AGITATION ONSET, FREQUENCY, AND ASSOCIATED TEMPORAL FACTORS IN CRITICALLY ILL ADULTS. Patient Safety Issues

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1 Patient Safety Issues AGITATION ONSET, FREQUENCY, AND ASSOCIATED TEMPORAL FACTORS IN CRITICALLY ILL ADULTS By Ruth S. Burk, RN, PhD, ANP-BC, Mary Jo Grap, RN, PhD, Cindy L. Munro, RN, PhD, ANP-C, Christine M. Schubert, PhD, and Curtis N. Sessler, MD 2014 American Association of Critical-Care Nurses doi: Background Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs. Objectives To describe the incidence, onset, and temporal factors related to agitation in critically ill adults. Methods Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient. Results Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation. Conclusions Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days. (American Journal of Critical Care. 2014;23: ) 296 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

2 Agitation is excessive restlessness, or nonpurposeful physical activity, thought to be caused or exacerbated by pain, anxiety, irritation caused by an endotracheal tube, or other unpleasant events. 1-3 Up to 71% of patients in intensive care units (ICUs) have some degree of agitation during their ICU stay. 4 Agitation can extend the length of hospital stay from a median of 5 days to a median of 12 days and is associated with adverse clinical outcomes such as a higher rate of self-extubation, unplanned catheter removal, longer duration of mechanical ventilation, excessive sedation, increased utilization of resources, and increased ICU costs. 3,5,6 Agitation can be manifested as simple apprehension or anxiety, inappropriate self-removal of indwelling tubes and catheters, and/or attempted assault of a care provider. 7,8 Recent guidelines 9 on sedation and analgesia from the Society of Critical Care Medicine highlight the need for prompt identification and treatment of possible underlying causes of agitation. Understanding the natural history of agitation may be important, because interventions can be implemented to prevent or ameliorate the phenomenon and its consequences. Although agitation is associated with deleterious outcomes, few data are available that describe the frequency, onset, and course of agitation in the critical care environment. Therefore, our specific aim was to describe the frequency, onset, and patterns of agitation in critically ill adult patients. Methods Patients and Setting The study was conducted in 2010 in an 865- bed academic medical center that offers all critical care specialties. Approval was obtained from the appropriate institutional review board. The sample consisted of all adult patients 18 years and older consecutively admitted during a 2-month period to a medical respiratory ICU (MRICU) or a surgical About the Authors Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio. Corresponding author: Ruth S. Burk, 34 High Bank Dr, Missouri City, TX ( burkrv@gmail.com). trauma ICU (STICU). Data were obtained from medical records. Exclusion criteria were an ICU length of stay less than 24 hours (to exclude patients who had a short ICU stay for overnight monitoring), unavailability of medical records, and previous admission during the study duration. Other exclusion criteria were conditions affecting patients movement that interfere with obtaining scores on the sedation scale, including administration of paralytic agents, neuromuscular disorders (eg, cerebral palsy and Parkinson disease), and head trauma or stroke. Documentation of Agitation Agitation was identified on the basis of documented scores on the Richmond Agitation-Sedation Scale (RASS), a 10-point scale from +4 (combative) to -5 (unarousable). 8 The RASS has excellent interrater reliability and criterion, construct, and face validity across a variety of critical care settings. 8,10-12 RASS scores are routinely obtained every 4 hours in the ICUs and more frequently if needed. Scores of +1 (restless) through +4 (combative) were considered indicative of agitation. The +1 score was accepted because positive RASS scores have been previously documented as indications of agitation. 8 Agitation was also documented by using the keyword agitation (all forms of the word: agitated, agitation, agit) recorded from the medical record by using physicians and nurses notes in the nursing bedside flow sheet, emergency department documentation, operating room notes, and circle-theitem for reporting agitation in flow sheets. Procedure Patients medical records were used as the primary source of information, and data were collected Prompt identification and treatment of underlying causes of agitation are important. AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No

3 Agitation was documented from the medical record by using scores on the Richmond Agitation-Sedation Scale and the keyword agitation. by 1 investigator (R.S.B.). A pilot study was performed with patients who were not part of the study cohort. Data audits were performed to verify accuracy of information by using convenience sampling on approximately 10% of all patients. The error rate on the data audit was less than 0.03%. The goal was to obtain an equal number of patients in each unit that would span most of the 2- month period, allowing for a broad representation of unit admissions. Data were collected on the first 5 days of ICU stay, because onset and duration of agitation are 3 to 5 days. 4,6 For all recurrent data collection, the hour was used as the documentation epoch. Each individual hour was documented as an agitation hour only if the RASS score was +1 or greater or the word agitation (and/or its forms) was documented during that hour. Patient demographics were recorded (age, sex, ethnicity, race); source of admission (clinic, emergency department, home, long-term care facility, other hospital); admission diagnosis; intubation status; scores obtained at the time of ICU admission for Acute Physiology and Chronic Health Evaluation III, 13 Sequential Organ Failure Assessment, 14 and Charlson Comorbidity Index 15 ; ICU and hospital lengths of stay; and administration of analgesics and sedatives. Data Analysis Data were summarized by hour, block (block = 4 hours), and day for each patient and categorized as an agitation or a nonagitation hour, block, or day. Hourly data were condensed into blocks because the standard ICU flow sheet contained 4-hour blocks with agitation available as an item to circle. The consolidation of hourly data into blocks reduced documentation redundancy error while smoothing data peaks. If any agitation was documented within the hour, block, or day, or multiple episodes of agitation were documented during the time period, the occurrence of agitation was considered to be 1 agitation hour, block, or day. Additional data collection included time, ICU day, day of the week, all RASS scores, and descriptors of agitated behavior. The percentages of agitation hours, blocks, and days were based on the number of hours, blocks, and days divided by the total number of observed hours, blocks, and days throughout the 5-day period; these varied according to the patient s duration of ICU stay. Agitation reported as any time included documentation of any agitation at any time during the study period. For data on the onset of agitation, only the first agitation event for hour, block, or day for each patient during the study period was evaluated. For investigation of the temporal patterns of agitation, all agitation hours and blocks were grouped by day of the week, day and night intervals, and time of day. Descriptive data were expressed as counts and percentages for all nominal and categorical data, and mean, range, and standard deviation for continuous measures. The significance level was =.05. Univariate analyses were used to compare the 2 groups of patients (nonagitated and agitated) by using 2 analysis and the Fisher exact test for categorical data and 2-sample t tests for continuous data. Results Characteristics of the Sample During the 2 months of data collection, 383 potential patients were screened (179 MRICU, 204 STICU). The final sample consisted of 200 patients (qualified by applying inclusion and exclusion criteria): 100 from the MRICU and 100 from the STICU. The majority of excluded patients were in the ICUs less than 24 hours. Data collection for up to 5 days of ICU stay for the 200 patients resulted in 791 patient-days ( hours of data; 4621 blocks). Patients had a mean age of 55.5 years and were primarily men, non-hispanic, and white or African American (Table 1). Characteristics of the sample are shown in Table 1; use of selected analgesic and sedative medications is shown in Table 2. Agitation Frequency Of the 200 patients, 118 (59%) were agitated at some time during the 5 days during 319 patient-days (40.3%). Approximately one-quarter (28.5%) of the agitation documentation was based on RASS scores; the balance was based on agitation keywords. Of total data hours, the overall agitation rate was 7.7% of the hourly time (1389 hours) and 19.1% of the block time (883 blocks). Of all 883 agitated blocks, 36.1% (319 blocks) occurred on day 1 (n = 102 patients), 20.7% (183 blocks) on day 2 (n = 71 patients), 16.8% (148 blocks) on day 3 (n = 60 patients), 14.7% (130 blocks) on day 4 (n = 50 patients), and 11.6% (103 blocks) on day 5 (n = 36 patients). Figure 1 depicts the percentage of agitation in blocks for each day. The percentage was higher on day 1 than on the other days. Agitation Onset The onset of agitation was a mean of 11.6 hours (SD, 22.3; range, 0-114; 25th-75th percentile 298 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

4 Table 1 Demographics and other descriptors for entire sample and by presence of agitation (at least 1 observation of agitation during the study period) No. (%) of patients Variable Entire sample 200 (100) Nonagitated 82 (41) Agitated 118 (59) Sex Male Female 113 (56.5) 87 (43.5) 42 (51) 40 (49) 73 (62) 45 (38) Ethnicity Hispanic or Latino Not Hispanic or Latino 6 (3) 94 (97) 5 (6) 77 (94) 1 (1) 117 (99) Race Asian Black or African American White 3 (1.5) 94 (47) 103 (51.5) 2 (2) 39 (48) 41 (50) 1 (1) 55 (47) 62 (53) ICU type Medical respiratory Surgical trauma 100 (50) 100 (50) 36 (44) 46 (56) 64 (54) 54 (46) Admission source Long-term care facility Home Clinic Other hospital Emergency department 3 (1.5) 6 (8) 20 (10) 60 (30) 101 (50.5) 2 (2) 4 (5) 7 (9) 23 (28) 46 (56) 1 (1) 12 (10) 13 (11) 37 (31) 55 (47) Admitting diagnosis Trauma Sepsis Respiratory failure Hematologic/oncological problem Other Renal/GI problem/dka Hepatic problem Cardiovascular problem Drug overdose/poisoning 36 (18) 35 (17.5) 27 (13.5) 27 (13.5) 22 (11) 28 (14) 13 (6.5) 8 (4) 4 (2) 18 (22) 17 (21) 6 (7) 8 (10) 9 (11) 15 (18) 4 (5) 4 (5) 1 (1) 18 (15) 18 (15) 21 (18) 20 (17) 12 (10) 13 (11) 9 (8) 4 (3) 3 (3) Intubated a 118 (59) 20 (24) 98 (83) Mean (range; SD) Age, years 55.5 (18-89; 16.4) 56 (19-87; 16.4) 55.1 (18-89; 16.5) ICU length of stay, days 7.1 (1-99.4; 9.7) 5.9 (1-99.4; 12.1) 7.9 ( ; 7.6) Hospital length of stay, days 16.6 (1-99.5; 15.3) 15.8 (1-99.5; 16.3) 17.1 (2.2-79; 14.7) APACHE III score (4-200; 31.9) 57.7 (4-200; 34.3) 74.7 (21-170; 28.2) SOFA (0-18; 3.8) 5.39 (1-17; 3.7) 7.48 (0-18 ; 3.7) Charlson Comorbidity Index (0-17; 3.3) 4.8 (0-13; 3.3) 4.6 (0-17; 3.4) Abbreviations: APACHE III, Acute Physiology and Chronic Health Evaluation III; DKA, diabetic ketoacidosis; GI, gastrointestinal; ICU, intensive care unit; SOFA, Sequential Organ Failure Assessment. a Each of the 2 ICUs had the same number of intubated patients. [interquartile range], ) from ICU admission. Of those patients who were agitated at any time during the study, 86% (n = 102) had agitation on day 1; for the remaining 14% (n = 16), onset of agitation was spread out over the next 4 days (Figure 2). The majority of patients (n = 102; 86%) with first-day agitation continued to have agitation on other days, whereas patients with later onset had a relatively low frequency of agitation. Of the 102 patients with first-day agitation, 44 (43.1%) had agitation reported on ICU admission; 30 more (another 29.4%) had agitation reported AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No

5 Table 2 Analgesic and sedative medications received at any time for total sample of 200 patients during 5-day data collection period Medication Analgesics Fentanyl Morphine Hydromorphone Sedatives Midazolam Propofol Lorazepam Haloperidol Diazepam Dexmedetomidine No. (%) of patients a 117 (58.5) 83 (41.5) 26 (13.0) a Total is more than 100% because patients received more than 1 drug. Time agitated, % (47.5) 52 (26.0) 32 (16.0) 24 (12.0) 2 (1.0) 1 (0.5) Day 1 Day 2 Day 3 Day 4 Day 5 Stay in intensive care unit Agitated patients All patients Figure 1 Percentage of block time agitated per day, for agitated patients and all patients. from 1 to 4 hours after ICU admission. The mean onset of agitation for those who had agitation on the first day was 3.97 hours from admission (SD, 6.4; range 0-24; interquartile range, 0-5). Patterns of Agitation: Onset and Frequency Patterns of agitation frequency and onset were investigated for day of the week, day and night intervals, and block of day. For day of the week, Tuesdays had the highest number of agitation hours (253), and Friday had the lowest (157). For firsttime agitation hours, Monday was highest (26), Tuesday was next highest (23), and Sunday was the lowest (11). Frequency of agitation during the day (7 AM to 7 PM) vs during the night (7 PM to 7 AM) were similar for day (n = 679) vs night (n = 710). First-event agitation hours during the day were 63 vs 55 during the night. For block-time, first agitation onset from 8 PM to midnight was higher than for other blocks. From a day perspective, of the 118 patients with agitation at any time, 88 (74.6%) had multiple days of agitation, including both those with intermittent and consecutive days of agitation (Figure 3). Agitation Patterns by Unit Patients in the 2 ICUs did not differ significantly in age, ethnicity, race, admitting diagnosis, or ICU and hospital lengths of stay. Compared with STICU patients, MRICU patients had a greater number of total documentation hours, but the difference between the 2 groups was not significant (Table 3). The 2 units did not differ in the number of patients with firstday, first-hour, or first-block agitation. Scores on the Acute Physiology and Chronic Health Evaluation III, Sequential Organ Failure Assessment, and Charlson Comorbidity Index on admission to the ICUs were significantly higher for MRICU patients than for STICU patients. The percentage of patients with agitation on days 1 and 2 was significantly higher in the MRICU than in the STICU, although the 2 units did not differ in mean hour of agitation onset. Discussion Agitation Frequency Agitation is common in critically ill patients. In our study, most patients (59%) were agitated at some time during the first 5 days of their ICU stay. This rate is generally similar to rates in previous studies. Jaber et al 6 studied 182 medical-surgical ICU patients for 8 months and reported an agitation frequency of 52%. Despite differences in inclusion criteria (we excluded patients who were in the ICU <24 hours, whereas Jaber et al did not) and identification of agitation (RASS scores and keywords vs Ramsay scores), the frequency of agitation was similar. Using nursing documentation to rate the level of agitation, Gardner et al 4 found an agitation frequency of 42% in 83 medical respiratory ICU patients during a 2-month period, and Fraser et al 16 found an agitation frequency of 70.8% in 130 medical and surgical ICU patients during a 4- month period. The exclusion criteria of Fraser et al were similar to ours; however, their identification of agitation differed. They used medical record narratives that described agitated behavior to quantify agitation by using the Sedation-Agitation Scale and included anxious as a keyword. Interestingly, using only data where the SAS score was 6 or 7, they reported an any-day agitation frequency of 46.1%, 300 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

6 similar to our finding. In a study of 143 medical ICU patients over a 5-month period, Woods et al 5 found an any-day agitation rate of 16.1%. The difference between their rate and our rate may be due to the differences in inclusion criteria (in their study, patients treated with mechanical ventilation, medical ICU, severity and definition of agitation) and their use of a sedative-analgesic protocol. Our findings for patient-days of agitation were similar to those of other studies. The rate in our study (31.9%) was generally similar to the rates reported by Gardner et al 4 (32%) and Fraser et al 16 (46.1% to 54%). These findings of generally similar agitation frequency suggest that agitation is pervasive. The hourly and block agitation rates for our study are unique because this level of detail has not been reported before. The higher block agitation rates may be due to variations in documentation but may also be more accurate because of the required documentation (using the unit data-entry form) at the end of the 4-hour period. Agitation is generally not a quickly resolving issue, and the use of the circle-the-item for a 4-hour block may have served as an efficient indicator. However, because of variation of individual documentation among health care providers, the per-day agitation rates may allow a more consistent comparison between studies. Agitation Onset In our study, the onset of agitation occurred early in the ICU stay. This finding is generally consistent with the published results of other investigators. Most of the patients in our sample experienced the onset of agitation early the first day of their ICU stay, considerably earlier than patients did in previous studies. In the study by Fraser et al, 16 the mean onset time from ICU admission to maximum agitation was 2.4 days. Differences between our results and their results may be due to definition of agitation onset. We computed the mean of all patients agitation onset hours, whereas Fraser et al reported hours to maximum agitation, but did not include any description of the method for determining maximum agitation. In the study by Jaber et al, 6 onset of agitation was 4.4 days (SD, 5.6 days), more than 4 times longer than our onset; however, they stated that most of the patients in their study became agitated in less than 3 to 5 days. The causes of such early agitation are unclear. Early onset of agitation may be linked to use of sedatives; the majority of patients who were agitated had received sedatives. Use of sedatives has been associated with agitation in several studies. 5,6,15 More studies are needed to determine if or what dose of Number of agitated patients Day 1 Day 2 Day 3 Day 4 Day 5 Day 1 agitation onset Day 3 agitation onset Day 5 agitation onset Stay in intensive care unit Figure 2 Number of agitated patients who experienced any agitation per day by the day of onset of agitation. Day 1 firsttime agitated patients (n = 102, blue column) were less each succeeding day (65, 44, 27, 21); on day 2, only 6 patients were agitated for the first time (red column) and that number also was less each succeeding day (4, 2, 1). sedative precipitates agitation or is involved in neurotransmitter imbalance. Severity of disease has also been suggested as a factor in early onset of agitation. However, an association between severity of disease and early onset appears unlikely because our severity-of-disease scores are generally comparable to those of other studies. 5,6,15 First-day agitation is common in critically ill patients. We found significantly higher first-day rates (86%) than did Woods et al 5 (7%). This difference may be attributed partially to dissimilar populations and outcome measurement discussed earlier. In addition to having high first-day agitation rates, more than half of our sample had agitation in the first hour of ICU admission. This finding suggests that compared with patients in other studies, our patients were admitted in an agitated state. The cause of this difference is unclear. The admission source from outside the hospital and the location immediately before ICU admission might influence this finding, but we found no statistically significant relationship or trend between these factors and agitation. Patterns of Agitation: Onset and Frequency In our study, the hourly patterns of agitation onset and frequency for day of the week, day or night, and block intervals were similar. Agitation frequency was higher in the day. Jaber et al 6 found no significant difference between day and night for Day 2 agitation onset Day 4 agitation onset Agitation is common in critically ill people and affected more than half of these patients. AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No

7 Intermittent agitation all other days Consecutive days of agitation day 1 Intermittent agitation day 1 Single day of agitation all other days Single day of agitation day 1 Consecutive days of agitation all other days Label Explanation The percentage of total agitation Intermittent agitation day 1 of all patients who had intermittent agitation on day 1 The percentage of total agitation of all patients who had intermittent agitation on any day other Intermittent agitation all other days than day 1 The percentage of total agitation Single day of agitation day 1 of all patients who had a single day of agitation on day 1 The percentage of total agitation of all patients who had a single Single day of agitation all other days day of agitation on any day other than day 1 The percentage of total agitation of all patients who had consecutive Consecutive days of agitation day 1 days of agitation beginning on day 1 The percentage of total agitation Consecutive days of agitation all of all patients who had consecutive days of agitation beginning other days on any day other than day 1 Figure 3 Day patterns of agitation depicting the significant portion of agitation that occurs on day 1. agitation. Our results and those of Jaber et al suggest that agitation may be heterogeneous, with little diurnal fluctuation. Of note, most patterns of consecutive, intermittent, and single-day agitation in our study involved day 1 agitation. Agitation patterns over time revealed that day 1 agitation is implicated in all trends, but more significantly in consecutive days. Patterns of Agitation by Unit In our study, differences between agitation rates of MRICU patients and STICU patients were not significant. However, agitation rates were higher in medical patients in the study by Jaber et al. 6 The significantly higher percentage of MRICU patients who had agitation on day 1 and day 2 compared with STICU patients may reflect higher severity of disease in the MRICU group. If agitation is a result of dysregulation of neurotransmitters, MRICU patients may have more comorbid conditions and severity of disease that may contribute to the higher agitation rate and earlier onset. In support of this notion, scores on the Acute Physiology and Chronic Health Evaluation III, scores on the Sequential Organ Failure Assessment, and the Charlson Comorbidity Index were significantly higher in the MRICU patients than in the STICU group. Jaber et al 6 also found a significantly higher Simplified Acute Physiology Score II in agitated medical patients than in nonagitated medical patients. Limitations Limitations of our study warrant mention. Because the study was a retrospective chart review, findings are dependent on data completeness and quality. The data were not originally recorded for research purposes and may be lacking in quantity and quality. To mitigate some of these disadvantages, we used a more stringent definition of agitation (documentation of the word agitation or score on the RASS) and did not rely on behavioral cues. Strengths of retrospective reviews exist: the results reflect usual care and allow investigators to examine processes and outcomes devoid of the Hawthorne effect. Data stamping/notation in hospital records allows the researcher to understand events occurring on a timeline with the ability to integrate multiple data sources. We currently have no continuous method for measuring agitation over time; the best alternative is hourly documentation. Differences between MRICU patients and STICU patients could be due to differences in unit documentation norms. Regardless of the evaluation of agitation whether frequency, onset, or pattern our data indicate that agitation in critically ill patients is an early phenomenon and involves consecutive days. These findings have clinical and resource allocation implications. Focusing efforts and resources and implementing protocols early in a patient s ICU stay (or before) may prevent the poor outcomes and dangerous sequelae of agitation and may reduce ICU costs. In addition, interrupting the trend of consecutive days of agitation might have an equal impact on lowering the overall frequency of agitation. 302 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

8 Table 3 Comparison of agitated patients between the MRICU and the STICU No. (%) of patients Variable MRICU (n = 100) STICU (n = 100) P Total documentation hours Total agitation hours 9228 (51.4) (48.6) 458 Total documentation blocks Total agitation blocks 2399 (51.9) 560 (23.3) 2222 (48.1) 323 (14.5) Agitated patients a 64 (54) 54 (46).20 Agitation hours in first day of admission Agitation blocks in first day of admission Patients agitated in first day of admission 57 (89.1) 45 (83.3).12 Patients agitated in first hour of admission 26 (48.1) 18 (33.3).23 Patients agitated in first block of admission 36 (56.3) 24 (44.4).09 Patient-level data Mean (SD; range) P Percentage agitation by hour 9.2 (9.5; 0-43 ) 4.7 (6.8; 0-29) <.001 Percentage agitation by block 21.7 (21.4; 0-68) 12.6 (16.4; 0-77).001 Percentage agitation by day Day 1 Day 2 Day 3 Day 4 Day (32.8; 0-100) 21.4 (26.7; 0-100) 15.1 (24.2; 0-100) 12.4 (24.6; 0-100) 8.9 (20.6; 0-83) 15.4 (21.6; 0-100) 9.2 (19.6; 0-100) 10.3 (24.8; 0-100) 9.5 (19.9; 0-83) 8.5 (22.9; 0-100) <.001 < Mean agitation onset hour from admission 8.4 (17.2; 0-85) 15.5 (26.9; 0-114).09 Age, y 56.7 (16.1; 18-89) 53.3 (16.8; 18-82).27 ICU length of stay, d 7.9 (7.5; ) 7.9 (7.9; ).97 Hospital length of stay, d 15.8 (13.1; ) 18.6 (16.3; ).31 APACHE III score on admission to the ICU 81.2 (27.2; ) 66.9 (27.7; ).006 SOFA 7.6 (3.9; 0-18) 5.6 (3.5; 1-16) <.001 Charlson Comorbidity Index 5.5 (3.3; 0-17) 3.8 (3.1; 0-13).008 Abbreviations: APACHE III, Acute Physiology and Chronic Health Evaluation III; ICU, intensive care unit; MRICU, medical-respiratory intensive care unit; SOFA, Sequential Organ Failure Assessment; STICU, surgical-trauma intensive care unit. a Agitated on any ICU study day. Conclusion In our study, agitation affected more than half of the patients in the sample, mainly occurred the first day in the ICU stay, and involved consecutive days. MRICU patients generally had a higher severity of illness and had higher day 1 and 2 rates of patient agitation than did STICU patients. Studies are needed to clarify patients risk factors and to identify strategies (both pharmacological and nonpharmacological) to prevent, ameliorate, or treat this complication. FINANCIAL DISCLOSURES This study was supported by grant F31-NR from the National Institute of Nursing Research. eletters Now that you ve read the article, create or contribute to an online discussion on this topic. Visit and click Responses in the second column of either the full-text or PDF view of the article. REFERENCES 1. Harvey MA. Managing agitation in critically ill patients. Am J Crit Care. 1996;5: The management of the agitated ICU patient. Crit Care Med. 2002;30(1 suppl management):s97-s Jacobi J, Fraser GL, Coursin DB, et al; Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult [published correction appears in Crit Care Med. 2002;39(3): 726]. Crit Care Med. 2002;30(1): AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No

9 4. Gardner K, Sessler CN, Grap MJ. Clinical factors associated with agitation. Am J Crit Care. 2006;15: Woods JC, Mion LC, Connor JT, et al. Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes. Intensive Care Med. 2004;30(6): Jaber S, Chanques G, Altairac C, et al. A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes. Chest. 2005;128(4): Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27(7): Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166: Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1): Ely EW, Gautam S, May L, et al. A comparison of different sedation scales in the ICU and validation of the Richmond Agitation-Sedation Scale (RASS) [abstract]. Am J Respir Crit Care Med. 2001;A Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289: Sessler CN, Gosnell MS, Grap MJ, et al. Reliability and validity of a new agitation-sedation scale for intensive care unit patients. Virginia Pulm J. 1999;5: Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. J Hosp Infect. 1991;100: Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsisrelated Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22: Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47: Fraser GL, Prato BS, Riker RR, Berthiaume D, Wilkins ML. Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU. Pharmacotherapy. 2000; 20(1): To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. 304 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

10 Agitation Onset, Frequency, and Associated Temporal Factors in Critically Ill Adults Ruth S. Burk, Mary Jo Grap, Cindy L. Munro, Christine M. Schubert and Curtis N. Sessler Am J Crit Care 2014; /ajcc American Association of Critical-Care Nurses Published online Personal use only. For copyright permission information: Subscription Information Information for authors Submit a manuscript alerts The American Journal of Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA Telephone: (800) , (949) , ext Fax: (949) Copyright 2016 by AACN. All rights reserved.