Discussion Guide for the Lawson Article

Every year, more than 6 million people around the globe die of stroke-related complications, many of which follow an intensive care unit (ICU) admission. Because of the highly comorbid presence of delirium following acute stroke, most ICU-based delirium research excludes patients with stroke. This systematic omission has obscured the understanding of delirium’s prevalence, risk factors, and consequences in critically ill patients recovering from a stroke, limiting the development of prevention and treatment strategies for these patients.These investigators examined delirium’s prevalence, severity, and associations with short-term outcomes among adults admitted to a neurological ICU for stroke (ie, acute ischemic stroke [AIS], intracerebral hemorrhage [ICH], and aneurysmal subarachnoid hemorrhage [aSAH]).This prospective, observational study of adults admitted to a neurocritical care unit within the previous 48 hours for a stroke excluded prisoners, non-English speakers, patients with hearing or visual impairments, those with traumatic ICH diagnoses, and those with imminent care-withdrawal plans. After obtaining informed consent, study personnel assessed delirium daily for up to 7 days using the Richmond Agitation-Sedation Scale (RASS), the Confusion Assessment Method for ICU (CAM-ICU), and the CAM-ICU-7 severity scale. They defined delirium as at least 1 positive CAM-ICU assessment during the 7 study days, excluding patients with coma (RASS score <–3) or radio-graphically correlated receptive aphasia. The investigators quantified delirium prevalence and severity and examined associations with mortality, ventilator days, tracheostomy, discharge disposition, and disability at discharge.The researchers observed delirium in 44% of the 169 enrolled patients, with the highest prevalence among those with ICH (60%), compared with those with AIS (38%) and aSAH (32%). Participants experiencing delirium were older (68.6 years vs 63.2 years) and required more days of mechanical ventilation (4.75 days vs 2.17 days, P = .007). They also had longer ICU stays (9.45 days vs 6.15 days, P = .001) and hospital stays (20.11 days vs 13.35 days, P < .001). Discharge to home was less frequent among patients with delirium (13.3% vs 27.7%, P = .04), and they exhibited higher rates of functional disability. In individuals with delirium, higher severity (CAM-ICU-7) scores correlated with increased ventilator days, prolonged ICU stays, and greater odds of poor functional outcomes. Mortality rates in the ICU and hospital did not differ significantly based on delirium status.Delirium affected 44% of critically ill stroke patients and 60% of those with ICH. Delirium’s presence and severity were associated with longer duration of mechanical ventilation, extended ICU and hospital stays, fewer home discharges, and increased functional disability. The investigators contend that these findings reinforce the importance of prioritizing delirium prevention and management in neurocritical care.Thomas N. Lawson, PhD, APRN-CNP, ACNP-BC, first ventured into research with a small-scale study about emergent intraosseous access. From there, he shifted his focus toward diagnostic reasoning, considering “how diagnostic bias affects patient care.” After reading a 2015 Wes Ely lecture about how delirium is often overlooked in medical ICUs, he looked “at the available literature on delirium among [neurocritical care unit] patients and found relatively little.” This gap served as his impetus to pursue a PhD, recognizing that he “didn’t have the skill set to rigorously address the practice problems [he] saw.”To complete this study, Dr Lawson assembled a team with expertise in ICU delirium, neurocritical care, and statistics “to help hone the proposal into something that was both meaningful and possible.” Given the project’s scope, Dr Lawson needed to collaborate with many people throughout his university, realizing that, “research is a team sport.” With limited funding and a full clinical load, Dr Lawson sought the support of his clinical colleagues to provide research-specific delirium assessments and hired a part-time graduate research assistant to extract chart data and help with patient recruitment. Striking a balance between clinical and research responsibilities was challenging for Dr Lawson and his colleagues. Unfortunately, “with these competing priorities, we ended up missing some delirium assessments.” Therefore, Dr Lawson and his graduate assistant supplemented their colleagues’ assessments with their own.Dr Lawson acknowledges that “like most research, this study won’t change anything—by itself. One study rarely does.” But, he believes that a body of evidence that “resonates with real-world clinical practice can be incredibly persuasive.” He hopes this work serves as a catalyst that shifts clinicians’ attitudes around delirium. Although delirium prevention and management Dr Lawson thinks that clinician-researchers are uniquely positioned to close the gap between evidence and practice: “living in both worlds, we see firsthand where care falls short, and we have the tools to ask and answer the questions that matter most.”This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Thomas N. Lawson, PhD, APRN-CNP, ACNP-BC, has spent more than half of his life in health care. He started his career in high school as a certified nursing assistant in a local nursing home, completed his BSN in 2001, and became an acute care nurse practitioner in 2006. As a clinician, he has worked in the emergency department and cardiothoracic ICU, shifting his focus to neurocritical care in 2011. Dr Lawson views clinical practice and research as fundamentally connected: “Clinical practice without research is stagnant, and what’s the point of health care research without a reality-based grounding in clinical practice?” His work seeks to link these worlds. Dr Lawson notes that some of the best ideas come from “a recurring moment at the bedside when you find yourself thinking, ‘there has to be a better way to do this.’” He recommends starting small, avoiding perfectionistic pitfalls, and resisting the temptation to chase funding trends: “The first dataset might have holes. Do it anyway. Iterate, improve, and [remember] the goal is smarter, safer, and more compassionate care.”