A Multidisciplinary Delirium Prevention Strategy Involving Psychiatry in the ICU

This is a prospective, single institution, controlled pilot study of adult patients admitted
to the surgical ICU. A sample size of 104 (52 per group) is targeted. Patients in the control
group will undergo usual care which includes ABCDEF bundle (Appendix 1) use, including daily
delirium screening using the CAM-ICU score (Appendix 2), but will not have routine
psychiatric involvement. Patients in the intervention group will also have ABCDEF bundle
performed, and additionally have psychiatry routinely participating in ICU rounds. A member
of the psychiatry team (attending, resident, or fellow) will round with the surgical ICU team
in the surgical ICU daily. On a daily basis, the ICU attending will review the list of the
ICU patients with the psychiatry team to determine if there are any changes to the patient's
management required.

Inclusion criteria are: 1. any patient >18 years of age admitted to the surgical ICU for >48
hours; 2. Patients admitted to the ICU <24 hours who have been in the hospital >48 hours; 3.
Patients who return to the ICU after being discharged from the ICU to the floor due a
complication or need for higher acuity care. Exclusion criteria are: 1. Patients in whom
CAM-ICU cannot be performed (severe dementia, stroke or other neurological condition,
encephalopathy, mental retardation, severe psychiatric disorder, vegetative state, severe
traumatic brain injury, deaf/blind, etc.); 2. Vulnerable patient populations (i.e. transplant
recipients); 3. Patients who don't speak or understand English; 4. Current alcohol or
substance abuse. Patients will be screened for eligibility on rounds daily. Study personnel
will obtain informed written consent from patients or their families.

A psychiatry attending, psychiatry resident, or psychiatry nurse practitioner will round with
the surgical ICU team on 7W daily until the target subject enrollment # of 52 is achieved. On
a daily basis, the ICU attending will review the list of the ICU patients with the psychiatry
team to determine if there are any changes to the patient's management required. The ABCDEF
bundle will be implemented on daily rounds, which includes daily screening for delirium using
the CAM-ICU scale.

Data which will be collected includes: age, gender, body mass index, history or alcohol or
substance abuse, admitting diagnosis, dementia, comorbid conditions, admitting SOFA score,
deliriogenic medications used during study enrollment, the interventions/medications used to
treat delirium as designated by psychiatry (in intervention group) and the ICU team (control
group), and the number of days from admission to study enrollment. Data on the incidence of
ICU delirium, duration of delirium/mechanical ventilation, in-house mortality, ICU and total
hospital length of stay will also be collected.

Descriptive statistics, including Student's t-test or Mann-Whitney U-test, for continuous
variables and χ2 or Fisher's exact test, for categorical variables, will be used to summarize
the data and compare characteristics between the 2 groups. The incidence of delirium will be
compared using χ2 test and multivariable logistic regression. Differences in the duration of
delirium and MV between the intervention and control groups will be analyzed by analysis of
variance (ANOVA). The length of stay will be compared by truncated negative binomial
regression, while mortality rates will be compared via logistic regression. A sensitivity
analysis will be performed in order to assess the possible confounding effect of the
non-randomized nature of our study design. A propensity score model for receipt of standard
care vs. psychiatric involvement will be performed in order to approximate a balanced
covariate distribution between the 2 groups as that would be expected by randomization. The
investigators will then use the propensity score for each subject to perform an inverse
probability weighted comparison of the groups on our trial outcomes.

Inclusion criteria are:

1. Patients who are ≥18 years of age

2. Patients admitted to the surgical ICU for >48 hours OR

3. Patients admitted to the ICU <24 hours who have been in the hospital >48 hours

OR

4. Patients who return to the ICU after being discharged from the ICU to the floor due a
complication or need for higher acuity care.

5. Patients admitted to any surgical service who are receiving care in the 7 West
surgical ICU, who are either medically or conservatively managed (non-surgical) or
surgically managed as part of their care

Exclusion criteria are:

1. Patients in whom CAM-ICU cannot be performed (severe dementia, stroke or other
neurological condition, encephalopathy, mental retardation, severe psychiatric
disorder, vegetative state, severe traumatic brain injury, deaf/blind, etc.)

2. Patients who don't speak or understand English

3. Current alcohol or substance abuse

4. Patients who already have delirium within 24-48 hours of their ICU admission [Defined
as a positive CAM-ICU test, or based on the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition ( DSM-V) diagnostic criteria:

- Disturbance in attention (ie, reduced ability to direct, focus, sustain, and
shift attention) and awareness.

- Change in cognition (eg, memory deficit, disorientation, language disturbance,
perceptual disturbance) that is not better accounted for by a preexisting,
established, or evolving dementia.

- The disturbance develops over a short period (usually hours to days) and tends to
fluctuate during the course of the day.

- There is evidence from the history, physical examination, or laboratory findings
that the disturbance is caused by a direct physiologic consequence of a general
medical condition, an intoxicating substance, medication use, or more than one
cause.]