BACKGROUND/OBJECTIVES: Systematic screening can improve detection of delirium, but lack of time is often cited as why such screening is not performed. We investigated the time required to implement four screening protocols that use the Ultra-Brief two-item screener for delirium (UB-2) and the 3-Minute Diagnostic Interview for Confusion Assessment Method (CAM)-defined Delirium (3D-CAM), with and without a skip pattern that can further shorten the assessment. Our objective was to compare the sensitivity, specificity, and time required to complete four protocols: (1) full 3D-CAM on all patients, (2) 3D-CAM with skip on all patients, (3) UB-2, followed by the full 3D-CAM in "positives," and (4) UB-2, followed by the 3D-CAM with skip in "positives." DESIGN: Comparative efficiency simulation study using secondary data. SETTING: Two studies (3D-CAM and Researching Efficient Approaches to Delirium Identification (READI)) conducted at a large academic medical center (3D-CAM and READI) and a small community hospital (READI only). PARTICIPANTS: General medicine inpatients, aged 70 years and older (3D-CAM, n = 201; READI, n = 330). MEASUREMENTS: We used 3D-CAM data to simulate the items administered under each protocol and READI data to calculate median administration time per item. We calculated sensitivity, specificity, and total administration time for each of the four protocols. RESULTS: The 3D-CAM and READI samples had similar characteristics, and all four protocols had similar simulated sensitivity and specificity. Mean administration times were 3 minutes 13 seconds for 3D-CAM, 2 minutes 19 seconds for 3D-CAM with skip, 1 minute 52 seconds for UB-2 + 3D-CAM in positives, and 1 minute 14 seconds for UB-2 + 3D-CAM with skip in positives, which was 1 minute 59 seconds faster than the 3D-CAM (P < .001). CONCLUSION: The UB-CAM, consisting of the UB-2, followed in positives by the 3D-CAM with skip pattern, is a time-efficient delirium screening protocol that holds promise for increasing systematic screening for delirium in hospitalized older adults.

Acute limb ischemia (ALI) and bleeding complications after venoarterial (VA) extracorporeal membrane oxygenation (ECMO) are frequent and are associated with worse outcomes. We sought to describe the rates and modifiable risk factors of ECMO-related vascular complications and to evaluate strategies believed to reduce those complications, such as distal perfusion catheters (DPC) and ultrasound-guided cannulation.Methods: This is a retrospective cohort study of adult patients placed on ECMO at a tertiary medical center between 2014 and 2018. Patient and periprocedural variables were collected from the electronic medical record. ECMO-related ALI was defined as ischemia of the extremity ipsilateral to the arterial cannulation site. Significant cannulation site bleeding was defined as excessive bleeding that required an intervention (eg, transfusion or reoperation). Univariate analyses were used to identify factors associated with ECMO-related ALI, bleeding, and in-hospital mortality.Results: Two hundred twenty-three consecutive patients were placed on ECMO during the study period. Most patients (144/223; 64%) underwent VA cannulation, of whom 40.5% were for extracorporeal cardiopulmonary resuscitation. The majority of patients (142/ 208; 68.3%) were percutaneously cannulated, and ultrasound examination was used during cannulation in 42 of 126 patients (33.3%) of. DPC were placed in 38 of 94 VA-ECMO patients (40.4%). Average duration of ECMO support and ICU stay were 7.4 days (standard deviation [SD], 10.9 days) and 21.0 days (SD, 25.9 days), respectively. ECMO-related ALI occurred in 26 of 211 (12.3%) and significant bleeding in 34 of 211 (16.1%) patients. Overall in-hospital mortality was 59.6% and death while on ECMO was 47.1%. Most patients with ALI (21/26; 80.8%) or significant bleeding (30/34; 88.2%) had VA cannulation. While DPC and ultrasound examination use were not associated with ALI, there were more bleeding complications when ultrasound was not used (17% vs 0%; P < .01). Being transferred from an outside hospital while on or for ECMO cannulation was also associated with a higher rate of ALI (20.4% vs 5.9%; P < .01). ALI was associated with in-hospital mortality (P < .05), but bleeding was not (P ¼ .71). extracorporeal cardiopulmonary resuscitation was not associated with higher rates of ALI or bleeding.Conclusions: ALI and bleeding are frequent complications of VA-ECMO cannulation. ALI is associated with worsened mortality. Future efforts at reducing ALI should focus on identifying factors surrounding intrahospital transfer. The use of ultrasound examination at the time cannulation may reduce rates of bleeding complications but does not seem to decrease rates of ALI. While DPC have been shown to prevent ALI, our population did not experience a significant benefit.

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