Multinational development and validation of an early prediction model for delirium in ICU patients

A Wassenaar, M van den Boogaard, T van Achterberg, A J C Slooter, M A Kuiper, M E Hoogendoorn, K S Simons, E Maseda, N Pinto, C Jones, A Luetz, A Schandl, W Verbrugghe, L M Aitken, F M P van Haren, A R T Donders, L Schoonhoven, P Pickkers, A Wassenaar, M van den Boogaard, T van Achterberg, A J C Slooter, M A Kuiper, M E Hoogendoorn, K S Simons, E Maseda, N Pinto, C Jones, A Luetz, A Schandl, W Verbrugghe, L M Aitken, F M P van Haren, A R T Donders, L Schoonhoven, P Pickkers

Abstract

Rationale: Delirium incidence in intensive care unit (ICU) patients is high and associated with poor outcome. Identification of high-risk patients may facilitate its prevention.

Purpose: To develop and validate a model based on data available at ICU admission to predict delirium development during a patient's complete ICU stay and to determine the predictive value of this model in relation to the time of delirium development.

Methods: Prospective cohort study in 13 ICUs from seven countries. Multiple logistic regression analysis was used to develop the early prediction (E-PRE-DELIRIC) model on data of the first two-thirds and validated on data of the last one-third of the patients from every participating ICU.

Results: In total, 2914 patients were included. Delirium incidence was 23.6%. The E-PRE-DELIRIC model consists of nine predictors assessed at ICU admission: age, history of cognitive impairment, history of alcohol abuse, blood urea nitrogen, admission category, urgent admission, mean arterial blood pressure, use of corticosteroids, and respiratory failure. The area under the receiver operating characteristic curve (AUROC) was 0.76 [95% confidence interval (CI) 0.73-0.77] in the development dataset and 0.75 (95% CI 0.71-0.79) in the validation dataset. The model was well calibrated. AUROC increased from 0.70 (95% CI 0.67-0.74), for delirium that developed <2 days, to 0.81 (95% CI 0.78-0.84), for delirium that developed >6 days.

Conclusion: Patients' delirium risk for the complete ICU length of stay can be predicted at admission using the E-PRE-DELIRIC model, allowing early preventive interventions aimed to reduce incidence and severity of ICU delirium.

Figures

Fig. 1
Fig. 1
Study flow chart
Fig. 2
Fig. 2
Area under the receiver operating characteristic curve (AUROC) of development dataset (AUROC = 0.76)
Fig. 3
Fig. 3
Area under the receiver operating characteristic curve (AUROC) during ICU stay. Error bars 95 % CIs

References

    1. APA . Diagnostic and statistical manual of mental disorders. 5. Washington: American Psychiatric Association (APA) ; 2013.
    1. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007;33:66–73. doi: 10.1007/s00134-006-0399-8.
    1. van den Boogaard M, Schoonhoven L, van der Hoeven JG, van Achterberg T, Pickkers P. Incidence and short-term consequences of delirium in critically ill patients: a prospective observational cohort study. Int J Nurs Stud. 2012;49:775–783. doi: 10.1016/j.ijnurstu.2011.11.016.
    1. Mehta S, Cook D, Devlin JW, Skrobik Y, Meade M, Fergusson D, Herridge M, Steinberg M, Granton J, Ferguson N, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Mallick R, Reynolds S, Keenan S, Burry L, Investigators S, the Canadian Critical Care Trials G Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults*. Crit Care Med. 2015;43:557–566. doi: 10.1097/CCM.0000000000000727.
    1. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW, Investigators B-IS. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369:1306–1316. doi: 10.1056/NEJMoa1301372.
    1. Zhang Z, Pan L, Ni H. Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. Gen Hosp Psychiatry. 2013;35:105–111. doi: 10.1016/j.genhosppsych.2012.11.003.
    1. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA. 2001;286:2703–2710. doi: 10.1001/jama.286.21.2703.
    1. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R, American College of Critical Care M Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306. doi: 10.1097/CCM.0b013e3182783b72.
    1. Antonelli M, Bonten M, Cecconi M, Chastre J, Citerio G, Conti G, Curtis JR, Hedenstierna G, Joannidis M, Macrae D, Maggiore SM, Mancebo J, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2012: I. Neurology and neurointensive care, epidemiology and nephrology, biomarkers and inflammation, nutrition, experimentals. Intensive Care Med. 2013;39:232–246. doi: 10.1007/s00134-012-2774-y.
    1. Inouye SK, Bogardus ST, Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM., Jr A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669–676. doi: 10.1056/NEJM199903043400901.
    1. Zaubler TS, Murphy K, Rizzuto L, Santos R, Skotzko C, Giordano J, Bustami R, Inouye SK. Quality improvement and cost savings with multicomponent delirium interventions: replication of the Hospital Elder Life Program in a community hospital. Psychosomatics. 2013;54:219–226. doi: 10.1016/j.psym.2013.01.010.
    1. Colombo R, Corona A, Praga F, Minari C, Giannotti C, Castelli A, Raimondi F. A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol. 2012;78:1026–1033.
    1. Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91:536–542. doi: 10.1016/j.apmr.2010.01.002.
    1. Patel J, Baldwin J, Bunting P, Laha S. The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia. 2014;69:540–549. doi: 10.1111/anae.12638.
    1. Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG, Needham DM. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013;41:800–809. doi: 10.1097/CCM.0b013e3182746442.
    1. Page VJ, Ely EW, Gates S, Zhao XB, Alce T, Shintani A, Jackson J, Perkins GD, McAuley DF. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1:515–523. doi: 10.1016/S2213-2600(13)70166-8.
    1. van den Boogaard M, Pickkers P. Hope for haloperidol in delirium. Lancet Resp Med. 2013;1:e27. doi: 10.1016/S2213-2600(13)70210-8.
    1. van den Boogaard M, Schoonhoven L, van Achterberg T, van der Hoeven JG, Pickkers P. Haloperidol prophylaxis in critically ill patients with a high risk for delirium. Crit Care. 2013;17:R9. doi: 10.1186/cc11933.
    1. Wang W, Li HL, Wang DX, Zhu X, Li SL, Yao GQ, Chen KS, Gu XE, Zhu SN. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med. 2012;40:731–739. doi: 10.1097/CCM.0b013e3182376e4f.
    1. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383:911–922. doi: 10.1016/S0140-6736(13)60688-1.
    1. Mistraletti G, Pelosi P, Mantovani ES, Berardino M, Gregoretti C. Delirium: clinical approach and prevention. Best Prac Res Clin Anaesthesiol. 2012;26:311–326. doi: 10.1016/j.bpa.2012.07.001.
    1. Huybrechts KF, Gerhard T, Crystal S, Olfson M, Avorn J, Levin R, Lucas JA, Schneeweiss S. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012;344:e977. doi: 10.1136/bmj.e977.
    1. van den Boogaard M, Pickkers P, Slooter AJ, Kuiper MA, Spronk PE, van der Voort PH, van der Hoeven JG, Donders R, van Achterberg T, Schoonhoven L. Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study. BMJ. 2012;344:e420. doi: 10.1136/bmj.e420.
    1. van den Boogaard M, Schoonhoven L, Maseda E, Plowright C, Jones C, Luetz A, Sackey PV, Jorens PG, Aitken LM, van Haren FM, Donders R, van der Hoeven JG, Pickkers P. Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study. Intensive Care Med. 2014;40:361–369. doi: 10.1007/s00134-013-3202-7.
    1. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–1762. doi: 10.1001/jama.291.14.1753.
    1. Serafim RB, Dutra MF, Saddy F, Tura B, de Castro JE, Villarinho LC, da Gloria Santos M, Bozza FA, Rocco JR. Delirium in postoperative nonventilated intensive care patients: risk factors and outcomes. Ann Intensive Care. 2012;2:51. doi: 10.1186/2110-5820-2-51.
    1. Wassenaar A, Van den Boogaard M, Van Achterberg T, Slooter AJC, Kuiper MA, Hoogendoorn ME, K.S. S, Maseda E, Pinto N, Jones C, Luetz A, Schandl A, Verbrugghe W, Aitken LM, Van Haren FMP, Donders ART, Schoonhoven L, Pickkers P (2014) Early PREdiction of DELIRium in ICu patients (E-PRE-DELIRIC): Multinational development and validation of an early delirium prediction model for intensive care patients. In: 27th Annual Congress of the European Society of Intensive Care Medicine, Barcelona, Spain, September 27–October 1, 40: 291
    1. Van den Boogaard M, Wassenaar A, Van Achterberg T, Slooter AJC, Kuiper MA, Hoogendoorn ME, K.S. S, Maseda E, Pinto N, Jones C, Luetz A, Schandl A, Verbrugghe W, Aitken LM, Van Haren FMP, Donders ART, Schoonhoven L, Pickkers P (2014) Early PREdiction of DELIRium in ICu patients (E-PRE-DELIRIC): Multinational development and validation of an early delirium prediction model for intensive care patients. In: 9th Annual meeting European Delirium Association, Cremona, Italy, November 6–7, Session 1, nr 4
    1. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for intensive care delirium: a systematic review. Intensive Crit Care Nurs. 2008;24:98–107. doi: 10.1016/j.iccn.2007.08.005.
    1. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Crit Care Med. 2001;29:1370–1379. doi: 10.1097/00003246-200107000-00012.
    1. Moons KG, Kengne AP, Woodward M, Royston P, Vergouwe Y, Altman DG, Grobbee DE. Risk prediction models: I. development, internal validation, and assessing the incremental value of a new (bio)marker. Heart. 2012;98:683–690. doi: 10.1136/heartjnl-2011-301246.
    1. Steyerberg EW. Clinical prediction models: a practical approach to development, validation, and updating. New York: Springer; 2009.
    1. R Core Team (2013) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. Available at
    1. Localio AR, Stack CB. TRIPOD: a new reporting baseline for developing and interpreting prediction models. Ann Intern Med. 2015;162:73–74. doi: 10.7326/M14-2423.
    1. Moons KG, Royston P, Vergouwe Y, Grobbee DE, Altman DG. Prognosis and prognostic research: what, why, and how? BMJ. 2009;338:b375. doi: 10.1136/bmj.b375.
    1. Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, Truman B, Bernard GR, Dittus RS, Ely EW. Costs associated with delirium in mechanically ventilated patients. Crit Care Med. 2004;32:955–962. doi: 10.1097/01.CCM.0000119429.16055.92.
    1. Huai J, Ye X. A meta-analysis of critically ill patients reveals several potential risk factors for delirium. Gen Hosp Psychiatry. 2014;36:488–496. doi: 10.1016/j.genhosppsych.2014.05.002.
    1. Zaal IJ, Devlin JW, Peelen LM, Slooter AJ. A systematic review of risk factors for delirium in the ICU. Crit Care Med. 2015;43:40–47. doi: 10.1097/CCM.0000000000000625.
    1. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care. 2009;13:R77. doi: 10.1186/cc7892.
    1. van Eijk MM, van den Boogaard M, van Marum RJ, Benner P, Eikelenboom P, Honing ML, van der Hoven B, Horn J, Izaks GJ, Kalf A, Karakus A, Klijn IA, Kuiper MA, de Leeuw FE, de Man T, van der Mast RC, Osse RJ, de Rooij SE, Spronk PE, van der Voort PH, van Gool WA, Slooter AJ. Routine use of the confusion assessment method for the intensive care unit: a multicenter study. Am J Respir Crit Care Med. 2011;184:340–344. doi: 10.1164/rccm.201101-0065OC.
    1. Haenggi M, Blum S, Brechbuehl R, Brunello A, Jakob SM, Takala J. Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC. Intensive Care Med. 2013;39:2171–2179. doi: 10.1007/s00134-013-3034-5.
    1. Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP. Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. Am J Respir Crit Care Med. 2014;189:658–665. doi: 10.1164/rccm.201310-1815OC.
    1. Royston P, Moons KG, Altman DG, Vergouwe Y. Prognosis and prognostic research: developing a prognostic model. BMJ. 2009;338:b604. doi: 10.1136/bmj.b604.

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