“The Times They Are A-Changin”: Universal Delirium Screening in Pediatric Critical Care*
Until recently, it was expected that young children with life-threatening illnesses, particularly those needing invasive mechanical ventilation, required sedation and immobilization. Delirium, when recognized, was dismissed as the necessary price of doing business—a transient (albeit distressing) phenomenon that would resolve without long-term effects. We taught our trainees: “this is the way it has always been.” We now know that this approach was incorrect (3).
Pediatric delirium is a frequent hospital-acquired complication in the PICU, affecting children of all ages. A recent multinational point prevalence study showed a delirium rate of 25%, with a predilection for children younger than 2 years (4). Pediatric delirium is independently correlated with increased time on mechanical ventilation, longer ICU length of stay, and a dramatic increase in hospital costs (5–7). A recent single-center study demonstrated that pediatric delirium is associated with a four-fold increase in mortality, even after controlling for severity of illness and other widely accepted predictors of pediatric in-hospital death (8).
So pediatric delirium is common and linked to poor outcome. But perhaps this is simply an epiphenomenon—something worth recognizing, but not amenable to intervention? In this issue of Pediatric Critical Care Medicine, Simone et al (9) provide evidence that this is not the case. The authors describe a quality improvement initiative designed to enhance detection, management, and prevention of delirium. Over a 22-month period, a multidisciplinary team systematically introduced three bundles of care: delirium screening, followed by protocol-driven sedation, and then early mobilization. They demonstrated a 39% decrease in delirium rates (19–12%) with this targeted approach to changing their PICU’s standard procedures.
This important article makes three valuable contributions to the pediatric critical care literature. It establishes the feasibility of implementing unit-wide delirium screening with the Cornell Assessment for Pediatric Delirium (10) in a PICU with no prior history of delirium monitoring. It suggests sustainability, with compliance rates greater than 95% over a 22-month period, and it provides proof of principle: effectiveness of implementation, with an admirable decrease in delirium rates in this cohort.
In most respects, the study is consistent with previous pediatric delirium literature. Preimplementation, a survey assessing staff knowledge and attitudes demonstrated a significant lack of overall knowledge regarding delirium, and a complete lack of confidence in assessing delirium in young children, similar to other recent studies (11). Notably, 22 months after implementation, 100% of respondents indicated sustained improvement in both their knowledge and confidence (9). Similar to other pediatric delirium studies, increased delirium rates were found in children with baseline cognitive impairment and in children on invasive mechanical ventilation (4–6). Inconsistent with existing literature was the finding of increased delirium rates in females in this cohort.
The authors make a distinction between delirium that lasts longer than 48 hours, and delirium of shorter duration, designating these cases as “emerging delirium,” and grouping them with nondelirious children for analysis. We caution that this may be a misinterpretation, and note that it is inconsistent with existing delirium research. A large body of ICU literature shows that the average duration of delirium in adults is short, ranging from 1 to 3 days (12).