Symptoms and Delirium in Critical Illness

Abstract

The number of chronically critically ill (CCI) [i.e. patients recovering from an extended intensive care unit (ICU) stay] is expected to reach 600,000 within a decade with associated hospital costs nearing $60 billion annually (Kahn et, al., 2015). Increasingly, these patients are discharged to long-term acute care hospitals (LTACHs) for ventilator liberation and rehabilitation. Few studies describing symptom burden in patients admitted to LTACHs have been undertaken. The purpose of this study is to identify symptoms experienced in patients who require mechanical ventilation in an LTACH. This prospective observational study of 5 mechanically ventilated patients admitted to an LTACH following an ICU stay was completed in Columbus, OH. Symptoms were assessed daily using Puntillo’s Patient Symptom Survey (Puntillo et al., 2010). Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Sedation state was measured using the Richmond Agitation and Sedation Scale (RASS). Validity and reliability for these instruments have been established. We calculated frequencies and determined if sedated patients were able to participate in the symptom assessment by assessing delirium presence. Five patients of an average age of 60.8 and of both genders were enrolled in the study and assessed between 5-27 days. Patients experienced pain for 46.7% (29/62), anxiety 56.5% (35/62), fatigue 88.7% (55/62), and delirium 46.7% (29/62) of the days measured. From the total days assessed, 61% (38/62) were spent at a goal RASS (i.e., -1 to +1), 37% (23/62) deeply sedated (i.e., -2, -3) 2% (1/62) in coma, and no days agitated. Excluding the one coma day, delirium occurred on 50% (31/62) of all days assessed. This is the first study to describe continued symptom burden in patients admitted to a LTACH. This knowledge is applicable to the clinical setting because data shows that sedation level and delirium presence may have a negative impact on participation in weaning trials or rehabilitation, which are the focus of LTACH admission.