Shu‐Fen Siao

Survivors of critical illness commonly experience post-intensive care syndrome (PICS), including cognitive, mental health, physical, quality-of-life, and social impairments after discharge. Telemedicine may improve access to post-ICU recovery clinic care, but its feasibility and effect on recovery outcomes remain unclear. We evaluated the feasibility of a multidisciplinary telemedicine post-ICU recovery clinic and collecting 6-month outcome data. We conducted a two-site pilot feasibility randomized controlled trial at an academic medical center and regional community medical center in the southeastern United States. Adults admitted to medical or surgical ICUs with sepsis and/or acute respiratory distress syndrome were randomized 1:1 to telemedicine ICU recovery clinic visits or standard care. The intervention included two multidisciplinary visits at 3 weeks and 3 months after hospital discharge; participants accessed visits via a secure web-based personal health portal, where they videoconferenced simultaneously with an ICU clinician, pharmacist, and psychologist. Participants in the standard of care group received usual post-discharge care. Feasibility outcomes included enrollment, retention, attendance, clinician fidelity, and participant ratings of acceptability, appropriateness, and feasibility. Exploratory outcomes included cognitive, mental health (i.e., depression, anxiety, PTSD), and physical health (i.e., activities of daily living, independent activities of daily living) composite scores measured at 1 week and 6 months after hospital discharge. Of 1,108 screened patients, 91 were randomized (telemedicine, n = 46; standard care, n = 45). Among 83 participants completing the 1-week assessment, median age was 56 years, 51% were male, and 91% were White. In the telemedicine arm, 23 participants (57.5%) attended at least one visit; attendance was 55% at 3 weeks and 42.5% at 3 months among eligible participants. Primary 6-month outcome assessment was completed by 31 participants in each group (67%). Clinician participation fidelity was high, and telemedicine attendees reported favorable acceptability, appropriateness, and feasibility ratings. Exploratory analyses of PICS composite outcomes did not differ significantly between groups. A multidisciplinary telemedicine post-ICU recovery clinic and associated trial procedures were feasible, with high clinician fidelity and favorable participant ratings. Larger trials are needed to explore engagement strategies and evaluate effectiveness on long-term recovery outcomes, prioritizing inclusion of more diverse and historically underrepresented populations. NCT03926533 (posted 4/24/2019).

Background: Delirium in critically ill patients is not an all‐or‐none condition. It often follows fluctuating patterns—such as resolution, recurrence or persistence—but how these delirium patterns relate to mortality remains unclear. Aim: This study aimed to investigate delirium patterns associated with ICU and 30‐day mortality following ICU admission. Study Design: This prospective cohort study included adult patients admitted to six medical ICUs who were prospectively monitored for delirium once daily for up to 14 days or until ICU discharge. Participants were classified into four delirium‐pattern groups: no delirium (no ICU‐acquired delirium), resolved delirium (sustained negative assessments after initial delirium), recurrent delirium (delirium recurrence after at least two consecutive days without delirium) and persistent delirium (persistent delirium with fewer than two consecutive delirium‐free days). ICU and 30‐day mortality of ICU admission were recorded by an independent assessor. Results: Among 253 classified participants, 158 (62.5%) experienced delirium. Patients were categorized into the four delirium groups: no delirium ( n = 95; 37.5%), resolved delirium ( n = 44; 17.4%), recurrent delirium ( n = 29; 11.5%) and persistent delirium ( n = 85; 33.6%). Independent of covariates, participants with recurrent delirium (aHR, 1.51; 95% CI, 0.57–3.96) and persistent delirium (aHR, 2.03; 95% CI, 0.85–4.81) did not associate with increased ICU mortality. However, 30 days following ICU admission, those with persistent delirium had a 2.99‐fold increase in mortality (aHR, 2.99; 95% CI, 1.53–5.83), and those with recurrent delirium had a 2.68‐fold increase in mortality (aHR, 2.68; 95% CI, 1.18–6.07). Patients with resolved delirium had mortality rates comparable to those in the no delirium group. Conclusion: Only specific ICU delirium patterns—recurrent and persistent delirium—are associated with higher ICU and 30‐day mortality. Relevance to Clinical Practice: Although prevention remains critical, timely and effective delirium management aimed at rapid resolution is equally essential to reducing mortality risk. Recognizing and distinguishing these delirium patterns is therefore imperative for targeted clinical intervention. Prevention and treatment in the most vulnerable group of patients with delirium require more research. Clinical Trial Registration: Clinical Trials Registry (Trial No: NCT 04206306).

There is limited information on the relationship between multidisciplinary bundle compliance and long-term outcomes. We explored the association between bundle compliance and outcomes at 3 and 12 months after hospital discharge. We conducted secondary analyses of a randomized controlled trial comparing haloperidol, ziprasidone, and placebo for delirium in patients with critical illness. From 2011 to 2017, adult patients with respiratory failure and/or shock were recruited from 16 US medical centers. Participants received a daily ABCDE bundle during their critical illness. We assessed cognition, disability, mental health, quality of life, and survival over 12 months of follow-up. We analyzed data using linear mixed effects regression and Cox proportional hazards models. Among 566 participants, 418 survived to hospital discharge, 304 were assessed for 3-month outcomes, and 251 for 12-month outcomes. Median proportional bundle compliance was 97%, indicating high overall fidelity. After adjusting for covariates, greater proportional bundle compliance was associated with better functional independence and health-related quality of life, as evidenced by lower 12-month Functional Activity Questionnaire scores (β = - 9.6, CI = - 19.6, - 1.7, p = 0.04) and higher 12-month EuroQol-5D scores (β = 0.5, CI = 0.1, 0.9, p = 0.01). Greater bundle compliance was not associated with better long-term cognition, mental health, or survival. In this multi-site cohort with high-fidelity bundle compliance, greater bundle compliance was associated with less disability in instrumental activities of daily living and better health-related quality of life at 12 months, though associations were inconsistent and absent across other domains. Future research should evaluate integrated bundle care with post-discharge interventions to optimize long-term recovery. The Modifying the Impact of ICU-Associated Neurological Dysfunction-USA Study (MIND-USA), NCT01211522, https://clinicaltrials.gov/ct2/show/NCT01211522 .

Background: Delirium is a prevalent and serious ICU complication, particularly in elderly or ventilated patients. Accurate assessment is crucial but often inconsistent. Intensive care unit (ICU) nurses' use of the Intensive Care Delirium Screening Checklist (ICDSC) may be limited without structured training. Aim: To evaluate the delirium assessment performance of ICU nurses using ICDSC and assess the effectiveness of a multimodal educational intervention for performance enhancement. Study Design: This pre‐ and post‐intervention study was conducted in three medical ICUs in Northern Taiwan. The delirium assessment performance of ICU nurses using ICDSC was evaluated, followed by a three‐month multimodal educational intervention aimed at improving assessment performance. Each nurse's ICDSC assessment was paired with an independent assessment by a trained expert nurse. To ensure representation that reflects the true performance level, accounting for variations in nurses' working shifts, weekday and weekend staff ratios and sampling fairness across the three MICU units, the pairings were made using a three‐step randomization process, managed by an independent third party. A 3‐month multimodal educational intervention, including didactic lectures, difficult scenario reviews and one‐to‐one bedside mentoring, was implemented afterward. Inter‐rater agreement before and after the intervention was assessed using Cohen's kappa and Gwet's AC1 statistics. Results: The baseline agreement between ICU nurses and the expert nurse was suboptimal (kappa = 0.63, 95% CI: 0.57–0.70). The multimodal educational intervention was well‐received by the units, particularly among new nurses. Following the intervention, kappa significantly improved to 0.74 (95% CI: 0.69–0.80). Notable improvements were observed in key items of ICDSC, including the assessment of altered level of consciousness, inattention, disorientation, psychomotor agitation or retardation, and sleep–wake cycle disturbances. However, agreement remained poor for certain patient populations, especially those aged over 85 years and those subjected to physical restraint. Conclusions: A structured, multimodal educational intervention significantly improved the delirium assessment performance of ICU nurses using the ICDSC. One‐to‐one coaching and scenario‐based learning were particularly effective in enhancing clinical assessment skills. However, additional strategies may be required to address persistent challenges in assessing very elderly patients and those subjected to physical restraint. Relevance to Clinical Practice: A structured, multimodal educational intervention can substantially enhance the performance of ICU nurses in delirium screening using the ICDSC. Tailored training strategies may help bridge the knowledge–practice gap, leading to more reliable clinical assessments in critical care settings.

Aims: To compare the individual and combined effects on 90‐day mortality among four critically ill survivor groups: normal (without ICU‐acquired delirium or ICU‐acquired weakness), delirium‐only (with ICU‐acquired delirium only), weakness‐only (with ICU‐acquired weakness only) and delirium–weakness (combined ICU‐acquired delirium and weakness).Methods: A prospective cohort study consecutively recruited delirium‐free critically ill patients admitted to six medical ICUs at a university hospital. Delirium was assessed once daily for 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the ICU. Participants who were discharged from the ICUs were assessed for weakness using the Medical Research Council scale. A summed score below 48 defines ICU‐acquired weakness. These survivors were evaluated again for 90‐day mortality. The study is reported using the STROBE checklist.Results: Delirium developed in 107 (43.2%) participants during their first 14 days of ICU stay; 55 (22.2%) met criteria for weakness by ICU discharge. Participants with delirium were at increased risk for also developing ICU‐acquired weakness, and the 90‐day mortality was 18.2%. Independent of age and Acute Physiology and Chronic Health Evaluation II score at ICU admission, delirium‐only and weakness‐only were not associated with higher 90‐day mortality, while participants in the delirium–weakness group had a 3.69‐fold higher risk of death, compared to those who were normal during the ICU stay. A non‐significant interaction was found, suggesting the joint effect of delirium and weakness on mortality is not higher than the sum of both effects individually.Conclusions: Mortality is substantially high among critically ill survivors who experience both delirium and weakness, although no additive effect on mortality was observed when these conditions occur together. Our findings highlight the urgent need to optimise ICU care by prioritising the prevention, early identification and management of these two common ICU‐acquired conditions.Patient Contribution: Study participation and completion of all assessments.Trial Registration: ClinicalTrials.gov identifier: NCT04206306

Introduction: As patients nowadays tend to have multiple diseases and complex medical histories, our aim was to identify high‐quality, non‐instrumental dysphagia screening tools used for the detection of adult dysphagia cases in all disease categories in acute‐care settings.Method: A literature search was conducted in five databases from each database's earliest inception to 31 July 2021 and guided by five keywords: ‘dysphagia’, ‘deglutition’, ‘screening’, ‘test’ and ‘measure’. Without limiting the search in any specific disease category, reviewers assessed original studies and identified tools if they had been validated against instrumental evaluations and if they had been designed as a pass–fail procedure to screen whether dysphagia is absent or present. We further excluded any tool if it was (1) for pediatric focus, or (2) a patient self‐report questionnaire. All final tool candidates underwent a methodological quality appraisal using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2).Result: Out of 195 studies with 165 tools identified, 20 tool candidates underwent QUADAS‐2 review. We found six high‐quality, non‐instrumental screening tools for detecting adult dysphagia cases in acute‐care settings, including the Yale Swallow Protocol, Gugging Swallowing Screen, Toronto Bedside Swallowing Screening Test (both English and Portuguese versions), Sapienza Global Bedside Evaluation of Swallowing and Two‐Step Thickened Water Test. These high‐quality tools were developed primarily for patients with stroke. Only Yale Swallow Protocol was originally tested for heterogeneous populations with stroke, multiple sclerosis, traumatic brain injury, oesophageal surgery, neurosurgery and head‐and‐neck cancer.Conclusions: The results highlight the gap in the unavailability of high‐quality dysphagia screening tool in several emerged high‐risk populations including elderly inpatients, or patients following endotracheal extubation. Further research is needed to determine whether these six tools can be effectively applied across different high‐risk populations in acute‐care settings to screen for cases finding.