Isolation For Antibiotic-Resistant Infections, ICU Stay Before IMC Admission, As Well As The Types And Quantities Of Deliriogenic Medications Received Before The Data Collection Day Could Also Contribute To The Development Of Delirium. Finally, This Study Was Not Designed To Evaluate Long-Term Effects Of Delirium. Although We Know From Other Studies That Episodes Of Acute Delirium Are Detrimental To Long-Term Health Outcomes, We Were Unable To Draw Conclusions Specically Related To Our Younger Trauma Patients. This Topic Is A Potential Area For Study In Trauma Patients. Other Foci For Future Research Include Investigating The Impact Of A Delirium Prevention Initiative In Patients Who Are Not Receiving Mechanical Ventilation Or Who Have Mild Traumatic Brain Injury. Studies Related To The Prevention Of Delirium In The Trauma Population Are Limited. Education Regarding Delirium Before Implementing A Screening Program May Be Effective In Preventing Delirium.32,34 Use Of Validated Assessment Tools For Pain, Agitation, And Delirium In Conjunction With Delirium-Prevention Strategies Is Of The Trauma Intermediate Care Unit Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients.

Other Nonpharmacological Strategies That Are Within The Nursing Scope Of Practice Include Interventions Such As Music Or Light Therapy, Use Of Earplugs, And Sleep Promotion.37,38 Thus, Through Independent Interventions, Nurses Are Able To Directly Inuence The Outcomes Of Trauma Patients And Others Who Are At Risk For Delirium Developing, By Reducing The Occurrence Of Acute Delirium And Therefore Its Untoward Effects On Length Of Stay, Mortality, Long-Term Cognitive Function, And Cost Of Care.39

Conclusions

In This Study, Delirium Was Detected In Nearly 24% Of Hospitalized Trauma Patients. Use Of Mechanical Ventilation And Psychotropic Medications, Higher APACHE III Score, And Lower RASS Score Were Independent Predictors Of Delirium. Although The Presence Of Delirium In The Current Investigation Was Lower Than Reported In Other Studies Of Critically Ill Patients, Our Subset Of Trauma Patients Was Younger, Had Fewer Comorbid Conditions, And Included Patients Not Receiving Mechanical Ventilation And IMC Patients. Importantly, Delirium Was Present In Both The IMC Patients And The Patients Not Receiving Mechanical Ventilation. These Ndings Suggest That Delirium Assessment And Incorporation Of Delirium-P Revention Strategies Into The Routine Management Of All Hospitalized Trauma Patients May Be Benecial. Considering The Unfavorable Effects That Delirium Has On Patients And Their Postdischarge Outcomes, Nurses’ Attention To Prevention Strategies Is Crucial.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

Delirium In Trauma Patients: Prevalence And Predictors Kathryn T. Von Rueden, RN, MS, CNS-BC Breighanna Wallizer, RN, MS, CCRN, AG-ACNP Paul Thurman, RN, MS, ACNPC, CCNS Karen McQuillan, RN, MS, CNS-BC, CCRN

BACKGROUND Delirium Is Associated With Increased Mortality, Morbidity, Hospital Costs, And Postdischarge Cognitive Dysfunction. Most Research Focuses On Nontrauma Patients Receiving Mechanical Ventilation In The Intensive Care Unit. OBJECTIVES To Determine The Prevalence And Predictors Of Delirium In Trauma Patients Residing In Intensive And Intermediate Care Units Of An Academic Medical Center.

 

METHODS

Trauma Patients Were Screened For Delirium By Using The Confusion Assessment Method For The Intensive Care Unit. Exclusion Criteria Included Documented Brain Injury, History Of Psychosis Or Cognitive Impairment, Not Speaking English, And Hearing Or Vision Loss. RESULTS Of The 215 Study Patients, 24% Were Positive For Delirium; 36% Of Patients In The Intensive Care Unit And 11% Of Patients In The Intermediate Care Unit. Delirium-Positive Patients Were Older (Mean Age, 53.4 Years) Than Patients Who Were Not (Mean Age, 44 Years; P = .004). Although Mechanical Ventilation (Odds Ratio, 4.73, P = .004) Was The Strongest Independent Risk Factor For Delirium, 12% Of Delirium-Positive Patients Were Not Receiving Mechanical Ventilation. Other Predictors Of Delirium Were Use Of Antipsychotic Medications, Higher Scores On The Acute Physiology And Chronic Health Evaluation III, And Lower Scores On The Richmond Agitation-Sedation Scale.

 

CONCLUSIONS

Patients In Both The Intermediate And Intensive Care Units, Whether Mechanical Ventilation Was Used Or Not, Were Positive For Delirium. Delirium Prevention Protocols May Benet Trauma Patients Regardless Of Their Inpatient Location.

In The Past 2 Decades, Delirium Has Been An Increasing Focus Of Research In Critically Ill Patients Receiving Mechanical Ventilation. Acute Delirium, More Recently Referred To As Acute Brain Dysfunction, Has Been Reported In Up To 60% To 80% Of Critically Ill Patients Undergoing Mechanical Ventilation1-3 And Is Often Undiagnosed In Hospitalized Patients.4,5

 

Delirium Has A Marked Impact On Patients’ Outcomes. It Is Associated With Increased Mortality,2-4,6,7 Length Of Stay,2,8,9 And Rate Of Postdischarge Cognitive Dysfunction And Institutionalization.10-13 Delirium Leads To An Additional 17.5 Million Inpatient Days, With More Than $5 Billion In Medicare Charges Annually. Predictors Of Delirium Include Preexisting Medical Conditions, Conditions Associated With Acute Illness, As Well As Iatrogenic And Environmental Factors.14,15 Preexisting Or Nonmodiable Risk Factors For Delirium At The Time Of Hospital Admission Include Advanced Age (> 65 Years), Alcohol Use, Brain Trauma, Dementia, Hypertension, Smoking, Depression, Chronic Illnesses, And Male Sex.14,15 Illness-Related Factors Include Hypoxia, Sepsis, Metabolic And Electrolyte Disturbances, Respiratory And Cardiac Failure, And Immobility.3,14,16 Iatrogenic Factors Include Opioid, Sedative, And Antipsychotic Medications; Physical And Chemical Restraints; And Nutritional Deciencies.9,10,14-17 A Recent Systematic Review Suggested That Age, Dementia, Coma, Scores On The Acute Physiology And Chronic Health Evaluation (APACHE) II, Previous Delirium, Emergency Surgery And Trauma, Mechanical Ventilation, And Metabolic Acidosis Were Well Supported By Evidence To Contribute To Development Of Delirium.15

Incidence, Risk Factors, And Predictors Of Acute Delirium Are Widely Reported In Critically Ill Medical And Surgical Patients Receiving Mechanical Ventilation, But Less Is Known About Acute Delirium In Trauma Patients, Particularly Those Who Require Mechanical Ventilation. Studies Of Delirium In Trauma Patients Have Been Retrospective In Nature,18,19 Have Included Only Patients Undergoing Mechanical Ventilation,5,17,20 Or Have Had Limited Sample Sizes.5,17,20,21 The Objective Of This Prospective, Observational Study Was To Determine The Prevalence Of Delirium In Trauma Patients Who Reside In Intermediate Care Units (IMCs) Or In Intensive Care Units (ICUs). Secondary Aims Were To Explore And Dene Characteristics And Predictors Of Delirium In Trauma Patients.

 

Methods

The Investigation Was Approved By The Institutional Review Board With A Waiver Of Informed Consent As A Noninterventional, Observational Point Prevalence Study. This Cross-Sectional Descriptive Study Was Conducted At A Large, Urban Academic Trauma Center And Included Patients From 3 Trauma IMCs And ICUs. Data Were Collected During The Day Shift (Between 7 AM And 7 PM) On 13 Different Days For Several Months. Prevalence, Presence Of Delirium In Patients On The Data Collection Days, Was Used Because The Incidence Of Delirium Could Not Be Determined As Delirium Was Not Routinely Assessed. The Trauma Center’s Daily Patient Census Was Used To Identify Potential Study Participants On Each Data Collection Day. Eligible Patients Met The Following Inclusion Criteria: 18 Years Or Older, English Speaking, No Diagnosed Traumatic Brain Injury, And A Score Of At Least 8 On The Glasgow Coma Scale At The Time Of Data Collection. Exclusion Criteria Were Nontrauma Admissions, Hospital Readmissions, Known History Of Psychosis Or Cognitive Impairment, Brain Injury Documented On Computed Tomography (CT) Of The Brain, Signicant Hearing Or Vision Loss, And A Level Of Arousal Less Than -3 As Dened By The Richmond Agitation-Sedation Scale (RASS). Because Mild Traumatic Brain Injury Is Difcult To Diagnose And Not Readily Detectable With Brain CT,22 These Patients Could Not Be Excluded On The Basis Of A Known Brain Injury. Other Patients Were Excluded If They Had Previously Been Included In The Study Or Were Scheduled For Surgery Or Hospital Discharge On The Screening And Data Collection Days. The Data Collected From Medical Records Of Eligible Patients Included Mechanism Of Injury; Demographics Such As Medical History, Age, And Sex; Criteria For Mild Traumatic Brain Injury; Past Use Of Illicit Drugs Or Alcohol; Results Of Admission Toxicology And Blood Alcohol Screenings; Use Of Medications Known To Affect Delirium; Illness Severity As Measured By APACHE III Score; And Presence Of Sepsis. Criteria For Evaluating Potential Mild Traumatic Brain Injury Included At Least 2 Of The Following: Loss Of Consciousness For More Than 30 Minutes At The Scene, Amnesia At Or Near The Time Of The Event, And Score Of 13 To 14 On The Glasgow Coma Scale On Admission.22 Medications Administered To Patients At The Time Of Data Collection That May Inuence Results Of The Confusion Assessment Method For The Intensive Care Unit (CAMICU) And Delirium Were Classied As Sedatives (Propofol, Dexmedetomidine), Antipsychotic Agents (Haloperidol, Ziprasidone), Benzodiazepines (Lorazepam, Diazepam, Midazolam), And Narcotics (Fentanyl, Hydromorphone, Oxycodone). APACHE III Score Was Used Rather Than APACHE II Score To Quantify Illness Severity Because The APACHE III Was Developed From A More Contemporary Database23,24 And Assigns Points For Age Ranges Younger Than The APACHE II Score Does. APACHE III Has Been Validated In Trauma Patients.25 Eligible Patients Were Assessed With The CAM-ICU To Detect Delirium. This Well-Validated Tool Evaluates For Acute Onset Of Changes Or Fluctuations In Mental Status, Inattention, And Either Disorganized Thinking Or An Altered Level Of Consciousness.26 Published Directions For Scoring The CAM-ICU Are Available.27 Because

The Institution Did Not Use A Formal Delirium Assessment And Prevention Protocol At The Time Of The Study, A Team Of 7 Nurses Was Trained To Use The CAM-ICU. Training, Overseen By An Expert Clinical Nurse Specialist, Was Conducted Via Video And Live Demonstrations That Used Standardized Scenarios With Return Demonstrations On Patients. This Team Also Collected All Of The Data From The Medical Records.

Statistical Analysis

Bivariate Analysis With R2 Test, T Test, And Correlation Examined The Association Between The Outcome Variables Of Delirium And Each Factor. Variables Showing A Signicant (P < .20) Bivariate Relationship To Delirium Were Included In The Nal Logistic Regression To Predict Delirium. Logistic Regression With A Sample Size Of 215 Observations Achieved 84% Power At A .05 Signifcance Level And Medium Effect Size (R = 0.3).

Results Of The 800 Patients Screened, 215 Met Eligibility Requirements For Inclusion. Many Patients Were Excluded Because Of A Large Number Of Nontrauma Admissions, Readmissions, And Patients With Radiographically Documented Traumatic Brain Injuries During The Data Collection Period. Overall Delirium Prevalence In This Sample Of Trauma Patients In Both The ICUs And IMCs Was 23.7% (N = 51). Patients’ Characteristics Were Classified Into Categories Related To Prehospitalization Variables (Table 1),

Table 1 Prehospitalization Characteristics Of Patients And Relationships To Acute Delirium

Variable Male Female Mechanism Of Injury Vehicle Penetration Sports Crushing Falling Tobacco Use Hypertension Vascular Disease Depression Past Illicit Drug Use Past Alcohol Use

P

.63

.34

.38 .46 .52 .62 .76 .22

R2

0.2

4.5

3.1 1.6 1.3 1.0 0.5 3.1

Total (N = 215)  164 (76.3) 51 (23.7)

89 (41.4) 47 (21.9) 6 (2.8) 9 (4.2) 64 (29.8) 77 (35.8) 61 (28.4) 19 (8.8) 19 (8.8) 52 (24.2) 49 (22.8)

No Delirium (N = 164)  124 (75.6) 40 (24.4)

68 (41.5) 39 (23.8) 6 (3.7) 7 (4.3) 44 (26.8) 60 (36.6) 44 (26.8) 13 (7.9) 14 (8.5) 38 (23.2) 33 (20.1)

Delirium (N = 51) 40 (78.4) 11 (21.6)

21 (41.2) 8 (15.7) 0 (0) 2 (3.9) 20 (39.2) 17 (33.3) 17 (33.3) 6 (11.8) 5 (9.8) 14 (27.5) 16 (31.4)

No. (%) Of Patients

 

Admission Variables (Table 2), And Inpatient Variables From The Day Of Data Collection (Table 3). Prehospitalization Variables Included Age, Mechanism Of Injury, Preexisting Comorbid Conditions, And History Of Tobacco, Illicit Drug, And Alcohol Use. The Mean Sample Age Was 46.3 Years (SD, 14.9 Years; Range, 18-95 Years). Signicant Differences Were Found In Age Between Those Who Screened Positive For Delirium (Mean, 53.4 Years; SD, 20.0 Years) And Those Who Did Not (Mean, 44.1 Years; SD, 19.6 Years; T = 2.95, P = .004). In Patients Aged 65 Years And Older, 35% Had Delirium Compared With 21% Of Patients Less Than 65 Years Old, But The Difference Was Not Signicant (R2 = 3.4, P = .06). No Other Signicant Relationships Were Found Between Prehospitalization Variables And Delirium (Table 1). Admission Variables Included Routinely Collected Blood Alcohol Level, Results Of Drug Toxicology Screening, And Signs And Symptoms Of Mild Brain Injury (Table 2). None Of These Variables Demonstrated A Relationship With A Positive Nding On The CAM-ICU.

Inpatient Variables From The Day Of Delirium Assessment Included Illness Severity, Patient Location, RASS Score, Sepsis Or Infection Diagnosis, Use Of Mechanical Ventilation, And Administration Of Medications Known To Be Associated With Acute Delirium (Table 3). Of The 215 Eligible Patients, 113 Were In The ICUs And 102 Were In The IMCs. ICU Patients Had A Higher Prevalence Of Delirium Than IMC Patients, With 36% Of ICU Patients Screening Positive For Delirium Versus 11% Of Patients In The IMC (R2 = 18.7, P < .001). Lower RASS Score Was Related To Delirium (T = -5.58, P < .001). Of Those Testing Positive For Delirium, 40 Patients (78%) Had A RASS Score Of -1, -2, Or -3. Higher Severity Of Illness Was Associated With Delirium. Mean APACHE III Score Was 38.9 (SD, 15.7) In CAM-ICU-Positive Patients Compared With 26.4 (SD, 13.3) In CAM-ICU-Negative Patients (T = 5.75, P < .001). Patients Who Screened Positive For Delirium Differed Signicantly From Patients Who Did Not In The Use Of Mechanical Ventilation And Medications (Table 3). Delirium Was Present In 51% Of Those Requiring Mechanical

Table 2 Admission Variables And Relationships To Acute Delirium

Variable Blood Alcohol Level > 0.08 Mg/DL Toxicology Screening Positive Mild Brain Injury

P .83 .41 .09

R2 0.4 1.8 4.8

Total (N = 215)  55 (25.6) 64 (29.8) 37 (17.2)

No Delirium (N = 164)  41 (25.0) 49 (29.9) 27 (16.5)

Delirium (N = 51) 14 (27.5) 15 (29.4) 10 (19.6)

No. (%) Of Patients

D I I I Bl (T Bl 2) Di I I Bl I I I Bl F H D Fd Li I

Table 3 Inpatient Variables On The Day Of Delirium Assessment

Variables APACHE III Score, Mean (SD) RASS Score, Mean (SD) Location, No. (%) Of Patients ICU IMC Mechanical Ventilation, No. (%) Of Patients Sepsis/Infection, No. (%) Of Patients Benzodiazepines, No. (%) Of Patients Antipsychotics, No. (%) Of Patients Narcotics, No. (%) Of Patients Sedatives, No. (%) Of Patients

P < .001 < .001 < .001

< .001 .26 .43 .001 .54 < .001

Total (N = 215)  29.3 (14.9)  -0.39 (0.95)

113 (52.6) 102 (47.4)  48 (22.3)  31 (14.4)  66 (30.7)  32 (14.9) 197 (91.6) 17 (7.9)

No Delirium (N = 164)  26.4 (13.3) -0.13 (0.56)

72/113 (63.7) 91/102 (89.2) 22 (13.4) 21 (12.8) 48 (29.3) 17 (10.4) 150 (91.5) 6 (3.7)

Delirium (N = 51) 38.9 (15.7) -1.22 (1.40)

41/113 (36.3) 11/102 (10.8) 26 (51.0) 10 (19.6) 18 (35.3) 15 (29.4) 47 (92.2) 12 (21.6)

Statistic T = 5.75 T = -5.58 R2 = 18.7

R2 = 33.4 R2 = 1.3 R2 = 0.6 R2 = 11.0 R2 = 0.4 R2 = 19.9

Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; ICU, Intensive Care Unit; IMC, Intermediate Care Unit; RASS, Richmond Agitation-Sedation Scale.

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Our Findings Provide Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not.

Ventilation (R2 = 33.8, P < .001). The Patients Screening Positive For Delirium Had Greater Use Of Antipsychotic Agents (29% Vs 10.4%, R2 = 11.0, P = .001) As Well As The Use Of Sedative Medications On The Day Of Screening (21.6% Vs 3.7%, R2 = 19.9, P < .001). The Use Of Benzodiazepines And Narcotics Did Not Differ Between Patients Who Screened Positive For Delirium And Patients Who Were Negative For Delirium On The Day Of Data Collection. Six Variables Showed At Least Small Correlations With Delirium: Age (R = 0.17, P = .003), Sedative Use (R = 0.29, P < .001), Mechanical Ventilation (R = 0.38, P < .001), Antipsychotic Medication Administration (R = 0.23, P = .001), APACHE III Score (R = 0.29, P < .001), And RASS Score (R = -0.492, P < .001). The Best Model Included These 6 Variables, Signicantly Predicting Delirium (P < .001), Explaining 51.9% Of Variance (Cox And Snell R2 = 0.34; Nagelkerke R2 = 0.52). Table 4 Shows The Results Of Logistic Regression. Four Factors Predictive Of Delirium Were Mechanical Ventilation, Use Of Antipsychotic Agents, Higher APACHE III Score, And Lower RASS Score.

Discussion In Our Study, 24% Of Trauma Patients Screened With The CAM-ICU Tested Positive For Delirium In Both ICUs And IMCs, With Delirium Affecting More ICU Patients (36%). We Suspect That The Overall Lower Prevalence Of Delirium In Our Study Compared With Previous Studies May Be Due To Several Factors. One Factor Was The Small Numbers Of Patients With Preexisting Comorbid Conditions Such As Hypertension, Vascular Disease, And Pulmonary Disease. These Small Numbers Were Most Likely Due To The Younger Mean Age Of This Trauma Population Compared With Other Studies Of Critically Ill Patients. Although The Mean Age Of This Sample Was Younger Than The Mean Age In Other Investigations, Older Age Was Signicant For Higher Prevalence Of Delirium And Was Included In The Predictive Model. Similar To Other Studies Of Delirium In Trauma Patients,17,20,28 The Age Of Our Trauma Patients And Those Patients Testing Positive For Delirium Were Younger Than The Ages Reported In The General ICU Population.1-3,9 These Ndings Are Important Because Younger Patients Are Not Usually Considered To Be At High Risk For Delirium.

This Nding Underscores The Need For Delirium-Prevention Strategies In Hospitalized Trauma Patients, Regardless Of The Patients’ Age. Detrimental Effects Of Delirium Such As Increased Risk Of Death, Dementia, And Cognitive Dysfunction Following Discharge From The Hospital7,11,14,29,30 Underscores The Signicance Of Delirium Prevention Across The Age Span. Admission Variables Identied By Others To Be Related To Delirium Development Include Positive Results Of A Toxicology Screening, Elevated Blood Alcohol Content (> 0.08 G/DL), And Abnormal Score On The Glasgow Coma Scale (≤ 14). Unlike Studies Based On The National Trauma Databank19 And A Trauma Registry,18 Positive Blood Alcohol On Admission And History Of Alcohol Use Were Not Associated With Or Predictive Of Delirium In This Study Of Trauma Patients And In A Large Systematic Review.15 In Addition, Other Previously Reported Risk Factors Such As Positive Results Of Drug Toxicology Screening On Admission19,21 And Abnormal Score On The Glasgow Coma Scale21 Were Not Related To Delirium In Our Sample. Inpatient Variables Associated With Delirium Include Mechanical Ventilation And Administration Of Sedatives And Analgesics.9,10,15,17 Our Ndings Provide Additional Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not, Although The Prevalence Of Delirium In Our Sample Of Trauma Patients Receiving Mechanical Ventilation Was Lower Than Reported In Other Studies. This Lower Prevalence May Be Due To The Younger Age Of Trauma Patients And Fewer Comorbid Conditions That Would Predispose Individuals To Respiratory Dysfunction Or Failure. However, A Number Of The Study Patients In The ICU In Whom Mechanical Ventilation Was Not Being Used Thi  Di D Th Df D Li I Ti

Table 4 Multivariate Analysis Of Delirium Predictors In Trauma Patients

Variable Age Sedative Mechanical Ventilation Psychotropic Agent APACHE III Score RASS Score

Adjusted Odds Ratio (95% CI) 1.017 (0.993-1.042) 1.235 (0.296-5.163) 4.726 (1.628-13.716) 3.850 (1.280-11.579) 1.057 (1.020-1.095) 0.311 (0.188-0.516)

P .17 .77 .004 .02 .002 < .001 Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; RASS, Richmond Agitation-Sedation Scale.

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Tested Positive For Delirium On The Day Of Screening. Thomason And Colleagues31 Similarly Reported That 48% Of Medical ICU Patients Who Were Not Receiving Mechanical Ventilation Experienced At Least 1 Episode Of Delirium. An Important Nding Of This Investigation Was That Patients Who Tested Positive For Delirium Were Not Limited To Those Residing In The ICU. Of The Trauma IMC Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients. This Finding Is Noteworthy Because Most Studies Have Focused More Exclusively On Critically Ill Patients Who Require Mechanical Ventilation. These Results Suggest That Implementation Of Delirium Assessment And Prevention Strategies May Benet Trauma Patients Who Are Not Receiving Mechanical Ventilation Or Are Not In The ICU. Interestingly, Half Of The Patients Receiving Antipsychotic (Ziprasidone, Haloperidol) Or Sedative (Dexmedetomidine, Propofol) Medications Tested Positive For Delirium. At The Time Of This Study, Use Of Ziprasidone, Dexmedetomidine, And Haloperidol Was The Common Practice In Our Trauma Center For Treating Agitation Or Suspected Delirium. The High Percentage Of Patients Receiving These Medications Also May Have Been Related To Deliberate Attempts To Avoid Benzodiazepines And Narcotics To Facilitate More Rapid Liberation From Mechanical Ventilation, Practices Consistent With The Current Pain, Agitation, And Delirium Guidelines.32 Zall And Colleagues15 Identied Dexmedetomidine To Be Associated With Reduced Delirium Occurrence. This Same Review And Our Analysis Did Not Nd The Use Of Narcotics Or Benzodiazepines To Be Signicantly Associated With Delirium On The Day Of Data Collection, Although These Agents Have Been Reported To Be Risk Factors For The Development Of Delirium.9,10,17 The Use Of These Medications Can Result In A Lower RASS Score, Which We Found To Be Predictive Of Delirium. A RASS Score Of -1 To -3 Was Identied In 75% Of The Studied Patients. Delirium Is Often Underrecognized In This Subset Of Patients.1,5,11 Higher Illness Severity Has Been Associated With Delirium.10,14,15,18 Our Ndings Were Consistent With Results Of These Other Studies. In Our Sample, Higher APACHE III Scores Were Also Predictive Of Delirium. Mild Brain Injury Is Not Easily Detectable By Brain CT And May Go Undiagnosed.22,33 Thus, Patients With Normal Ndings On A Brain CT Scan But Signs And Symptoms Of A Possible Mild Brain Injury Were Included In Data Collection

To Ascertain If Delirium Is Related To Mild Brain Injury. In Trauma Patients Who Are CAM-ICU Positive, Differentiating Physiological Dysfunction Associated With Mild Traumatic Brain Injury And Cognitive Decits Related To Delirium Is Important To Guide Appropriate Interventions. Potentially Because Of The Limited Sample Size, No Signicant Relationship Was Detected Between Mild Brain Injury And Delirium. Further Exploration Of This Population Of Patients Is Warranted As Previous Studies Have Shown A Positive Relationship Between These 2 Variables.13 Limitations Of This Study Merit Further Exploration. Delirium Was Not Routinely Assessed In The ICUs And IMCs Of The Trauma Center At The Time Of This Investigation, Necessitating Collection Of Data On Point Prevalence; Thus The True Incidence Of Delirium Is Not Known, And We Were Inhibited From Being Able To Monitor Changes Over Time. We Were Unable To Differentiate Those Patients Who Were Receiving Antipsychotic Therapy For Suspected Delirium From Patients Receiving It For The Prevention Or Management Of Agitation. Although We Explored A Wide Variety Of Variables, It Is Possible That Other Factors Such As Use Of Isolation For Antibiotic-Resistant Infections, ICU Stay Before IMC Admission, As Well As The Types And Quantities Of Deliriogenic Medications Received Before The Data Collection Day Could Also Contribute To The Development Of Delirium. Finally, This Study Was Not Designed To Evaluate Long-Term Effects Of Delirium. Although We Know From Other Studies That Episodes Of Acute Delirium Are Detrimental To Long-Term Health Outcomes, We Were Unable To Draw Conclusions Specically Related To Our Younger Trauma Patients. This Topic Is A Potential Area For Study In Trauma Patients. Other Foci For Future Research Include Investigating The Impact Of A Delirium Prevention Initiative In Patients Who Are Not Receiving Mechanical Ventilation Or Who Have Mild Traumatic Brain Injury. Studies Related To The Prevention Of Delirium In The Trauma Population Are Limited. Education Regarding Delirium Before Implementing A Screening Program May Be Effective In Preventing Delirium.32,34 Use Of Validated Assessment Tools For Pain, Agitation, And Delirium In Conjunction With Delirium-Prevention Strategies Is Of The Trauma Intermediate Care Unit Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients.

Other Nonpharmacological Strategies That Are Within The Nursing Scope Of Practice Include Interventions Such As Music Or Light Therapy, Use Of Earplugs, And Sleep Promotion.37,38 Thus, Through Independent Interventions, Nurses Are Able To Directly Inuence The Outcomes Of Trauma Patients And Others Who Are At Risk For Delirium Developing, By Reducing The Occurrence Of Acute Delirium And Therefore Its Untoward Effects On Length Of Stay, Mortality, Long-Term Cognitive Function, And Cost Of Care.39

Conclusions

In This Study, Delirium Was Detected In Nearly 24% Of Hospitalized Trauma Patients. Use Of Mechanical Ventilation And Psychotropic Medications, Higher APACHE III Score, And Lower RASS Score Were Independent Predictors Of Delirium. Although The Presence Of Delirium In The Current Investigation Was Lower Than Reported In Other Studies Of Critically Ill Patients, Our Subset Of Trauma Patients Was Younger, Had Fewer Comorbid Conditions, And Included Patients Not Receiving Mechanical Ventilation And IMC Patients. Importantly, Delirium Was Present In Both The IMC Patients And The Patients Not Receiving Mechanical Ventilation. These Ndings Suggest That Delirium Assessment And Incorporation Of Delirium-P Revention Strategies Into The Routine Management Of All Hospitalized Trauma Patients May Be Benecial. Considering The Unfavorable Effects That Delirium Has On Patients And Their Postdischarge Outcomes, Nurses’ Attention To Prevention Strategies Is Crucial.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

QUESTION: Give An Example Of Reliability And Validity From Article Below.

Delirium In Trauma Patients: Prevalence And Predictors Kathryn T. Von Rueden, RN, MS, CNS-BC Breighanna Wallizer, RN, MS, CCRN, AG-ACNP Paul Thurman, RN, MS, ACNPC, CCNS Karen McQuillan, RN, MS, CNS-BC, CCRN

BACKGROUND Delirium Is Associated With Increased Mortality, Morbidity, Hospital Costs, And Postdischarge Cognitive Dysfunction. Most Research Focuses On Nontrauma Patients Receiving Mechanical Ventilation In The Intensive Care Unit. OBJECTIVES To Determine The Prevalence And Predictors Of Delirium In Trauma Patients Residing In Intensive And Intermediate Care Units Of An Academic Medical Center.

 

METHODS

Trauma Patients Were Screened For Delirium By Using The Confusion Assessment Method For The Intensive Care Unit. Exclusion Criteria Included Documented Brain Injury, History Of Psychosis Or Cognitive Impairment, Not Speaking English, And Hearing Or Vision Loss. RESULTS Of The 215 Study Patients, 24% Were Positive For Delirium; 36% Of Patients In The Intensive Care Unit And 11% Of Patients In The Intermediate Care Unit. Delirium-Positive Patients Were Older (Mean Age, 53.4 Years) Than Patients Who Were Not (Mean Age, 44 Years; P = .004). Although Mechanical Ventilation (Odds Ratio, 4.73, P = .004) Was The Strongest Independent Risk Factor For Delirium, 12% Of Delirium-Positive Patients Were Not Receiving Mechanical Ventilation. Other Predictors Of Delirium Were Use Of Antipsychotic Medications, Higher Scores On The Acute Physiology And Chronic Health Evaluation III, And Lower Scores On The Richmond Agitation-Sedation Scale.

 

CONCLUSIONS

Patients In Both The Intermediate And Intensive Care Units, Whether Mechanical Ventilation Was Used Or Not, Were Positive For Delirium. Delirium Prevention Protocols May Benet Trauma Patients Regardless Of Their Inpatient Location.

In The Past 2 Decades, Delirium Has Been An Increasing Focus Of Research In Critically Ill Patients Receiving Mechanical Ventilation. Acute Delirium, More Recently Referred To As Acute Brain Dysfunction, Has Been Reported In Up To 60% To 80% Of Critically Ill Patients Undergoing Mechanical Ventilation1-3 And Is Often Undiagnosed In Hospitalized Patients.4,5

 

Delirium Has A Marked Impact On Patients’ Outcomes. It Is Associated With Increased Mortality,2-4,6,7 Length Of Stay,2,8,9 And Rate Of Postdischarge Cognitive Dysfunction And Institutionalization.10-13 Delirium Leads To An Additional 17.5 Million Inpatient Days, With More Than $5 Billion In Medicare Charges Annually. Predictors Of Delirium Include Preexisting Medical Conditions, Conditions Associated With Acute Illness, As Well As Iatrogenic And Environmental Factors.14,15 Preexisting Or Nonmodiable Risk Factors For Delirium At The Time Of Hospital Admission Include Advanced Age (> 65 Years), Alcohol Use, Brain Trauma, Dementia, Hypertension, Smoking, Depression, Chronic Illnesses, And Male Sex.14,15 Illness-Related Factors Include Hypoxia, Sepsis, Metabolic And Electrolyte Disturbances, Respiratory And Cardiac Failure, And Immobility.3,14,16 Iatrogenic Factors Include Opioid, Sedative, And Antipsychotic Medications; Physical And Chemical Restraints; And Nutritional Deciencies.9,10,14-17 A Recent Systematic Review Suggested That Age, Dementia, Coma, Scores On The Acute Physiology And Chronic Health Evaluation (APACHE) II, Previous Delirium, Emergency Surgery And Trauma, Mechanical Ventilation, And Metabolic Acidosis Were Well Supported By Evidence To Contribute To Development Of Delirium.15

Incidence, Risk Factors, And Predictors Of Acute Delirium Are Widely Reported In Critically Ill Medical And Surgical Patients Receiving Mechanical Ventilation, But Less Is Known About Acute Delirium In Trauma Patients, Particularly Those Who Require Mechanical Ventilation. Studies Of Delirium In Trauma Patients Have Been Retrospective In Nature,18,19 Have Included Only Patients Undergoing Mechanical Ventilation,5,17,20 Or Have Had Limited Sample Sizes.5,17,20,21 The Objective Of This Prospective, Observational Study Was To Determine The Prevalence Of Delirium In Trauma Patients Who Reside In Intermediate Care Units (IMCs) Or In Intensive Care Units (ICUs). Secondary Aims Were To Explore And Dene Characteristics And Predictors Of Delirium In Trauma Patients.

 

Methods

The Investigation Was Approved By The Institutional Review Board With A Waiver Of Informed Consent As A Noninterventional, Observational Point Prevalence Study. This Cross-Sectional Descriptive Study Was Conducted At A Large, Urban Academic Trauma Center And Included Patients From 3 Trauma IMCs And ICUs. Data Were Collected During The Day Shift (Between 7 AM And 7 PM) On 13 Different Days For Several Months. Prevalence, Presence Of Delirium In Patients On The Data Collection Days, Was Used Because The Incidence Of Delirium Could Not Be Determined As Delirium Was Not Routinely Assessed. The Trauma Center’s Daily Patient Census Was Used To Identify Potential Study Participants On Each Data Collection Day. Eligible Patients Met The Following Inclusion Criteria: 18 Years Or Older, English Speaking, No Diagnosed Traumatic Brain Injury, And A Score Of At Least 8 On The Glasgow Coma Scale At The Time Of Data Collection. Exclusion Criteria Were Nontrauma Admissions, Hospital Readmissions, Known History Of Psychosis Or Cognitive Impairment, Brain Injury Documented On Computed Tomography (CT) Of The Brain, Signicant Hearing Or Vision Loss, And A Level Of Arousal Less Than -3 As Dened By The Richmond Agitation-Sedation Scale (RASS). Because Mild Traumatic Brain Injury Is Difcult To Diagnose And Not Readily Detectable With Brain CT,22 These Patients Could Not Be Excluded On The Basis Of A Known Brain Injury. Other Patients Were Excluded If They Had Previously Been Included In The Study Or Were Scheduled For Surgery Or Hospital Discharge On The Screening And Data Collection Days. The Data Collected From Medical Records Of Eligible Patients Included Mechanism Of Injury; Demographics Such As Medical History, Age, And Sex; Criteria For Mild Traumatic Brain Injury; Past Use Of Illicit Drugs Or Alcohol; Results Of Admission Toxicology And Blood Alcohol Screenings; Use Of Medications Known To Affect Delirium; Illness Severity As Measured By APACHE III Score; And Presence Of Sepsis. Criteria For Evaluating Potential Mild Traumatic Brain Injury Included At Least 2 Of The Following: Loss Of Consciousness For More Than 30 Minutes At The Scene, Amnesia At Or Near The Time Of The Event, And Score Of 13 To 14 On The Glasgow Coma Scale On Admission.22 Medications Administered To Patients At The Time Of Data Collection That May Inuence Results Of The Confusion Assessment Method For The Intensive Care Unit (CAMICU) And Delirium Were Classied As Sedatives (Propofol, Dexmedetomidine), Antipsychotic Agents (Haloperidol, Ziprasidone), Benzodiazepines (Lorazepam, Diazepam, Midazolam), And Narcotics (Fentanyl, Hydromorphone, Oxycodone). APACHE III Score Was Used Rather Than APACHE II Score To Quantify Illness Severity Because The APACHE III Was Developed From A More Contemporary Database23,24 And Assigns Points For Age Ranges Younger Than The APACHE II Score Does. APACHE III Has Been Validated In Trauma Patients.25 Eligible Patients Were Assessed With The CAM-ICU To Detect Delirium. This Well-Validated Tool Evaluates For Acute Onset Of Changes Or Fluctuations In Mental Status, Inattention, And Either Disorganized Thinking Or An Altered Level Of Consciousness.26 Published Directions For Scoring The CAM-ICU Are Available.27 Because

The Institution Did Not Use A Formal Delirium Assessment And Prevention Protocol At The Time Of The Study, A Team Of 7 Nurses Was Trained To Use The CAM-ICU. Training, Overseen By An Expert Clinical Nurse Specialist, Was Conducted Via Video And Live Demonstrations That Used Standardized Scenarios With Return Demonstrations On Patients. This Team Also Collected All Of The Data From The Medical Records.

Statistical Analysis

Bivariate Analysis With R2 Test, T Test, And Correlation Examined The Association Between The Outcome Variables Of Delirium And Each Factor. Variables Showing A Signicant (P < .20) Bivariate Relationship To Delirium Were Included In The Nal Logistic Regression To Predict Delirium. Logistic Regression With A Sample Size Of 215 Observations Achieved 84% Power At A .05 Signifcance Level And Medium Effect Size (R = 0.3).

Results Of The 800 Patients Screened, 215 Met Eligibility Requirements For Inclusion. Many Patients Were Excluded Because Of A Large Number Of Nontrauma Admissions, Readmissions, And Patients With Radiographically Documented Traumatic Brain Injuries During The Data Collection Period. Overall Delirium Prevalence In This Sample Of Trauma Patients In Both The ICUs And IMCs Was 23.7% (N = 51). Patients’ Characteristics Were Classified Into Categories Related To Prehospitalization Variables (Table 1),

Table 1 Prehospitalization Characteristics Of Patients And Relationships To Acute Delirium

Variable Male Female Mechanism Of Injury Vehicle Penetration Sports Crushing Falling Tobacco Use Hypertension Vascular Disease Depression Past Illicit Drug Use Past Alcohol Use

P

.63

.34

.38 .46 .52 .62 .76 .22

R2

0.2

4.5

3.1 1.6 1.3 1.0 0.5 3.1

Total (N = 215)  164 (76.3) 51 (23.7)

89 (41.4) 47 (21.9) 6 (2.8) 9 (4.2) 64 (29.8) 77 (35.8) 61 (28.4) 19 (8.8) 19 (8.8) 52 (24.2) 49 (22.8)

No Delirium (N = 164)  124 (75.6) 40 (24.4)

68 (41.5) 39 (23.8) 6 (3.7) 7 (4.3) 44 (26.8) 60 (36.6) 44 (26.8) 13 (7.9) 14 (8.5) 38 (23.2) 33 (20.1)

Delirium (N = 51) 40 (78.4) 11 (21.6)

21 (41.2) 8 (15.7) 0 (0) 2 (3.9) 20 (39.2) 17 (33.3) 17 (33.3) 6 (11.8) 5 (9.8) 14 (27.5) 16 (31.4)

No. (%) Of Patients

 

Admission Variables (Table 2), And Inpatient Variables From The Day Of Data Collection (Table 3). Prehospitalization Variables Included Age, Mechanism Of Injury, Preexisting Comorbid Conditions, And History Of Tobacco, Illicit Drug, And Alcohol Use. The Mean Sample Age Was 46.3 Years (SD, 14.9 Years; Range, 18-95 Years). Signicant Differences Were Found In Age Between Those Who Screened Positive For Delirium (Mean, 53.4 Years; SD, 20.0 Years) And Those Who Did Not (Mean, 44.1 Years; SD, 19.6 Years; T = 2.95, P = .004). In Patients Aged 65 Years And Older, 35% Had Delirium Compared With 21% Of Patients Less Than 65 Years Old, But The Difference Was Not Signicant (R2 = 3.4, P = .06). No Other Signicant Relationships Were Found Between Prehospitalization Variables And Delirium (Table 1). Admission Variables Included Routinely Collected Blood Alcohol Level, Results Of Drug Toxicology Screening, And Signs And Symptoms Of Mild Brain Injury (Table 2). None Of These Variables Demonstrated A Relationship With A Positive Nding On The CAM-ICU.

Inpatient Variables From The Day Of Delirium Assessment Included Illness Severity, Patient Location, RASS Score, Sepsis Or Infection Diagnosis, Use Of Mechanical Ventilation, And Administration Of Medications Known To Be Associated With Acute Delirium (Table 3). Of The 215 Eligible Patients, 113 Were In The ICUs And 102 Were In The IMCs. ICU Patients Had A Higher Prevalence Of Delirium Than IMC Patients, With 36% Of ICU Patients Screening Positive For Delirium Versus 11% Of Patients In The IMC (R2 = 18.7, P < .001). Lower RASS Score Was Related To Delirium (T = -5.58, P < .001). Of Those Testing Positive For Delirium, 40 Patients (78%) Had A RASS Score Of -1, -2, Or -3. Higher Severity Of Illness Was Associated With Delirium. Mean APACHE III Score Was 38.9 (SD, 15.7) In CAM-ICU-Positive Patients Compared With 26.4 (SD, 13.3) In CAM-ICU-Negative Patients (T = 5.75, P < .001). Patients Who Screened Positive For Delirium Differed Signicantly From Patients Who Did Not In The Use Of Mechanical Ventilation And Medications (Table 3). Delirium Was Present In 51% Of Those Requiring Mechanical

Table 2 Admission Variables And Relationships To Acute Delirium

Variable Blood Alcohol Level > 0.08 Mg/DL Toxicology Screening Positive Mild Brain Injury

P .83 .41 .09

R2 0.4 1.8 4.8

Total (N = 215)  55 (25.6) 64 (29.8) 37 (17.2)

No Delirium (N = 164)  41 (25.0) 49 (29.9) 27 (16.5)

Delirium (N = 51) 14 (27.5) 15 (29.4) 10 (19.6)

No. (%) Of Patients

D I I I Bl (T Bl 2) Di I I Bl I I I Bl F H D Fd Li I

Table 3 Inpatient Variables On The Day Of Delirium Assessment

Variables APACHE III Score, Mean (SD) RASS Score, Mean (SD) Location, No. (%) Of Patients ICU IMC Mechanical Ventilation, No. (%) Of Patients Sepsis/Infection, No. (%) Of Patients Benzodiazepines, No. (%) Of Patients Antipsychotics, No. (%) Of Patients Narcotics, No. (%) Of Patients Sedatives, No. (%) Of Patients

P < .001 < .001 < .001

< .001 .26 .43 .001 .54 < .001

Total (N = 215)  29.3 (14.9)  -0.39 (0.95)

113 (52.6) 102 (47.4)  48 (22.3)  31 (14.4)  66 (30.7)  32 (14.9) 197 (91.6) 17 (7.9)

No Delirium (N = 164)  26.4 (13.3) -0.13 (0.56)

72/113 (63.7) 91/102 (89.2) 22 (13.4) 21 (12.8) 48 (29.3) 17 (10.4) 150 (91.5) 6 (3.7)

Delirium (N = 51) 38.9 (15.7) -1.22 (1.40)

41/113 (36.3) 11/102 (10.8) 26 (51.0) 10 (19.6) 18 (35.3) 15 (29.4) 47 (92.2) 12 (21.6)

Statistic T = 5.75 T = -5.58 R2 = 18.7

R2 = 33.4 R2 = 1.3 R2 = 0.6 R2 = 11.0 R2 = 0.4 R2 = 19.9

Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; ICU, Intensive Care Unit; IMC, Intermediate Care Unit; RASS, Richmond Agitation-Sedation Scale.

44  CriticalCareNurse Vol 37, No. 1, FEBRUARY 2017 Www.Ccnonline.Org

Our Findings Provide Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not.

Ventilation (R2 = 33.8, P < .001). The Patients Screening Positive For Delirium Had Greater Use Of Antipsychotic Agents (29% Vs 10.4%, R2 = 11.0, P = .001) As Well As The Use Of Sedative Medications On The Day Of Screening (21.6% Vs 3.7%, R2 = 19.9, P < .001). The Use Of Benzodiazepines And Narcotics Did Not Differ Between Patients Who Screened Positive For Delirium And Patients Who Were Negative For Delirium On The Day Of Data Collection. Six Variables Showed At Least Small Correlations With Delirium: Age (R = 0.17, P = .003), Sedative Use (R = 0.29, P < .001), Mechanical Ventilation (R = 0.38, P < .001), Antipsychotic Medication Administration (R = 0.23, P = .001), APACHE III Score (R = 0.29, P < .001), And RASS Score (R = -0.492, P < .001). The Best Model Included These 6 Variables, Signicantly Predicting Delirium (P < .001), Explaining 51.9% Of Variance (Cox And Snell R2 = 0.34; Nagelkerke R2 = 0.52). Table 4 Shows The Results Of Logistic Regression. Four Factors Predictive Of Delirium Were Mechanical Ventilation, Use Of Antipsychotic Agents, Higher APACHE III Score, And Lower RASS Score.

Discussion In Our Study, 24% Of Trauma Patients Screened With The CAM-ICU Tested Positive For Delirium In Both ICUs And IMCs, With Delirium Affecting More ICU Patients (36%). We Suspect That The Overall Lower Prevalence Of Delirium In Our Study Compared With Previous Studies May Be Due To Several Factors. One Factor Was The Small Numbers Of Patients With Preexisting Comorbid Conditions Such As Hypertension, Vascular Disease, And Pulmonary Disease. These Small Numbers Were Most Likely Due To The Younger Mean Age Of This Trauma Population Compared With Other Studies Of Critically Ill Patients. Although The Mean Age Of This Sample Was Younger Than The Mean Age In Other Investigations, Older Age Was Signicant For Higher Prevalence Of Delirium And Was Included In The Predictive Model. Similar To Other Studies Of Delirium In Trauma Patients,17,20,28 The Age Of Our Trauma Patients And Those Patients Testing Positive For Delirium Were Younger Than The Ages Reported In The General ICU Population.1-3,9 These Ndings Are Important Because Younger Patients Are Not Usually Considered To Be At High Risk For Delirium.

This Nding Underscores The Need For Delirium-Prevention Strategies In Hospitalized Trauma Patients, Regardless Of The Patients’ Age. Detrimental Effects Of Delirium Such As Increased Risk Of Death, Dementia, And Cognitive Dysfunction Following Discharge From The Hospital7,11,14,29,30 Underscores The Signicance Of Delirium Prevention Across The Age Span. Admission Variables Identied By Others To Be Related To Delirium Development Include Positive Results Of A Toxicology Screening, Elevated Blood Alcohol Content (> 0.08 G/DL), And Abnormal Score On The Glasgow Coma Scale (≤ 14). Unlike Studies Based On The National Trauma Databank19 And A Trauma Registry,18 Positive Blood Alcohol On Admission And History Of Alcohol Use Were Not Associated With Or Predictive Of Delirium In This Study Of Trauma Patients And In A Large Systematic Review.15 In Addition, Other Previously Reported Risk Factors Such As Positive Results Of Drug Toxicology Screening On Admission19,21 And Abnormal Score On The Glasgow Coma Scale21 Were Not Related To Delirium In Our Sample. Inpatient Variables Associated With Delirium Include Mechanical Ventilation And Administration Of Sedatives And Analgesics.9,10,15,17 Our Ndings Provide Additional Support That Delirium Is More Likely To Develop In Patients Undergoing Mechanical Ventilation Than In Those Who Are Not, Although The Prevalence Of Delirium In Our Sample Of Trauma Patients Receiving Mechanical Ventilation Was Lower Than Reported In Other Studies. This Lower Prevalence May Be Due To The Younger Age Of Trauma Patients And Fewer Comorbid Conditions That Would Predispose Individuals To Respiratory Dysfunction Or Failure. However, A Number Of The Study Patients In The ICU In Whom Mechanical Ventilation Was Not Being Used Thi  Di D Th Df D Li I Ti

Table 4 Multivariate Analysis Of Delirium Predictors In Trauma Patients

Variable Age Sedative Mechanical Ventilation Psychotropic Agent APACHE III Score RASS Score

Adjusted Odds Ratio (95% CI) 1.017 (0.993-1.042) 1.235 (0.296-5.163) 4.726 (1.628-13.716) 3.850 (1.280-11.579) 1.057 (1.020-1.095) 0.311 (0.188-0.516)

P .17 .77 .004 .02 .002 < .001 Abbreviations: APACHE III, Acute Physiology And Chronic Health Evaluation III; RASS, Richmond Agitation-Sedation Scale.

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Tested Positive For Delirium On The Day Of Screening. Thomason And Colleagues31 Similarly Reported That 48% Of Medical ICU Patients Who Were Not Receiving Mechanical Ventilation Experienced At Least 1 Episode Of Delirium. An Important Nding Of This Investigation Was That Patients Who Tested Positive For Delirium Were Not Limited To Those Residing In The ICU. Of The Trauma IMC Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients. This Finding Is Noteworthy Because Most Studies Have Focused More Exclusively On Critically Ill Patients Who Require Mechanical Ventilation. These Results Suggest That Implementation Of Delirium Assessment And Prevention Strategies May Benet Trauma Patients Who Are Not Receiving Mechanical Ventilation Or Are Not In The ICU. Interestingly, Half Of The Patients Receiving Antipsychotic (Ziprasidone, Haloperidol) Or Sedative (Dexmedetomidine, Propofol) Medications Tested Positive For Delirium. At The Time Of This Study, Use Of Ziprasidone, Dexmedetomidine, And Haloperidol Was The Common Practice In Our Trauma Center For Treating Agitation Or Suspected Delirium. The High Percentage Of Patients Receiving These Medications Also May Have Been Related To Deliberate Attempts To Avoid Benzodiazepines And Narcotics To Facilitate More Rapid Liberation From Mechanical Ventilation, Practices Consistent With The Current Pain, Agitation, And Delirium Guidelines.32 Zall And Colleagues15 Identied Dexmedetomidine To Be Associated With Reduced Delirium Occurrence. This Same Review And Our Analysis Did Not Nd The Use Of Narcotics Or Benzodiazepines To Be Signicantly Associated With Delirium On The Day Of Data Collection, Although These Agents Have Been Reported To Be Risk Factors For The Development Of Delirium.9,10,17 The Use Of These Medications Can Result In A Lower RASS Score, Which We Found To Be Predictive Of Delirium. A RASS Score Of -1 To -3 Was Identied In 75% Of The Studied Patients. Delirium Is Often Underrecognized In This Subset Of Patients.1,5,11 Higher Illness Severity Has Been Associated With Delirium.10,14,15,18 Our Ndings Were Consistent With Results Of These Other Studies. In Our Sample, Higher APACHE III Scores Were Also Predictive Of Delirium. Mild Brain Injury Is Not Easily Detectable By Brain CT And May Go Undiagnosed.22,33 Thus, Patients With Normal Ndings On A Brain CT Scan But Signs And Symptoms Of A Possible Mild Brain Injury Were Included In Data Collection

To Ascertain If Delirium Is Related To Mild Brain Injury. In Trauma Patients Who Are CAM-ICU Positive, Differentiating Physiological Dysfunction Associated With Mild Traumatic Brain Injury And Cognitive Decits Related To Delirium Is Important To Guide Appropriate Interventions. Potentially Because Of The Limited Sample Size, No Signicant Relationship Was Detected Between Mild Brain Injury And Delirium. Further Exploration Of This Population Of Patients Is Warranted As Previous Studies Have Shown A Positive Relationship Between These 2 Variables.13 Limitations Of This Study Merit Further Exploration. Delirium Was Not Routinely Assessed In The ICUs And IMCs Of The Trauma Center At The Time Of This Investigation, Necessitating Collection Of Data On Point Prevalence; Thus The True Incidence Of Delirium Is Not Known, And We Were Inhibited From Being Able To Monitor Changes Over Time. We Were Unable To Differentiate Those Patients Who Were Receiving Antipsychotic Therapy For Suspected Delirium From Patients Receiving It For The Prevention Or Management Of Agitation. Although We Explored A Wide Variety Of Variables, It Is Possible That Other Factors Such As Use Of Isolation For Antibiotic-Resistant Infections, ICU Stay Before IMC Admission, As Well As The Types And Quantities Of Deliriogenic Medications Received Before The Data Collection Day Could Also Contribute To The Development Of Delirium. Finally, This Study Was Not Designed To Evaluate Long-Term Effects Of Delirium. Although We Know From Other Studies That Episodes Of Acute Delirium Are Detrimental To Long-Term Health Outcomes, We Were Unable To Draw Conclusions Specically Related To Our Younger Trauma Patients. This Topic Is A Potential Area For Study In Trauma Patients. Other Foci For Future Research Include Investigating The Impact Of A Delirium Prevention Initiative In Patients Who Are Not Receiving Mechanical Ventilation Or Who Have Mild Traumatic Brain Injury. Studies Related To The Prevention Of Delirium In The Trauma Population Are Limited. Education Regarding Delirium Before Implementing A Screening Program May Be Effective In Preventing Delirium.32,34 Use Of Validated Assessment Tools For Pain, Agitation, And Delirium In Conjunction With Delirium-Prevention Strategies Is Of The Trauma Intermediate Care Unit Patients, 11% Screened Positive For Delirium, And Mechanical Ventilation Was Not In Use In Any Of Those Patients.

Other Nonpharmacological Strategies That Are Within The Nursing Scope Of Practice Include Interventions Such As Music Or Light Therapy, Use Of Earplugs, And Sleep Promotion.37,38 Thus, Through Independent Interventions, Nurses Are Able To Directly Inuence The Outcomes Of Trauma Patients And Others Who Are At Risk For Delirium Developing, By Reducing The Occurrence Of Acute Delirium And Therefore Its Untoward Effects On Length Of Stay, Mortality, Long-Term Cognitive Function, And Cost Of Care.39

Conclusions

In This Study, Delirium Was Detected In Nearly 24% Of Hospitalized Trauma Patients. Use Of Mechanical Ventilation And Psychotropic Medications, Higher APACHE III Score, And Lower RASS Score Were Independent Predictors Of Delirium. Although The Presence Of Delirium In The Current Investigation Was Lower Than Reported In Other Studies Of Critically Ill Patients, Our Subset Of Trauma Patients Was Younger, Had Fewer Comorbid Conditions, And Included Patients Not Receiving Mechanical Ventilation And IMC Patients. Importantly, Delirium Was Present In Both The IMC Patients And The Patients Not Receiving Mechanical Ventilation. These Ndings Suggest That Delirium Assessment And Incorporation Of Delirium-P Revention Strategies Into The Routine Management Of All Hospitalized Trauma Patients May Be Benecial. Considering The Unfavorable Effects That Delirium Has On Patients And Their Postdischarge Outcomes, Nurses’ Attention To Prevention Strategies Is Crucial.