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The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill
Heidi A B Smith1, Maalobeeka Gangopadhyay, Christina M Goben
11Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.2Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN.3Department of Psychiatry, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY.4Department of Psychiatry, Massachusetts General Hospital, Boston, MA.5Department of Psychiatry, Georgia Regents University, Augusta, GA.6Department of Psychiatry, Kalispell Regional Healthcare, Kalispell, MT.7Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN.8Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN.9Department of Developmental Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN.10Department of Internal Medicine, Center for Health Services Research and Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, and the Tennessee Valley VA GRECC, Nashville, TN.
Insights
The PreSchool Confusion Assessment Method for the ICU is a valid tool for detecting delirium in critically ill young children. This study found high reliability and prevalence of delirium in this vulnerable population.
Area of Science:
- Pediatric Critical Care Medicine
- Child Psychiatry
- Neuroscience
Background:
- Assessing delirium in critically ill infants and children presents unique challenges due to developmental variations in cognitive and language skills.
- Existing delirium assessment tools may not be developmentally appropriate for this age group.
Purpose of the Study:
- To validate the PreSchool Confusion Assessment Method for the ICU (PCCM-ICU) as an objective and developmentally appropriate tool for delirium assessment in critically ill infants and preschool-aged children.
- To determine the prevalence of delirium in this patient population.
Main Methods:
- A prospective, observational cohort validation study was conducted in a tertiary medical center's Pediatric Intensive Care Unit (PICU).
- Participants aged 6 months to 5 years were enrolled.
- The PCCM-ICU was used for daily delirium assessments by the research team, with concurrent assessments by a child psychiatrist using DSM criteria for validity. Reliability was assessed via blinded, concurrent PCCM-ICU evaluations.
Main Results:
- A total of 530 paired delirium assessments were completed on 300 patients (median age 20 months).
- The PCCM-ICU demonstrated high validity: specificity 91%, sensitivity 75%, PPV 84%, NPV 86%. Reliability was strong with a κ-statistic of 0.79.
- Delirium prevalence was 44% by PCCM-ICU and 47% by the reference rater, with similar rates across age subgroups. A short-form PCCM-ICU also showed high performance.
Conclusions:
- The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable instrument for monitoring delirium in critically ill infants and preschool-aged children.
- Delirium is highly prevalent in this critically ill pediatric population, underscoring the need for effective assessment tools like the PCCM-ICU.
Objectives:
Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence.
Design And Setting:
Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU.
Patients:
Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled.
Measurements And Main Results:
An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis.
Conclusions:
The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.
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