Clinical question: Do family meetings that require the use of an interpreter have different characteristics than those in which an interpreter is not needed?
Background: Communication about end-of-life care is essential in the ICU, yet limited English proficiency (LEP) can be a barrier to effective discussions. Overall, outcomes and satisfaction are improved when interpreters are used, but specific effects on ICU family conferences are unknown.
Study design: Cross-sectional evaluation of family meetings.
Setting: Four hospitals in Seattle.
Synopsis: Fifty-one noninterpreted (English-speaking members only) and 10 interpreted (non-English-speaking members present) ICU family meetings were recorded and analyzed for the amount of speaking time and content. The total duration was similar for interpreted versus noninterpreted conferences (26.3 minutes vs. 32.0 minutes, P=0.25), but clinician speech was significantly less in the interpreted group (10.9 minutes vs. 19.6 minutes, P=0.001). Family speaking time was similar in both interpreted and noninterpreted conversations (7.1 minutes vs. 8.2 minutes, P=0.66). Clinicians used more emotional support for families in noninterpreted meetings, including active listening and pausing for questions.
This study is limited by the use of an audio recorder; a video recorder would have provided researchers with participants’ physical interaction and expressions. Additionally, the study does not differentiate between cultural and linguistic difficulties, or provide a reference for the degree of complexity of each conference.
Bottom line: Family meetings in the ICU that require the use of an interpreter provide less information and emotional support to family members than those in which an interpreter is not required.
Citation: Thornton J, Pham K, Engelberg R, et al. Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences. Crit Care Med. 2009;37(1):89-95.
Clinical question: In patients 50 and older, what are the risk factors for the development of postoperative delirium, and how are outcomes affected by delirium?
Background: Delirium in the elderly postoperative patient is common. It results in increased costs, morbidity, and mortality. As the population ages, more elderly patients will undergo surgical procedures, so identification of delirium risk factors is essential.
Study design: Prospective, observational, cohort study.
Setting: Veterans Affairs Medical Center, Denver.
Synopsis: Researchers assessed 144 patients 50 and older who were scheduled to undergo surgical procedures with a planned, postoperative ICU stay for cognitive function, overall functional status, and comorbidities. Postoperatively, patients were assessed daily for the development of dementia using the cognitive assessment method-ICU instrument (CAM-ICU). Additionally, a validated chart review method for diagnosing delirium was used. The overall delirium incidence was 44%, and only 12% of cases had an identifiable etiology. The mean onset of delirium was 2.4 days; duration was 4.5 days. The incidence of delirium increased with age, reaching 92% in the 80- to 89-year-old group. In multivariate analysis, preoperative cognitive dysfunction was the strongest predictor of delirium.
Delirium development in patients 50 and older was associated with marked increases in costs ($50,000 vs. $32,000), length of stay (16 days vs. eight days), discharge to a facility (33% vs. 1%), and mortality (9% vs. 1%).
Limitations of this study included the patient population studied (97% men) and lack of data regarding medication use during hospitalization.
Bottom line: In older patients undergoing surgery requiring postoperative ICU care, delirium is common, is associated with prior cognitive dysfunction, and results in significant increases in LOS and mortality.
Citation: Robinson T, Raeburn C, Tran Z, et al. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009;249(1):173-178.