Child Psychiatry Engagement in the Management of Delirium in Critically Ill Children

Child Psychiatry Engagement in the Management of Delirium in Critically Ill Children Sean S. Barnes,1 Marco A. Grados,2 and Sapna R. Kudchadkar1,3,4 1Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA 2Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA 3Department of Pediatrics, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA 4Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA Correspondence should be addressed to Sapna R. Kudchadkar; ude.imhj@1ahcduks Received 30 November 2017; Revised 11 March 2018; Accepted 31 March 2018; Published 26 April 2018 Academic Editor: Giuseppe Ristagno Copyright © 2018 Sean S. Barnes et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Objectives. To characterize the engagement of child psychiatry by pediatric intensivists in cases of suspected delirium in a pediatric intensive care unit (PICU) prior to implementation of a delirium management algorithm with regards to recommendations, antipsychotic prescribing, and follow-up after PICU discharge. Design. Retrospective chart review. Setting. Single-center tertiary PICU. Subjects. Sixteen patients who received child psychiatry consultation for suspected delirium while in the PICU. Measurements and Main Results. Child psychiatry was consulted for 50 patients in the PICU during the 2-year period. Sixteen (32%) of these consultations were for delirium, and 15 (94%) of these patients were diagnosed with hyperactive delirium. Eighty-one percent of the patients were prescribed an antipsychotic, and over half of these patients had been initiated on the antipsychotic prior to child psychiatry consultation. All patients who transitioned from the PICU to the general floor received child psychiatry follow-up.Conclusions. Child psychiatry can play an integral role in collaborative management of PICU delirium. Continuity of care with child psychiatry after transfer or discharge is particularly important given the prevalence of antipsychotic use. Furthermore, the results of this retrospective study would suggest that staff education surrounding the delirium screening tool increased awareness of delirium, resulting in an increase in child psychiatry consultations. 1. Introduction The American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, defines delirium as a complex process with a pathophysiologic cause, characterized by an acute onset and fluctuating course of reduced awareness, impairments in attention, and changes in cognition [1]. The majority of data describing the association of delirium and adverse outcomes, including mortality and long-term cognitive impairment, come from adult studies [2,3]. Adult studies have highlighted the benefit of psychiatry consultation to facilitate delirium diagnosis and therapies, specifically in the management of pharmacological interventions [4–6]. Delirium in the pediatric population was previously difficult to characterize and quantify [7,8]. In the past, delirium could not be diagnosed in the PICU without the involvement of child psychiatry [9]. However, improved awareness and validated screening tools for use in the PICU have provided a framework for PICU staff to recognize delirium in critically ill children [10–12]. Leveraging these screening tools, a recent multi-institutional point prevalence study identified a prevalence of 38% among critically ill children in the PICU [13]. Thus, it is important to characterize how pediatric intensivists approach delirium moving forward. While psychiatrists are the experts in delirium diagnosis and management, there is a paucity of research describing the role of child psychiatry in the PICU beyond facilitating delirium diagnosis. The objective of this study was to characterize the engagement of child psychiatry by pediatric intensivists in cases of suspected delirium in a single-center tertiary PICU with regards to recommendations, antipsychotic prescribing, and follow-up after PICU discharge. 2. Materials and Methods After institutional review board approval, a chart review was performed for all child psychiatry consults in the Johns Hopkins Children’s Center PICU between 7/1/14 and 6/30/16. All patients were identified from billing records for child psychiatry consultation. The Johns Hopkins Children’s Center PICU is a 40-bed unit with a mixed population of both medical and surgical patients. On average, the PICU has 2,500 annual admissions. The two-y (...truncated)