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Inter-Rater Reliability of Delirium Screening of Infants in the Cardiac ICU: A Prospective, Observational Study
Melissa Cleveland1, Rebecca Baute1, Casey Clindaniel1
1Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University Health, Indianapolis, IN.
Insights
Inter-rater reliability of the Cornell Assessment for Pediatric Delirium (CAP-D) was poor to moderate in infants under 9 weeks old and those on mechanical ventilation. Further evaluation of the CAP-D tool is needed for these vulnerable pediatric cardiac intensive care unit patients.
Area of Science:
- Pediatric Critical Care Medicine
- Neonatology
- Nursing Research
Background:
- Delirium is a serious condition in critically ill infants, impacting outcomes.
- The Cornell Assessment for Pediatric Delirium (CAP-D) is used for screening, but its reliability in vulnerable populations needs assessment.
- Infants in the cardiac intensive care unit (CVICU) are at high risk for delirium due to age and medical complexity.
Purpose of the Study:
- To determine the inter-rater reliability (IRR) of the Cornell Assessment for Pediatric Delirium (CAP-D) in infants admitted to a pediatric cardiac intensive care unit (CVICU).
- To explore how younger age (≤ 9 weeks) and mechanical ventilation affect the IRR of the CAP-D.
- To assess the utility of the CAP-D tool in a high-risk pediatric population.
Main Methods:
- A prospective cross-sectional study involving 364 CAP-D screenings by CVICU nurses.
- Inter-rater reliability was evaluated using intraclass correlation coefficient (ICC) and Fleiss kappa.
- Infants were stratified into age groups (≤ 9 weeks and 9 weeks to < 1 year), and data were analyzed for mechanically ventilated versus non-ventilated patients.
Main Results:
- Overall IRR for the CAP-D showed slight to fair agreement (Fleiss kappa = 0.47).
- IRR was significantly lower in infants ≤ 9 weeks old (ICC = 0.59, poor to moderate) compared to older infants (ICC = 0.72, moderate to good).
- IRR was also significantly lower in mechanically ventilated infants (ICC = 0.50, poor to moderate) compared to non-ventilated infants (ICC = 0.69, moderate to good).
Conclusions:
- The CAP-D demonstrates suboptimal inter-rater reliability in the youngest and most vulnerable infants in the CVICU.
- Mechanical ventilation further diminishes the reliability of the CAP-D in this population.
- Additional research and potential modifications to the CAP-D are necessary to improve its accuracy for delirium screening in critically ill infants.
Objectives:
To determine the inter-rater reliability (IRR) of the Cornell Assessment for Pediatric Delirium (CAP-D) in infants admitted to a cardiac ICU (CVICU) and to explore the impact of younger age and mechanical ventilation on IRR.
Design:
Prospective cross-sectional study of delirium screening performed by bedside CVICU nurses. We collected data from September 2020 to April 2021. We evaluated IRR with intraclass correlation coefficient (ICC) one-way random effects and Fleiss kappa for multiple raters.
Setting:
Eighteen-bed academic pediatric CVICU.
Participants:
Subjects: Infants 1 day to 1 year old admitted to the CVICU, stratified in two age groups (≤ 9 wk and 9 wk to < 1 yr). Exclusion criteria were patients' immediate postoperative day, State Behavioral Scale score less than or equal to -2, or at risk for hemodynamic instability with assessment. Raters: CVICU nurses working in the unit during study days.
Interventions:
None.
Measurements And Main Results:
Groups of four raters performed 91 assessments, a total of 364 CAP-D screens. Forty-five of 91 (49%) were in patients less than or equal to 9 weeks old and 43 of 91 (47%) in mechanically ventilated patients. Sixty-eight of 81 nurses (81%) participated. In infants less than or equal to 9 weeks old, ICC was 0.59 (95% CI 0.44-0.71), poor to moderate reliability, significantly lower than the ICC in infants greater than 9 weeks and 0.72 (95% CI 0.61-0.82), moderate to good reliability. In mechanically ventilated infants, ICC was 0.5 (95% CI 0.34-0.65), poor to moderate reliability, significantly lower than the ICC in nonmechanically ventilated infants and 0.69 (95% CI 0.57-0.8), moderate to good reliability. Fleiss kappa for all infants was 0.47 (95% CI 0.34-0.6), slight to fair agreement. Use of anchor points did not improve reliability.
Conclusions:
In the youngest, most vulnerable infants admitted to the CVICU, further evaluation of the CAP-D tool is needed.
