Patient Safety: Cognitive Assessment at Intensive Care Unit Discharge

Abstract

Topic

Assessing functional cognition is a critical need for intensive care unit survivors transitioning to another level of care.

Clinical Relevance

Up to 62% of patients discharged from an intensive care unit have significant cognitive impairment that is not associated with severity of illness, number of comorbidities, or length of hospital stay. For more than 20 years, researchers have published an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services.

Purpose

To describe the impact of and potential interventions for cognitive decline at intensive care unit discharge and discharge readiness on 30-day readmission rates.

Content Covered

Assessing the patient’s functional cognition assessment and advocating for appropriate resources are needed to improve patient and clinical outcomes.

Ten percent of adults discharged from an intensive care unit (ICU) with high-risk conditions are readmitted to the hospital within 30 days.¹ The health care burden associated with these readmissions exceeds $26 billion annually.² One author group³ estimated that half of US hospitals pay between $7852 and $46 174 per readmission. Twenty-five percent of hospitals pay more than $45 000 per readmission. Despite the Centers for Medicare & Medicaid Services’ and many professional organizations’ efforts, readmissions remain a global challenge.⁴ For this invited review, we aim to describe the impact of cognitive decline at ICU discharge and of discharge readiness on 30-day hospital readmission rates.

Authors in one study found that as many as 62% of patients discharged from the ICU had significant cognitive impairment.⁵ The most severe deficits were in executive function and verbal learning. Although not as severe, deficits in working memory and psychomotor speed were also found.^5,6 These cognitive deficits were not correlated with severity of illness, number of comorbidities, or length of hospital stay. However, illness acuity and the complexity of postdischarge care leave patients physically and psychologically vulnerable, reducing their capacity for self-care. For more than 20 years, researchers have published studies of an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services. However, these studies did not examine the demands of these prescribed health care interventions on patients and their informal caregivers.⁷

With increasing patient age and shorter hospital stays,⁸ assessing executive function and higher-level cognition becomes more critical. Assessing patients’ orientation to person, place, time, and situation and their ability to follow simple single-step commands like squeezing a hand is a great start to identifying obvious cognitive deficits. However, subtle changes in cognitive function require further assessment. Functional cognition is the ability to think and process information needed to carry out instrumental activities of daily living and includes executive function, skill performance (eg, motor skills), and habits or routines.^9,10 Rather than assessing specific cognitive skills such as attention, memory, and executive function in isolation from one another, the goal of functional cognitive evaluation is to identify patients’ capacity to perform essential tasks given the totality of their abilities, including their use of strategies, habits and routines, and contextual and environmental resources.⁹

Approximately one-third of older adults who experience delirium while in the hospital have delirium episodes 1 month after hospital discharge. Delirium episodes at home increase the chance of hospital readmission. Being oriented is not an indicator that patients will be able to manage finances, make a grocery list, or remain adherent to discharge instructions, even if they remember those instructions. In 2014, Leppin et al⁷ identified the need to focus on transitions of care, particularly from hospital to home, to ensure that patients and informal caregivers are able to manage self-care and complex discharge plans. Additionally, teach-back methods for ensuring that patients understand discharge teaching have been recommended for more than a decade yet are inconsistently implemented in the hospital environment. Many discharged patients qualify for a postdischarge home visit, although this resource is underutilized.¹¹ Therefore, it remains unclear whether appropriate supports are in place to assist with grocery shopping and medication adherence.

Methods

For this invited review, we applied the following search terms to separate searches in CINAHL, PubMed, and PsycINFO: hospital readmission AND (cognition OR cognitive) AND (intensive care OR critical care) (n = 2476), as well as hospital discharge AND (cognition OR cognitive) AND (intensive care OR critical care) (n = 9419). The search was limited to clinical trials or research studies published between January 2012 and March 2022 and available in English. Two authors reviewed the title and abstract of each article, and discrepancies were adjudicated during video conferences. Articles approved for initial inclusion were then subjected to full readings (2 authors for each article). Authors rejected articles that did not provide new measurable content that addressed 30-day hospital readmission rates and either cognitive decline at ICU discharge or discharge readiness at ICU discharge. Data were then extracted from the 27 remaining articles.

Results

The literature review clearly showed that delirium and cognitive deficits are related to readmission and poor outcomes. Critical to improving care is accurate assessment of patients’ cognitive status during hospitalization.

Readmission

Although delirium severity does not predict the time to events such as emergency room visits or hospital readmissions, patients who experienced delirium in the ICU were consistently more likely to have emergency room visits and hospital readmissions and had a higher mortality rate than similar patients who did not experience delirium.^12,13 Half of ICU survivors were readmitted to the hospital within 12 months of ICU discharge.¹⁴ Those who experienced delirium were also 6 times more likely to be discharged to another facility rather than to home.¹⁵

Poor Outcomes

Considering the burden associated with poor clinical outcomes in patients who experience ICU delirium, there is an ever-increasing need to improve ICU culture and structure.¹⁵ To improve survival and clinical outcomes, effective delirium prevention and interventions are desperately needed.¹⁶ Consistently implementing the ABCDEF (pain assessment, spontaneous awakening and breathing trials, analgesia choice, delirium assessment, early mobility, and family engagement) bundle as soon as patients are eligible has been shown to significantly decrease delirium, coma, physical restraint use, mechanical ventilation use, and pain episodes the following day (P < .001).¹⁵

More than half of ICU patients are older adults. Although many survive beyond 1 year, they can experience long-term sequelae.^17,18 Prior studies reported that treatments that did not adhere to geriatric-focused practice, including frequent and prolonged orders for nothing by mouth, benzodiazepine exposure, and use of physical restraints, prolonged ICU and hospital stays and increased 30-day readmissions.^17–19 The use of urinary catheters significantly increased the odds of developing hospital-acquired pressure injuries (odds ratio, 8.9; 95% CI, 1.2-67.9) and the need for postacute care (odds ratio, 8.9; 95% CI, 1.2-67.9).^17–19 As the number of older adults increases, the availability of geriatric acute care clinicians becomes insufficient. Therefore, the need for multicomponent solutions to improve hospital-based clinician proficiency in geriatric medicine is urgent.¹⁹

Cognitive Assessment

Sinvani et al¹⁹ conducted a study to determine the accuracy of clinician-performed Confusion Assessment Method for the ICU (CAM-ICU) assessments. They found that most patients were assessed with the CAM-ICU at least 1 time each day, but less than 4% of patients assessed were identified as having delirium (ie, had a positive screening result for delirium) and more than half of the assessments were inaccurate. Because of limitations in the ability of screening methods such as the CAM-ICU to detect hypoactive delirium and the inaccuracy of clinician assessments when using validated screening tools, additional assessment methods are needed.²⁰

More than half of ICU patients who remember at least 1 stressful event have a positive screening result for cognitive impairment and depression (P = .03). The occurrence of depression and posttraumatic stress in ICU patients highlights the need to screen patients for psychological distress before hospital discharge.³ Care fragmentation and mismatches between discharge care needs and available services leave many ICU survivors vulnerable for weeks after hospital discharge. As a result, a significant number of ICU survivors are readmitted to the hospital within 5 months, and up to 50% are readmitted within the first year. Although severity-of-illness scores are strongly correlated with in-hospital mortality, they are not associated with functional outcomes after hospital discharge or readmission.^21,22

The timing of cognitive or delirium assessments and the timing of interventions designed to reduce delirium were inconsistent across all studies. The cue-response theory clearly identifies the importance of timing of nursing care.²³ Delirium is, by definition, a fluctuating state.²⁴ Therefore, assessing a patient at a random time of day (or on a random day) may result in a false-negative result (concluding that the patient does not have delirium when in fact they do have delirium). Novel methods of identifying the presence of delirium and clues to when nurses should assess for delirium would enhance the ability to individualize nursing care interventions and optimize discharge planning strategies.^25,26

Consultation and Referral

Care coordination led by nurses and social workers has been found to have a significant impact on readmissions. Efforts to decrease 30-day readmissions may be more effective when patient and informal caregiver preferences and quality-of-life indicators are considered.^27,28 New health care needs require further evaluation to ensure the safety and feasibility of providing combined ICU aftercare, such as in an ICU recovery clinic that also includes rehabilitation services.²⁹ Akhlaghi et al²⁹ described a program in which rehabilitation services were provided in individual supervised sessions once or twice a week, along with 3 to 4 telehealth rehabilitation sessions that were provided in the home. Rehabilitation services included assessment of the patient’s home environment for safety and the informal caregiver’s availability to assist with exercises during telehealth sessions.²⁹

Implications

To ensure that the transition of care is successful, nurses must consider the cognitive status of the patient. Discharge planning is a vital part of transitioning patients home after critical illness.³⁰ For ICU patients, the transition process can be improved by including a cognitive test such as the Mini-Cog instrument, which includes drawing a clock and demonstrating 3-item recall, before ICU discharge.³¹ Understanding the needs of ICU survivors early during recovery is critical for improving their long-term outcomes.³² To meet the complex needs of ICU survivors, clinicians must be able to identify, understand, and appropriately respond to deficiencies in everyday interactions for both patients and their informal caregivers.⁹ Clinicians should actively participate in quality improvement initiatives focused on functional cognition, such as by implementing screening tools (like the Mini-Cog) that test higher-level executive function. Collaboration with researchers and educators enables comprehensive dissemination and implementation of best practices.³³ Health care systems should incorporate documentation of functional cognition in electronic medical record platforms to support policy and payment decision-making.⁹

Conclusions

Older adults who are discharged from the ICU are at high risk for readmission, especially if they experienced delirium. According to current literature, executive functions are critical to performing self-care and comprehending discharge instructions. However, hospital standards do not include the assessments needed to ensure the safety of discharged patients. Strategies to bridge the transition from hospital discharge to home are needed to prevent hospital readmissions in high-risk populations such as older adults discharged from the ICU.