| BackgroundDelirium occurs frequently in ICU patients and is easily missed,which is closely related to the immediate and long term adverse outcomes of ICU patients.The selection of effective and practical delirium assessment tools by medical staff is of critical significance to manage delirium and improve the prognosis of ICU patients.However,delirium assessment still has problems of poor accuracy and low nurse acceptance,especially in the selection of assessment tools for ICU patients.Therefore,how to evaluate delirium simply and efficiently becomes the key problem to be solved urgently.PART 1Validity and reliability of 4AT revised Chinese version in ICU settings ObjectiveTo evaluate the reliability and validity of 4AT for ICU delirium assessment,and to explore the applicability of 4AT in evaluating ICU delirium assessment in China.Methods1.With the consent of Professor Alasdair MacLullich,the original author of 4AT,4AT was translated and sanitized according to the method of reinterpretation.After the completion of the above,the Chinese version of the 4AT scale was analyzed by the researchers using item analysis,content validity,criterion relevant validity and internal consistency.2.Convenience sampling method was used to select 170 ICU patients(comprehensive ICU and specialized ICU)from The First Affiliated Hospital of Nanchang University from July to August 2019 as the research object.In the validity test stage,a nurse used 4AT to evaluate delirium in patients,and then DSM-V was used by specialists to diagnose and evaluate delirium within 30 min.Based on this,the researcher used the validity of diagnostic validity test in Chinese version of 4AT in ICU patients.In the validity test stage,two nurses independently used 4AT to evaluate55 randomly selected patients,and the reliability of the Chinese version of theinterevaluator reliability test was adopted.Results1.Chinese version 4AT consists of four characteristics(Alertness,The4-item Abbreviated Mental Test,Attention,Acute Change or Fluctuating Course).The results of the project analysis showed that the Chinese version of 4AT had good discrimination and homogeneity,and all the features were stored for subsequent analysis.The content validity S-CVI of the scale was 1.00 after expert consultation.In the university-level correlation validity,the correlation coefficient between the four features of Chinese 4AT and the total score was 0.746~0.843(P < 0.001).In the exploratory factor analysis,the load values of each characteristic factor were 0.647,0.890,0.862 and 0.743,and the cumulative interpretation variance was 62.654%.The Cronbach 'of each feature in the Chinese version of 4AT was 0.689,0.644,0.659 and0.679.After the deletion of all items,the intrinsic consistency coefficient of 4AT was lower than that of the Chinese version,indicating good internal consistency of the scale.2.The positive rate of DSM-V and 4AT diagnosis of delirium was 51.2% and 54.1%respectively,Kappa was 0.894(P<0.01),The area under the ROC curve of 4AT was0.978(P<0.001),and the optimal diagnostic threshold was 3.5 points,respectively.Compared with the gold standard,sensitivity of 4AT was 97.7%,the specificity was 91.6%,the PPV was 97.7%(95% CI 91.2~99.6%),and NPV was91.5%(95% CI 82.9~96.3%).A total of 55 nurses were included in the reliability study,and the consistent kappa values of the four diagnostic characteristics among raters were 1.000,1.000,0.862 and 1.000,respectively(both P<0.01),the total consistency kappa was 0.906(P<0.01).ConclusionsThe Chinese version of 4AT has four characteristics(Alertness,The 4-item Abbreviated Mental Test,Attention,Acute Change or Fluctuating Course),which were applied to evaluate delirium in ICU patients to obtain satisfactory reliability and validity.At the same time,under high workload environment,4AT does not require special training and is suitable for use by non-psychiatric medical personnel.PART 2Validity and reliability of 3D-CAM revised Chinese version in ICU settings ObjectiveTo evaluate the reliability and validity of the Chinese version 3D-CAM for ICU delirium assessment,and to explore the applicability of 3D-CAM for ICU delirium assessment.MethodsWith the method of convenience sampling,150 ICU patients from September to October 2019 in The First Affiliated Hospital of Nanchang University were selected as the research objects.In the validity test stage,a nurse used 3D-CAM to evaluate delirium in patients,and then DSM-V was used by specialists to diagnose and evaluate delirium within 30 min.Based on this,the researchers used diagnostic validity test of 3D-CAM in ICU patients.In the validity test stage,the two nurses independently used 3D-CAM to evaluate the randomly selected 55 patients,and the reliability of 3D-CAM was tested by interevaluator reliability.ResultsDSM-V was used to diagnose delirium with a positive rate of 41.3%,3D-CAM was used to evaluate delirium with a positive rate of 38.8%,Kappa was0.736(P<0.01).Compared with gold standard,the sensitivity of 3D-CAM was 87.7%(95%CI 75.5~94.5%),specificity was 87.1%(95%CI 78.2~92.9%),PPV was 80.6%(95%CI 68.3~89.2%),NPV was 92.0%(95%CI 83.8~96.5%).The diagnostic results of 3D-CAM and DSM-V were consistent with kappa of 0.736(P<0.01).A total of 55 nurses were included in the reliability study,and the overall consistency of kappa among raters was 0.845(P<0.001),the consistent kappa values of the four diagnostic features were 0.777,0.809,0.791 and 0.829,respectively(P <0.01).ConclusionsThe application of 3D-CAM in delirium of ICU patients obtained better reliability and validity.Due to the characteristics of no special training,rapid assessment and high sensitivity,it is suitable for medical staff with non-psychiatric background.PART 3Comparison of 4AT,3D-CAM,and CAM-ICU used to assess delirium in ICU patients ObjectiveReliability and validity of 4AT,3D-CAM and CAM-ICU used for delirium evaluation of ICU patients and the feasibility,clinical practicability and preferred rate evaluation of nurses were compared to provide an effective and practical evaluation tool for delirium evaluation of ICU patients.Methods1.4AT,3D-CAM and CAM-ICU evaluation delirium positive rates were 44.2%(84/190),43.7%(83/190)and 46.3%(88/190).Compared with the gold standard,the sensitivity of 4AT,3D-CAM and CAM-ICU were 96.4%(95%CI 89.2~99.1%),88.0%(95%CI 78.5~93.8%)and 88.6%(95%CI 79.7~94.1%),respectively.Three specific degrees were 92.5%(95%CI 85.2~96.4%),85.0%((95%CI 76.6~91.0%)and 89.2%(95%CI 81.1~94.2%),respectively.Two relatively no statistical difference;Kappa was0.883,0.724 and 0.778(P<0.01).2.After the nurse assessment,50 nurses were randomly selected to evaluate the feasibility,clinical practicability and preferred rate of the three assessment tools.Resluts1.4AT,3D-CAM and CAM-ICU evaluation delirium positive rates were 44.2%(84/190),43.7%(83/190)and 46.3%(88/190).Compared with the gold standard,the sensitivity of 4AT,3D-CAM and CAM-ICU were 96.4%((95%CI 89.2~99.1%),88.0%((95%CI 78.5~93.8%)and 88.6%((95%CI 79.7~94.1%),respectively.Three specific degrees were 92.5%(95%CI 85.2~96.4%),85.0%((95%CI 76.6~91.0%)and89.2%((95%CI 81.1~94.2%),respectively.two relatively no statistical difference;Kappa was 0.883,0.724 and 0.778(P<0.01).2.The mean score of feasibility and clinical practicability of 4AT was significantly higher than that of 3D-CAM and CAM-ICU(44.08±1.904 VS 33.66±3.651,44.08± 1.904 VS 32.98 ± 2.199 P<0.001).The mean score of feasibility and clinical practicability of 3D-CAM was slightly higher than that of cam-icu,but there was no statistical difference between them(33.66 ± 3.651 VS 32.98 ± 2.199,P>0.0001).The preferred rate of the three assessment tools among the 50 nurses was respectively was 4AT(76.0%),CAM-ICU(18.0%)and 3D-CAM(6.0%).Conclusions4AT,3D-CAM and CAM-ICU are used for the evaluation of delirium in patients of ICU with equal accuracy.Based on feasibility,clinical availability and nurse preference rates,4AT is more suitable for evaluating delirium in ICU patients with language impairment. |
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