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Development of a Rapid Observational Assessment Tool Intensive Care Med (2012) 38:1025–1031 DOI 10.1007/s00134-012-2518-z PEDIATRIC ORIGINAL Gabrielle Silver Detecting pediatric delirium: development Chani Traube Julia Kearney of a rapid observational assessment tool Daniel Kelly Margaret J. Yoon Wendy Nash Moyal Maalobeeka Gangopadhyay Huibo Shao Mary Jo Ward W. Nash Moyal Á M. Gangopadhyay performed in a PICU at a university Received: 13 July 2011 Psychiatry, NY Presbyterian Hospital, Accepted: 23 January 2012 hospital. Fifty patients, ages 3 months New York, NY, USA Published online: 10 March 2012 to 21 years, admitted to the PICU Ó Copyright jointly held by Springer and over a 6-week period were included. ESICM 2012 H. Shao Public Health, Weill Cornell Medical No interventions were performed. College, New York, NY, USA Results: After informed consent was obtained, two study teams inde- M. J. Ward pendently assessed for delirium by Child Development, Weill Cornell Medical completing the CAP-D and by con- G. Silver Á M. J. Yoon College, NY Presbyterian Hospital, ducting psychiatric evaluation based Child Psychiatry, Weill Cornell Medical New York, NY, USA College, NY Presbyterian Hospital, on the DSM-IV criteria. Concordance New York, NY, USA between the CAP-D and DSM-IV Abstract Objective: Develop- criteria was excellent, at 97%. Prev- C. Traube ()) ment of a novel screening tool for the alence of delirium in this sample was Pediatric Critical Care, Weill Cornell detection of delirium in pediatric 29%. Conclusion: The CAP-D may Medical College, NY Presbyterian Hospital, be a valid screen for identification of 525 East 68th Street M-508, intensive care unit (PICU) patients of New York, NY 10065, USA all ages by comparison with psychi- delirium in PICU patients of all ages. e-mail: [email protected] atric assessment based on the Further studies are required to explore reference standard Diagnostic and its validity, inter-rater reliability, and J. Kearney Statistical Manual of Mental Disor- feasibility of use as a nursing screen. Child Psychiatry, Memorial Sloan Kettering ders (DSM-IV) criteria. Cancer Center, New York, NY, USA Methods: This was a prospective Keywords Delirium Á Pediatrics Á Intensive care units Á Critical care Á D. Kelly blinded pilot study investigating the Pediatrics, NY Presbyterian Hospital, feasibility of the Cornell Assessment Detection Á Screening New York, NY, USA of Pediatric Delirium (CAP-D) Introduction illness itself (e.g., serious infection or neoplasm), by- products of the illness (e.g., metabolic or endocrine dys- Delirium in critically ill children represents acute brain function), or side-effects of the treatment (e.g., sedative dysfunction and is characterized by a range of altered drugs or drug withdrawal) [1–8]. mental states and behaviors. The Diagnostic and Statis- Evidence-based assessments of outcomes and inter- tical Manual of Mental Disorders (DSM-IV) definition of ventions for pediatric delirium are lacking, largely due to delirium involves acute onset, fluctuating course, and two the absence of a simple and reliable screening tool [9]. To major categories: disturbance of consciousness (including date, delirium has not been considered a meaningful attention and awareness) and cognition (including mem- sequela of severe pediatric illness, but there is an emerging ory, orientation, language, and perception). This must be literature challenging this assumption [9–12]. The unique the result of a medical condition and can be caused by the combination of vulnerability and resiliency of children’s 1026 developing brains makes it imperative to conduct research The Delirium Rating Scale (DRS) [23], the most to improve recognition, establish efficient, reliable, and comprehensive scale used to date in adults, has been valid methods of assessment, and develop strategies to shown to have comparable cutoff scores in a pediatric prevent, treat, and understand long-term implications cohort in a retrospective chart review [5]. However, the [1–3, 10, 11, 13]. DRS requires considerable time and a trained psychiatrist. Pediatric delirium is associated with prolonged hos- It includes questions which are not applicable to younger pital stay [1, 3, 13] and residual perceptual-motor and children, including self-report of symptoms such as hal- behavior problems [2, 10, 14]. Children have reported lucinations and delusions. No prospective validation delusional memories of intensive care unit (ICU) expe- studies in pediatrics have been conducted. riences, which can become the basis for post-traumatic In the adult population the Confusion Assessment stress disorder (PTSD) [5, 11, 15, 16]. Small sample sizes, Method for the ICU (CAM-ICU) has been developed for lack of a common diagnostic tool, lack of prospective non-psychiatric trained ICU medical professionals to design, and other issues in these studies have contributed screen for delirium [24, 25]. The Vanderbilt Delirium to the difficulty in interpreting the impact of delirium on Group has developed the Pediatric Confusion Assess- critically ill children. ment Method for the ICU (pCAM), the first screening instrument developed specifically for critically ill chil- dren [26, 27]. Through the use of yes/no questions, Materials and methods pictures, and hand signals, the pCAM-ICU allows for the evaluation of children’s ‘‘inattention’’ and ‘‘disorganized Background thinking.’’ Sensitivity and specificity are currently being evaluated in pilot studies in the USA and Europe. A trial Screening seriously ill children for delirium is challenging of the pCAM-ICU in our unit found its neurocognitive due to the developmental differences in presentation [2]. approach to be impractical in very sick, often pharma- Agitated or combative behavior is readily recognized cologically sedated, and non-verbal patients. While a [17], but delirium is more often associated with hypoac- well-designed and elegant tool for diagnosing delirium in tive behavior, e.g., withdrawn affect and sparse responses cooperative older children, the pCAM-ICU requires [3, 18]. The great range and subtlety of delirium in chil- intensive training of the nursing staff and is not appli- dren have led some to suggest this condition is under- cable to patients who are developmentally impaired or recognized, under-studied, and likely common in pediat- less than 5 years old [28]. ric critical care [9, 18–21]. The Pediatric Anesthesia Emergence Delirium scale In clinical practice the diagnosis of pediatric delirium (PAED) was developed in studies of ‘‘emergence delir- is dependent on recognition by ICU staff who then consult ium’’, a proposed delirium subtype in anesthesiology, a child psychiatrist [5]. The psychiatrist’s assessment occurring when children are awakening from anesthesia, includes an interview of the family and medical staff and often with agitated or hyperactive symptoms. This a psychiatric examination of the patient. The reference observational scale evaluates the child’s eye contact with standard for diagnosing delirium is this psychiatric eval- the caregiver, awareness of surroundings, purposeful uation which assesses for the signs and symptoms nature of movements, ability to be consoled, and rest- delineated by the American Psychiatric Association’s lessness [29] (see footnote in Table 1). It is a quick, (APA) DSM [7]. This time-consuming and labor-inten- flexible tool which can be used by non-physician staff. It sive approach may work for managing delirium in the has been validated in children from age 19 months to agitated child, but it is not suitable for broad-based 6 years in postoperative settings and is being studied for screening or research on prevalence. As diagnosis use in pediatric intensive care unit (PICU) settings as part depends upon referral to psychiatry, many children with of a ‘‘diagnostic algorithm,’’ which includes caregiver and hypoactive or mixed delirium may go unrecognized [21, multidisciplinary team consensus [13]. The strength of the 22]. Identifying the prevalence of delirium in all its forms PAED as a screening tool is its focus on the observation and improving functional outcomes for children with of neurobehavioral symptoms, which makes it uniquely delirium has been hampered by the lack of an effective, suited for younger children (and potentially for develop- user-friendly tool. mentally delayed adults), in whom neurocognitive An ideal screen would be simple, quick, applicable to symptoms are difficult or impossible to assess. In a recent children of all ages and cognitive levels, and could be article, Jan Schieveld’s [30] group compared the PAED to administered by non-psychiatrists multiple times a day. It other delirium screening tools in a PICU population and would be flexible for use in intubated and non-intubated found it to be the most promising of the available tools, children, and would not require child cooperation. It but identified the need for improving upon it. The PAED would detect all delirium subtypes and take advantage of lacks any items to account for observation of hypoactive the ICU staff’s ongoing observation of the patient. delirious symptoms and has not been validated in infants Existing scales have not met these criteria. under age 19 months. 1027 Table 1 Cornell Assessment of Pediatric Delirium (CAP-D) RASS score ______ (if -4or-5 do not proceed) Not at all 4 Just a little 3 Quite a bit 2 Very much 1 Extremely 0 Score 1. Does the child make eye contact with the caregiver?a 2. Are the child’s actions purposeful?a 3. Is the child aware of his/her surroundings?a Not at all 0 Just a little
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