title: The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children.
abstract: OBJECTIVE
  Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence.
  
  
  METHODS
  Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU.
  
  
  METHODS
  Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled.
  
  
  RESULTS
  An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis.
  
  
  CONCLUSIONS
  The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.
authors.affiliation: 1Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.2Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN.3Department of Psychiatry, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY.4Department of Psychiatry, Massachusetts General Hospital, Boston, MA.5Department of Psychiatry, Georgia Regents University, Augusta, GA.6Department of Psychiatry, Kalispell Regional Healthcare, Kalispell, MT.7Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN.8Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN.9Department of Developmental Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN.10Department of Internal Medicine, Center for Health Services Research and Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, and the Tennessee Valley VA GRECC, Nashville, TN.
authors.forename: Heidi A B
authors.initials: HA
authors.lastname: Smith
authors.forename: Maalobeeka
authors.initials: M
authors.lastname: Gangopadhyay
authors.forename: Christina M
authors.initials: CM
authors.lastname: Goben
authors.forename: Natalie L
authors.initials: NL
authors.lastname: Jacobowski
authors.forename: Mary Hamilton
authors.initials: MH
authors.lastname: Chestnut
authors.forename: Shane
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authors.lastname: Savage
authors.forename: Michael T
authors.initials: MT
authors.lastname: Rutherford
authors.forename: Danica
authors.initials: D
authors.lastname: Denton
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Thompson
authors.forename: Rameela
authors.initials: R
authors.lastname: Chandrasekhar
authors.forename: Michelle
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authors.lastname: Acton
authors.forename: Jessica
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authors.lastname: Newman
authors.forename: Hannah P
authors.initials: HP
authors.lastname: Noori
authors.forename: Michelle K
authors.initials: MK
authors.lastname: Terrell
authors.forename: Stacey R
authors.initials: SR
authors.lastname: Williams
authors.forename: Katherine
authors.initials: K
authors.lastname: Griffith
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Cooper
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
authors.forename: D Catherine
authors.initials: DC
authors.lastname: Fuchs
authors.forename: Pratik P
authors.initials: PP
authors.lastname: Pandharipande
mesh_terms: D002675:Child, Preschool; D003221:Confusion / Q000175:diagnosis*; D016638:Critical Illness; D003693:Delirium / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D008297:Male; D009483:Neuropsychological Tests; D015588:Observer Variation; D011446:Prospective Studies; D015203:Reproducibility of Results; D012121:Respiration, Artificial; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index