Factors Influencing CAM-ICU Documentation and Inappropriate “Unable to Assess” Responses

Abstract

Background Detecting delirium with standardized assessment tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is important, but such detection is frequently hampered by poor documentation and inappropriate “unable to assess” responses (in noncomatose patients). Objective To identify patient, clinical, and workplace factors that may impede or facilitate appropriate delirium assessment through use of the CAM-ICU, specifically documentation and inappropriate “unable to assess” responses. Methods An electronic health record–based data set was used to quantify CAM-ICU documentation and inappropriate “unable to assess” responses during 24 months. Associated patient (eg, age), clinical (eg, diagnosis), and workplace (eg, geographic location within the ICU, shift) factors were evaluated with multivariable regression. Results Of 28 586 CAM-ICU documentation opportunities, 66% were documented; 16% of documentations in alert or lightly sedated patients had inappropriate “unable to assess” responses. Night shift was associated with lower CAM-ICU documentation rates (P = .001), whereas physical restraints and location on side B (rather than side A) of the ICU were associated with higher documentation rates (P < .05 for both). Age older than 80 years, non-White race, intubation, and physical restraints were associated with more inappropriate “unable to assess” responses (all P < .05), as was infusion of propofol, midazolam, dexmedetomidine, or fentanyl (all P < .05). Conclusion Data from electronic health records can identify patient, clinical, and workplace factors associated with CAM-ICU documentation and inappropriate “unable to assess” responses, which can help target quality improvement efforts related to delirium assessment.