Previous studies have advocated the importance of effective communication between clinicians as a critical component in the provision of high‐quality patient care.[1, 2, 3, 4] There is increasing interest in the use of information and communication technologies to improve how clinicians communicate in hospital settings. A number of hospitals have implemented different solutions to improve communication. These solutions include alphanumeric pagers,[5] smartphones,[6] e‐mail,[7] secure text messaging,[8] and a Web‐based interdisciplinary communication tool.[9]

These systems have different limitations that render them inefficient and likely inhibit collaborative care. Current systems, such as pagers, rely on the sender to ensure the message was received and are successful in delivering messages approximately 67% of the time.[5, 9, 10] Although alphanumeric pagers and secure text messaging can increase the likelihood of delivery, these messages are often isolated and not easily viewable by the whole care team.[11] Improved systems should also reduce unnecessary interruptions by providing support for both urgent and delayed messages. Finally, messages should be stored and retrievable to enable increased accountability and allow for review for quality improvement initiatives.

It is also important to consider the unintended consequences of technology implementations.[12] Moving communication to text messages and smartphones has the potential to reduce interprofessional relations and can increase confusion if used for complex issues.[10, 13] In this article, we present a system designed to improve interprofessional communication on general internal medicine wards by incorporating these desired features and describe the usage and attitudes toward the system, specifically assessing for effects on multiple domains including efficiency, interprofessional collaboration, and relationships.

METHODS

Intervention

To address issues with communication, we developed a systemClinical Message (CM)that included 2 main components: a physician handover tool and secure messaging module. The focus of CM was to improve communication and information flow among different healthcare providers (physicians, nurses, pharmacists, social workers and therapists) through a secure, shared platform.

Physician Handover

The physician handover tool was designed to facilitate the physician handover process at shift change and is used as a patient rounding tool for day‐to‐day management of patients. It is also accessed by nurses and other clinicians to view the physicians' notes and to stay informed on the overall care plan. The tool contains standard elements including a list of patients with the following information on each patient: demographics, diagnosis, code status, medical history, active issues, and discharge plans (Figure 1).

Figure 1

Secure Messaging

Secure messaging was designed around our dominant communication: nurses sending messages to physicians who would then respond. Nurses and other health professionals sent messages to the medical teams by accessing CM, selecting the appropriate patient, and filling out a message template. The system automatically populated the To field with the team assigned to the selected patient. Messaging for each team was centralized around a single team smartphone that was carried 24 hours a day, 7 days a week by a physician on that team. This removed the guesswork of trying to identify the individual physician responsible for that patient. For each message, a subject or issue and content were entered (Figure 2). Logic was also incorporated to reduce the amount of unnecessary interruptions. Senders would choose to send the message immediately as an interrupt message (urgent) for urgent/time sensitive issues or as an allow time to respond message (delayed). For the latter, the message was posted to the system where physicians could check and answer them. Interrupt messages were sent to the team smartphone using the Short Message Service (SMS) protocol. To try and ensure the communication loop on any issues was closed, when a message requested a response and did not receive it, the system sent another message. For urgent messages, a repeat message was initiated after 15 minutes. For delayed messages, the sender defined when they needed a response, typically within 2 to 8 hours. Senders were also able to select the mode of response that would best meet their needs from a workflow perspective: call back, text reply, or to specify that a reply was not required. Senders were also able to verify if the messages were received by the physician's smartphone. Physicians could view the messages within CM and reply. For messages that went to their team smartphone, physicians could respond from the smartphone through a secure Web link.

Figure 2

Because the messages were linked to the patients, they were visible to the entire care team, not just the message sender and recipient. If the care of the patient was transferred from 1 clinician to the next, the new clinician could easily review prior messages to understand recent patient events. The system was accessible through a browser on the intranet. The system regularly pulled patient demographic details such as name, age, medical record number, and location from our electronic medical record through a 1‐way interface. Information from this communication system was not considered part of the medical record but was retrievable.

The system was introduced as the new standard method of communication for nurses to reach physicians for all of the general internal medicine wards and for all medical teams at site 1 on May 2, 2011 and site 2 on June 6, 2011. The system replaced a text‐based Web‐paging system and supplemented the numeric pager carried by residents. Initial training of a half hour was provided to all nurses and residents.

RESULTS

DISCUSSION

We describe an implementation of a system to improve clinical communication in hospitals. The system was highly used and was perceived to improve communication by both nurses and physicians. Specifically, users found that the system increased efficiency, accountability, timeliness, and collaboration, but that there were issues with message clarity for complex medical issues.

Other systems and approaches have been implemented to improve communication. These included the use of alphanumeric pagers, e‐mail, secure texting, and smartphones. There is evidence that more advanced systems can improve efficiency for senders.[16] A recent randomized trial of secure text messaging found that it was perceived to be more efficient than paging, but overall usage was low and inconsistent.[8] There is also evidence that smartphones may increase interruptions, worsen interprofessional relationships, and cause issues with professional behavior.[10] Unfortunately, there are a limited number of interventions that improve communication, with some improving efficiency but none demonstrating improved patient‐oriented outcomes.[16, 17] This study evaluated a novel system, with functionality to link communication to patients, and created a system that aligned with the workflow of the clinicians. Messages were linked to the patient, not the sender or receiver, so other clinicians in the patient's circle of care could easily view the communication. Moreover, the system was designed to improve message response rates and allow for nonurgent messages.

Our communication system uses standard, commercially available components (smartphones, SMS), and relatively basic functionality (handover, secure messaging). Important findings are that the current system of paging can be transformed to a more efficient system that users will readily adopt. We found positive effects with components of the system. It appeared to improve efficiency and increase accountability. Accountability is crucial and moves from undocumented conversation to fully documented details of interactions. This can be used for both incident review and to review for quality improvement.

Using the system, physicians perceived that they were bothered by low‐value information, whereas nurses perceived a lack of response, and both found that the system was not ideal for complex messages. The mismatch between what physicians and nurses perceive as important has been attributed to their different timeframes and context.[18] For nurses with an upcoming change of shift, they wanted resolution of issues before handover. A physician on a different ward may not appreciate the context of a nurse having to directly interact with an irate family member. These different perceptions likely contributed to the lack of response to 8.6% of text messages. This is still better than other systems, such as paging, which can be as high as 33%.[10] For nonurgent items, clinicians would ideally check and clear items regularly from the system using a desktop computer, responding within the allotted timeframe. Unfortunately, this never became part of routine physician workflow, likely due to their busy workload, so many physicians would only respond when items became overdue. However, having a method to deal with nonurgent messages may have prevented some interruptions during protected educational times of trainees. The system was also not ideal for urgent or complex items. Complex items can be difficult to convey using the rarified communication medium of text messages.[19, 20] Urgent or complex issues are likely best resolved with a face‐to‐face or telephone conversation.

There are several limitations in our study that should be considered when interpreting the results. It is a study of usage and perceptions after implementation. Although more rigorous study is required to evaluate the effects, we see this as a first step in process improvement. Future research should measure the impact on improving patient care of this system and on patient outcomes such as adverse events. The study and intervention was limited to general internal medicine wards in 2 academic hospital settings where there are frequent rotations of medical personnel. The findings may not be generalizable to other hospital settings.

Future directions should be to further improve on the communication system and to educate and train staff on how to effectively communicate. Survey results showed that although users perceived increased efficiency, there was still significant opportunity to improve. One way to improve would be to have a mobile application in which physicians can easily review nonurgent items. Improvements could also be realized by educating clinicians on the use of the system and providing immediate feedback. Providing feedback to physicians on how well they respond could address nurses' issues around lack of timely response. By creating consensus between nurses and physicians on what is of high and low value to communicate could increase satisfaction for all users.

In summary, we present the usage and perceptions of a system designed to improve hospital communication. We found that there was high uptake, and that users perceived it to improve efficiency, collaboration, and accountability, but it may not be useful for communicating complex issues.

Previous studies have advocated the importance of effective communication between clinicians as a critical component in the provision of high‐quality patient care.[1, 2, 3, 4] There is increasing interest in the use of information and communication technologies to improve how clinicians communicate in hospital settings. A number of hospitals have implemented different solutions to improve communication. These solutions include alphanumeric pagers,[5] smartphones,[6] e‐mail,[7] secure text messaging,[8] and a Web‐based interdisciplinary communication tool.[9]

These systems have different limitations that render them inefficient and likely inhibit collaborative care. Current systems, such as pagers, rely on the sender to ensure the message was received and are successful in delivering messages approximately 67% of the time.[5, 9, 10] Although alphanumeric pagers and secure text messaging can increase the likelihood of delivery, these messages are often isolated and not easily viewable by the whole care team.[11] Improved systems should also reduce unnecessary interruptions by providing support for both urgent and delayed messages. Finally, messages should be stored and retrievable to enable increased accountability and allow for review for quality improvement initiatives.

It is also important to consider the unintended consequences of technology implementations.[12] Moving communication to text messages and smartphones has the potential to reduce interprofessional relations and can increase confusion if used for complex issues.[10, 13] In this article, we present a system designed to improve interprofessional communication on general internal medicine wards by incorporating these desired features and describe the usage and attitudes toward the system, specifically assessing for effects on multiple domains including efficiency, interprofessional collaboration, and relationships.

METHODS

Intervention

To address issues with communication, we developed a systemClinical Message (CM)that included 2 main components: a physician handover tool and secure messaging module. The focus of CM was to improve communication and information flow among different healthcare providers (physicians, nurses, pharmacists, social workers and therapists) through a secure, shared platform.

Physician Handover

The physician handover tool was designed to facilitate the physician handover process at shift change and is used as a patient rounding tool for day‐to‐day management of patients. It is also accessed by nurses and other clinicians to view the physicians' notes and to stay informed on the overall care plan. The tool contains standard elements including a list of patients with the following information on each patient: demographics, diagnosis, code status, medical history, active issues, and discharge plans (Figure 1).

Figure 1

Secure Messaging

Secure messaging was designed around our dominant communication: nurses sending messages to physicians who would then respond. Nurses and other health professionals sent messages to the medical teams by accessing CM, selecting the appropriate patient, and filling out a message template. The system automatically populated the To field with the team assigned to the selected patient. Messaging for each team was centralized around a single team smartphone that was carried 24 hours a day, 7 days a week by a physician on that team. This removed the guesswork of trying to identify the individual physician responsible for that patient. For each message, a subject or issue and content were entered (Figure 2). Logic was also incorporated to reduce the amount of unnecessary interruptions. Senders would choose to send the message immediately as an interrupt message (urgent) for urgent/time sensitive issues or as an allow time to respond message (delayed). For the latter, the message was posted to the system where physicians could check and answer them. Interrupt messages were sent to the team smartphone using the Short Message Service (SMS) protocol. To try and ensure the communication loop on any issues was closed, when a message requested a response and did not receive it, the system sent another message. For urgent messages, a repeat message was initiated after 15 minutes. For delayed messages, the sender defined when they needed a response, typically within 2 to 8 hours. Senders were also able to select the mode of response that would best meet their needs from a workflow perspective: call back, text reply, or to specify that a reply was not required. Senders were also able to verify if the messages were received by the physician's smartphone. Physicians could view the messages within CM and reply. For messages that went to their team smartphone, physicians could respond from the smartphone through a secure Web link.

Figure 2

Because the messages were linked to the patients, they were visible to the entire care team, not just the message sender and recipient. If the care of the patient was transferred from 1 clinician to the next, the new clinician could easily review prior messages to understand recent patient events. The system was accessible through a browser on the intranet. The system regularly pulled patient demographic details such as name, age, medical record number, and location from our electronic medical record through a 1‐way interface. Information from this communication system was not considered part of the medical record but was retrievable.

The system was introduced as the new standard method of communication for nurses to reach physicians for all of the general internal medicine wards and for all medical teams at site 1 on May 2, 2011 and site 2 on June 6, 2011. The system replaced a text‐based Web‐paging system and supplemented the numeric pager carried by residents. Initial training of a half hour was provided to all nurses and residents.

RESULTS

DISCUSSION

We describe an implementation of a system to improve clinical communication in hospitals. The system was highly used and was perceived to improve communication by both nurses and physicians. Specifically, users found that the system increased efficiency, accountability, timeliness, and collaboration, but that there were issues with message clarity for complex medical issues.

Other systems and approaches have been implemented to improve communication. These included the use of alphanumeric pagers, e‐mail, secure texting, and smartphones. There is evidence that more advanced systems can improve efficiency for senders.[16] A recent randomized trial of secure text messaging found that it was perceived to be more efficient than paging, but overall usage was low and inconsistent.[8] There is also evidence that smartphones may increase interruptions, worsen interprofessional relationships, and cause issues with professional behavior.[10] Unfortunately, there are a limited number of interventions that improve communication, with some improving efficiency but none demonstrating improved patient‐oriented outcomes.[16, 17] This study evaluated a novel system, with functionality to link communication to patients, and created a system that aligned with the workflow of the clinicians. Messages were linked to the patient, not the sender or receiver, so other clinicians in the patient's circle of care could easily view the communication. Moreover, the system was designed to improve message response rates and allow for nonurgent messages.

Our communication system uses standard, commercially available components (smartphones, SMS), and relatively basic functionality (handover, secure messaging). Important findings are that the current system of paging can be transformed to a more efficient system that users will readily adopt. We found positive effects with components of the system. It appeared to improve efficiency and increase accountability. Accountability is crucial and moves from undocumented conversation to fully documented details of interactions. This can be used for both incident review and to review for quality improvement.

Using the system, physicians perceived that they were bothered by low‐value information, whereas nurses perceived a lack of response, and both found that the system was not ideal for complex messages. The mismatch between what physicians and nurses perceive as important has been attributed to their different timeframes and context.[18] For nurses with an upcoming change of shift, they wanted resolution of issues before handover. A physician on a different ward may not appreciate the context of a nurse having to directly interact with an irate family member. These different perceptions likely contributed to the lack of response to 8.6% of text messages. This is still better than other systems, such as paging, which can be as high as 33%.[10] For nonurgent items, clinicians would ideally check and clear items regularly from the system using a desktop computer, responding within the allotted timeframe. Unfortunately, this never became part of routine physician workflow, likely due to their busy workload, so many physicians would only respond when items became overdue. However, having a method to deal with nonurgent messages may have prevented some interruptions during protected educational times of trainees. The system was also not ideal for urgent or complex items. Complex items can be difficult to convey using the rarified communication medium of text messages.[19, 20] Urgent or complex issues are likely best resolved with a face‐to‐face or telephone conversation.

There are several limitations in our study that should be considered when interpreting the results. It is a study of usage and perceptions after implementation. Although more rigorous study is required to evaluate the effects, we see this as a first step in process improvement. Future research should measure the impact on improving patient care of this system and on patient outcomes such as adverse events. The study and intervention was limited to general internal medicine wards in 2 academic hospital settings where there are frequent rotations of medical personnel. The findings may not be generalizable to other hospital settings.

Future directions should be to further improve on the communication system and to educate and train staff on how to effectively communicate. Survey results showed that although users perceived increased efficiency, there was still significant opportunity to improve. One way to improve would be to have a mobile application in which physicians can easily review nonurgent items. Improvements could also be realized by educating clinicians on the use of the system and providing immediate feedback. Providing feedback to physicians on how well they respond could address nurses' issues around lack of timely response. By creating consensus between nurses and physicians on what is of high and low value to communicate could increase satisfaction for all users.

In summary, we present the usage and perceptions of a system designed to improve hospital communication. We found that there was high uptake, and that users perceived it to improve efficiency, collaboration, and accountability, but it may not be useful for communicating complex issues.

Previous studies have advocated the importance of effective communication between clinicians as a critical component in the provision of high‐quality patient care.[1, 2, 3, 4] There is increasing interest in the use of information and communication technologies to improve how clinicians communicate in hospital settings. A number of hospitals have implemented different solutions to improve communication. These solutions include alphanumeric pagers,[5] smartphones,[6] e‐mail,[7] secure text messaging,[8] and a Web‐based interdisciplinary communication tool.[9]

These systems have different limitations that render them inefficient and likely inhibit collaborative care. Current systems, such as pagers, rely on the sender to ensure the message was received and are successful in delivering messages approximately 67% of the time.[5, 9, 10] Although alphanumeric pagers and secure text messaging can increase the likelihood of delivery, these messages are often isolated and not easily viewable by the whole care team.[11] Improved systems should also reduce unnecessary interruptions by providing support for both urgent and delayed messages. Finally, messages should be stored and retrievable to enable increased accountability and allow for review for quality improvement initiatives.

It is also important to consider the unintended consequences of technology implementations.[12] Moving communication to text messages and smartphones has the potential to reduce interprofessional relations and can increase confusion if used for complex issues.[10, 13] In this article, we present a system designed to improve interprofessional communication on general internal medicine wards by incorporating these desired features and describe the usage and attitudes toward the system, specifically assessing for effects on multiple domains including efficiency, interprofessional collaboration, and relationships.

METHODS

Intervention

To address issues with communication, we developed a systemClinical Message (CM)that included 2 main components: a physician handover tool and secure messaging module. The focus of CM was to improve communication and information flow among different healthcare providers (physicians, nurses, pharmacists, social workers and therapists) through a secure, shared platform.

Physician Handover

The physician handover tool was designed to facilitate the physician handover process at shift change and is used as a patient rounding tool for day‐to‐day management of patients. It is also accessed by nurses and other clinicians to view the physicians' notes and to stay informed on the overall care plan. The tool contains standard elements including a list of patients with the following information on each patient: demographics, diagnosis, code status, medical history, active issues, and discharge plans (Figure 1).

Figure 1

Secure Messaging

Secure messaging was designed around our dominant communication: nurses sending messages to physicians who would then respond. Nurses and other health professionals sent messages to the medical teams by accessing CM, selecting the appropriate patient, and filling out a message template. The system automatically populated the To field with the team assigned to the selected patient. Messaging for each team was centralized around a single team smartphone that was carried 24 hours a day, 7 days a week by a physician on that team. This removed the guesswork of trying to identify the individual physician responsible for that patient. For each message, a subject or issue and content were entered (Figure 2). Logic was also incorporated to reduce the amount of unnecessary interruptions. Senders would choose to send the message immediately as an interrupt message (urgent) for urgent/time sensitive issues or as an allow time to respond message (delayed). For the latter, the message was posted to the system where physicians could check and answer them. Interrupt messages were sent to the team smartphone using the Short Message Service (SMS) protocol. To try and ensure the communication loop on any issues was closed, when a message requested a response and did not receive it, the system sent another message. For urgent messages, a repeat message was initiated after 15 minutes. For delayed messages, the sender defined when they needed a response, typically within 2 to 8 hours. Senders were also able to select the mode of response that would best meet their needs from a workflow perspective: call back, text reply, or to specify that a reply was not required. Senders were also able to verify if the messages were received by the physician's smartphone. Physicians could view the messages within CM and reply. For messages that went to their team smartphone, physicians could respond from the smartphone through a secure Web link.

Figure 2

Because the messages were linked to the patients, they were visible to the entire care team, not just the message sender and recipient. If the care of the patient was transferred from 1 clinician to the next, the new clinician could easily review prior messages to understand recent patient events. The system was accessible through a browser on the intranet. The system regularly pulled patient demographic details such as name, age, medical record number, and location from our electronic medical record through a 1‐way interface. Information from this communication system was not considered part of the medical record but was retrievable.

The system was introduced as the new standard method of communication for nurses to reach physicians for all of the general internal medicine wards and for all medical teams at site 1 on May 2, 2011 and site 2 on June 6, 2011. The system replaced a text‐based Web‐paging system and supplemented the numeric pager carried by residents. Initial training of a half hour was provided to all nurses and residents.

RESULTS

DISCUSSION

We describe an implementation of a system to improve clinical communication in hospitals. The system was highly used and was perceived to improve communication by both nurses and physicians. Specifically, users found that the system increased efficiency, accountability, timeliness, and collaboration, but that there were issues with message clarity for complex medical issues.

Other systems and approaches have been implemented to improve communication. These included the use of alphanumeric pagers, e‐mail, secure texting, and smartphones. There is evidence that more advanced systems can improve efficiency for senders.[16] A recent randomized trial of secure text messaging found that it was perceived to be more efficient than paging, but overall usage was low and inconsistent.[8] There is also evidence that smartphones may increase interruptions, worsen interprofessional relationships, and cause issues with professional behavior.[10] Unfortunately, there are a limited number of interventions that improve communication, with some improving efficiency but none demonstrating improved patient‐oriented outcomes.[16, 17] This study evaluated a novel system, with functionality to link communication to patients, and created a system that aligned with the workflow of the clinicians. Messages were linked to the patient, not the sender or receiver, so other clinicians in the patient's circle of care could easily view the communication. Moreover, the system was designed to improve message response rates and allow for nonurgent messages.

Our communication system uses standard, commercially available components (smartphones, SMS), and relatively basic functionality (handover, secure messaging). Important findings are that the current system of paging can be transformed to a more efficient system that users will readily adopt. We found positive effects with components of the system. It appeared to improve efficiency and increase accountability. Accountability is crucial and moves from undocumented conversation to fully documented details of interactions. This can be used for both incident review and to review for quality improvement.

Using the system, physicians perceived that they were bothered by low‐value information, whereas nurses perceived a lack of response, and both found that the system was not ideal for complex messages. The mismatch between what physicians and nurses perceive as important has been attributed to their different timeframes and context.[18] For nurses with an upcoming change of shift, they wanted resolution of issues before handover. A physician on a different ward may not appreciate the context of a nurse having to directly interact with an irate family member. These different perceptions likely contributed to the lack of response to 8.6% of text messages. This is still better than other systems, such as paging, which can be as high as 33%.[10] For nonurgent items, clinicians would ideally check and clear items regularly from the system using a desktop computer, responding within the allotted timeframe. Unfortunately, this never became part of routine physician workflow, likely due to their busy workload, so many physicians would only respond when items became overdue. However, having a method to deal with nonurgent messages may have prevented some interruptions during protected educational times of trainees. The system was also not ideal for urgent or complex items. Complex items can be difficult to convey using the rarified communication medium of text messages.[19, 20] Urgent or complex issues are likely best resolved with a face‐to‐face or telephone conversation.

There are several limitations in our study that should be considered when interpreting the results. It is a study of usage and perceptions after implementation. Although more rigorous study is required to evaluate the effects, we see this as a first step in process improvement. Future research should measure the impact on improving patient care of this system and on patient outcomes such as adverse events. The study and intervention was limited to general internal medicine wards in 2 academic hospital settings where there are frequent rotations of medical personnel. The findings may not be generalizable to other hospital settings.

Future directions should be to further improve on the communication system and to educate and train staff on how to effectively communicate. Survey results showed that although users perceived increased efficiency, there was still significant opportunity to improve. One way to improve would be to have a mobile application in which physicians can easily review nonurgent items. Improvements could also be realized by educating clinicians on the use of the system and providing immediate feedback. Providing feedback to physicians on how well they respond could address nurses' issues around lack of timely response. By creating consensus between nurses and physicians on what is of high and low value to communicate could increase satisfaction for all users.

In summary, we present the usage and perceptions of a system designed to improve hospital communication. We found that there was high uptake, and that users perceived it to improve efficiency, collaboration, and accountability, but it may not be useful for communicating complex issues.

Arousal is defined as the patient's overall level of responsiveness to the environment. Its assessment is standard of care in most intensive care units (ICUs) to monitor depth of sedation and underlying brain dysfunction. There has been recent interest in expanding the role of arousal assessment beyond the ICU. Specifically, the Veterans Affairs Delirium Working Group proposed that simple arousal assessment be a vital sign to quantify underlying brain dysfunction.[1] The rationale is that impaired arousal is closely linked with delirium,[2] and is an integral component of multiple delirium assessments.[3, 4, 5] Chester et al. observed that the presence of impaired arousal was 64% sensitive and 93% specific for delirium diagnosed by a psychiatrist.[2] Delirium is an under‐recognized public health problem that affects up to 25% of older hospitalized patients,[6, 7] is associated with a multitude of adverse outcomes such as death and accelerated cognitive decline,[8] and costs the US healthcare system an excess of $152 billion dollars.[9]

Most delirium assessments require the patient to undergo additional cognitive testing. The assessment of arousal, however, requires the rater to merely observe the patient during routine clinical care and can be easily integrated into the clinical workflow.[10] Because of its simplicity and brevity, assessing arousal alone using validated scales such as the Richmond Agitation‐Sedation Scale (RASS) may be a more appealing alternative to traditional, more complex delirium screening in the acute care setting. Its clinical utility would be further strengthened if impaired arousal was also associated with mortality, and conferred risk even in the absence of delirium. As a result, we sought to determine if impaired arousal at initial presentation in older acutely ill patients predicted 6‐month mortality and whether this relationship was present in the absence of delirium.

METHODS

RESULTS

A total of 1903 patients were screened, and 1084 patients met enrollment criteria (Figure 1). Of these, 1051 (97.0%) were non‐ICU patients. Patient characteristics of this cohort can be seen in Table 2. Enrolled patients and potentially eligible patients who presented to the emergency department during the enrollment window were similar in age, gender, and severity of illness, but enrolled patients were slightly more likely to have a chief complaint of chest pain and syncope (unpublished data).

Figure 1

Of those enrolled, 249 (23.0%) had an abnormal RASS at initial presentation, and their distribution can be seen in Figure 2. Within 6 months, patients with an abnormal RASS were more likely to die compared with patients with a RASS of 0 (23.7% vs 9.7%, P<0.001). The Kaplan‐Meier survival curves for all enrolled patients with impaired and normal RASS can be seen in Figure 3; the survival curve declined more slowly in patients with a normal RASS compared with those with an abnormal RASS.

Figure 2

Figure 3

Using Cox proportional hazards regression, the relationship between an abnormal RASS at initial presentation and 6‐month mortality persisted (HR: 1.73, 95% CI: 1.21‐2.49) after adjusting for age, sex, nonwhite race, comorbidity burden, severity of illness, dementia, functional dependence, nursing home residence, psychoactive medications given, and admission status. The interaction between an abnormal RASS and APS (severity of illness) had a P value of 0.52. The interaction between an abnormal RASS and benzodiazepine or opioid medication administration had a P value of 0.38. The interaction between an abnormal RASS and admission status had a P value of 0.57. This indicated that severity of illness, psychoactive medication administration, and admission status did not modify the relationship between an abnormal RASS and 6‐month mortality.

We analyzed a subset of 406 patients who received a psychiatrist's assessment to determine if an abnormal RASS was associated with 6‐month mortality regardless of delirium status using Cox proportional hazard regression weighted by the inverse of the propensity score. Patients with an abnormal RASS and no delirium were significantly associated with higher mortality compared to those with a normal RASS (HR: 2.20, 95% CI: 1.10‐4.41). Patients with an abnormal RASS with delirium also had an increased risk for 6‐month mortality (HR: 2.86, 95% CI: 1.29‐6.34).

All regression models were internally validated. There was no evidence of substantial overfitting or collinearity. The Schoenfeld residuals for each model were examined graphically and there was good model fit overall, and no significant outliers were observed.

DISCUSSION

Vital sign measurements are a fundamental component of patient care, and abnormalities can serve as an early warning signal of the patient's clinical deterioration. However, traditional vital signs do not include an assessment of the patient's brain function. Our chief finding is that impaired arousal at initial presentation, as determined by the nonphysician research staff, increased the risk of 6‐month mortality by 73% after adjusting for confounders in a diverse group of acutely ill older patients. This relationship existed regardless of severity of illness, administration of psychoactive medications, and admission status. Though impaired arousal is closely linked with delirium,[2, 24] which is another well‐known predictor of mortality,[11, 25, 26] the prognostic significance of impaired arousal appeared to extend beyond delirium. We observed that the relationship between 6‐month mortality and impaired arousal in the absence of delirium was remarkably similar to that observed with impaired arousal with delirium. Arousal can be assessed for by simply observing the patient during routine clinical care and can be performed by nonphysician and physician healthcare providers. Its assessment should be performed and communicated in conjunction with traditional vital sign measurements in the emergency department and inpatient settings.[1]

Most of the data linking impaired arousal to death have been collected in the ICU. Coma, which represents the most severe form of depressed arousal, has been shown to increase the likelihood of death regardless of underlying etiology.[27, 28, 29, 30, 31] This includes patients who have impaired arousal because they received sedative medications during mechanical ventilation.[32] Few studies have investigated the effect of impaired arousal in a non‐ICU patient population. Zuliani et al. observed that impaired arousal was associated with 30‐day mortality, but their study was conducted in 469 older stroke patients, limiting the study's external validity to a more general patient population.[33] Our data advance the current stage of knowledge; we observed a similar relationship between impaired arousal and 6‐month mortality in a much broader clinical population who were predominantly not critically ill regardless of delirium status. Additionally, most of our impaired arousal cohort had a RASS of 1, indicating that even subtle abnormalities portended adverse outcomes.

In addition to long‐term prognosis, the presence of impaired arousal has immediate clinical implications. Using arousal scales like the RASS can serve as a way for healthcare providers to succinctly communicate the patient's mental status in a standardized manner during transitions of care (eg, emergency physician to inpatient team). Regardless of which clinical setting they are in, older acutely ill patients with an impaired arousal may also require close monitoring, especially if the impairment is acute. Because of its close relationship with delirium, these patients likely have an underlying acute medical illness that precipitated their impaired arousal.

Understanding the true clinical significance of impaired arousal in the absence of delirium requires further study. Because of the fluctuating nature of delirium, it is possible that these patients may have initially been delirious and then became nondelirious during the psychiatrist's evaluation. Conversely, it is also possible that these patients may have eventually transitioned into delirium at later point in time; the presence of impaired arousal alone may be a precursor to delirium. Last, these patients may have had subsyndromal delirium, which is defined as having 1 or more delirium symptoms without ever meeting full DSM‐IV‐TR criteria for delirium.[34] Patients with subsyndromal delirium have poorer outcomes, such as prolonged hospitalizations, and higher mortality than patients without delirium symptoms.[34]

Additional studies are also needed to further clarify the impact of impaired arousal on nonmortality outcomes such as functional and cognitive decline. The prognostic significance of serial arousal measurements also requires further study. It is possible that patients whose impaired arousal rapidly resolves after an intervention may have better prognoses than those who have persistent impairment. The measurement of arousal may have additional clinical applications in disease prognosis models. The presence of altered mental status is incorporated in various disease‐specific risk scores such as the CURB‐65 or Pneumonia Severity Index for pneumonia,[35, 36] and the Pulmonary Embolism Severity Index for pulmonary embolism.[37] However, the definition of altered mental status is highly variable; it ranges from subjective impressions that can be unreliable to formal cognitive testing, which can be time consuming. Arousal scales such as the RASS may allow for more feasible, reliable, and standardized assessment of mental status. Future studies should investigate if incorporating the RASS would improve the discrimination of these disease‐severity indices.

This study has several notable limitations. We excluded patients with a RASS of 4 and 5, which represented comatose patients. This exclusion, however, likely biased our findings toward the null. We enrolled a convenience sample that may have introduced selection bias. However, our enrolled cohort was similar to all potentially eligible patients who presented to the emergency department during the study period. We also attempted to mitigate this selection bias by using multivariable regression and adjusting for factors that may have confounded the relationship between RASS and 6‐month mortality. This study was performed at a single, urban, academic hospital and enrolled patients who were aged 65 years and older. Our findings may not be generalizable to other settings and to those who are under 65 years of age. Because 406 patients received a psychiatric evaluation, this limited the number of covariates that could be incorporated into the multivariable model to evaluate if impaired arousal in the absence of delirium is associated with 6‐month mortality. To minimize residual confounding, we used the inverse weighted propensity score, but we acknowledge that this bias may still exist. Larger studies are needed to clarify the relationships between arousal, delirium, and mortality.

CONCLUSION

In conclusion, impaired arousal at initial presentation is an independent predictor for 6‐month mortality in a diverse group of acutely ill older patients, and this risk appears to be present even in the absence of delirium. Because of its ease of use and prognostic significance, it may be a useful vital sign for underlying brain dysfunction. Routine standardized assessment and communication of arousal during routine clinical care may be warranted.

Disclosures: Research reported in this publication was supported by the Vanderbilt Physician Scientist Development Award, Emergency Medicine Foundation, and National Institute on Aging of the National Institutes of Health under award number K23AG032355. This study was also supported by the National Center for Research Resources, grant UL1 RR024975‐01, and is now at the National Center for Advancing Translational Sciences, grant 2 UL1 TR000445‐06. Dr. Vasilevskis was supported in part by the National Institute on Aging of the National Institutes of Health under award number K23AG040157. Dr. Powers was supported by Health Resources and Services Administration Geriatric Education Centers, grant 1D31HP08823‐01‐00. Dr. Storrow was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K12HL1090 and the National Center for Advancing Translational Sciences under award number UL1TR000445. Dr. Ely was supported in part by the National Institute on Aging of the National Institutes of Health under award numbers R01AG027472 and R01AG035117, and a Veteran Affairs MERIT award. Drs. Vasilevskis, Schnelle, Dittus, Powers, and Ely were supported by the Veteran Affairs Geriatric Research, Education, and Clinical Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of Vanderbilt University, Emergency Medicine Foundation, National Institutes of Health, and Veterans Affairs. The funding agencies did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

J.H.H., E.W.E., J.F.S., A.B.S., and R.D.S. conceived the trial. J.H.H., E.W.E., A.B.S., J.F.S., R.D.S., A.S., and A.W. participated in the study design. J.H.H. and A.W. recruited patients and collected the data. J.H.H., A.J.G., and A.S. analyzed the data. All authors participated in the interpretation of results. J.H.H. drafted the manuscript, and all authors contributed to the critical review and revision of the manuscript.

The authors report no conflicts of interest.

Arousal is defined as the patient's overall level of responsiveness to the environment. Its assessment is standard of care in most intensive care units (ICUs) to monitor depth of sedation and underlying brain dysfunction. There has been recent interest in expanding the role of arousal assessment beyond the ICU. Specifically, the Veterans Affairs Delirium Working Group proposed that simple arousal assessment be a vital sign to quantify underlying brain dysfunction.[1] The rationale is that impaired arousal is closely linked with delirium,[2] and is an integral component of multiple delirium assessments.[3, 4, 5] Chester et al. observed that the presence of impaired arousal was 64% sensitive and 93% specific for delirium diagnosed by a psychiatrist.[2] Delirium is an under‐recognized public health problem that affects up to 25% of older hospitalized patients,[6, 7] is associated with a multitude of adverse outcomes such as death and accelerated cognitive decline,[8] and costs the US healthcare system an excess of $152 billion dollars.[9]

Most delirium assessments require the patient to undergo additional cognitive testing. The assessment of arousal, however, requires the rater to merely observe the patient during routine clinical care and can be easily integrated into the clinical workflow.[10] Because of its simplicity and brevity, assessing arousal alone using validated scales such as the Richmond Agitation‐Sedation Scale (RASS) may be a more appealing alternative to traditional, more complex delirium screening in the acute care setting. Its clinical utility would be further strengthened if impaired arousal was also associated with mortality, and conferred risk even in the absence of delirium. As a result, we sought to determine if impaired arousal at initial presentation in older acutely ill patients predicted 6‐month mortality and whether this relationship was present in the absence of delirium.

METHODS

RESULTS

A total of 1903 patients were screened, and 1084 patients met enrollment criteria (Figure 1). Of these, 1051 (97.0%) were non‐ICU patients. Patient characteristics of this cohort can be seen in Table 2. Enrolled patients and potentially eligible patients who presented to the emergency department during the enrollment window were similar in age, gender, and severity of illness, but enrolled patients were slightly more likely to have a chief complaint of chest pain and syncope (unpublished data).

Figure 1

Of those enrolled, 249 (23.0%) had an abnormal RASS at initial presentation, and their distribution can be seen in Figure 2. Within 6 months, patients with an abnormal RASS were more likely to die compared with patients with a RASS of 0 (23.7% vs 9.7%, P<0.001). The Kaplan‐Meier survival curves for all enrolled patients with impaired and normal RASS can be seen in Figure 3; the survival curve declined more slowly in patients with a normal RASS compared with those with an abnormal RASS.

Figure 2

Figure 3

Using Cox proportional hazards regression, the relationship between an abnormal RASS at initial presentation and 6‐month mortality persisted (HR: 1.73, 95% CI: 1.21‐2.49) after adjusting for age, sex, nonwhite race, comorbidity burden, severity of illness, dementia, functional dependence, nursing home residence, psychoactive medications given, and admission status. The interaction between an abnormal RASS and APS (severity of illness) had a P value of 0.52. The interaction between an abnormal RASS and benzodiazepine or opioid medication administration had a P value of 0.38. The interaction between an abnormal RASS and admission status had a P value of 0.57. This indicated that severity of illness, psychoactive medication administration, and admission status did not modify the relationship between an abnormal RASS and 6‐month mortality.

We analyzed a subset of 406 patients who received a psychiatrist's assessment to determine if an abnormal RASS was associated with 6‐month mortality regardless of delirium status using Cox proportional hazard regression weighted by the inverse of the propensity score. Patients with an abnormal RASS and no delirium were significantly associated with higher mortality compared to those with a normal RASS (HR: 2.20, 95% CI: 1.10‐4.41). Patients with an abnormal RASS with delirium also had an increased risk for 6‐month mortality (HR: 2.86, 95% CI: 1.29‐6.34).

All regression models were internally validated. There was no evidence of substantial overfitting or collinearity. The Schoenfeld residuals for each model were examined graphically and there was good model fit overall, and no significant outliers were observed.

DISCUSSION

Vital sign measurements are a fundamental component of patient care, and abnormalities can serve as an early warning signal of the patient's clinical deterioration. However, traditional vital signs do not include an assessment of the patient's brain function. Our chief finding is that impaired arousal at initial presentation, as determined by the nonphysician research staff, increased the risk of 6‐month mortality by 73% after adjusting for confounders in a diverse group of acutely ill older patients. This relationship existed regardless of severity of illness, administration of psychoactive medications, and admission status. Though impaired arousal is closely linked with delirium,[2, 24] which is another well‐known predictor of mortality,[11, 25, 26] the prognostic significance of impaired arousal appeared to extend beyond delirium. We observed that the relationship between 6‐month mortality and impaired arousal in the absence of delirium was remarkably similar to that observed with impaired arousal with delirium. Arousal can be assessed for by simply observing the patient during routine clinical care and can be performed by nonphysician and physician healthcare providers. Its assessment should be performed and communicated in conjunction with traditional vital sign measurements in the emergency department and inpatient settings.[1]

Most of the data linking impaired arousal to death have been collected in the ICU. Coma, which represents the most severe form of depressed arousal, has been shown to increase the likelihood of death regardless of underlying etiology.[27, 28, 29, 30, 31] This includes patients who have impaired arousal because they received sedative medications during mechanical ventilation.[32] Few studies have investigated the effect of impaired arousal in a non‐ICU patient population. Zuliani et al. observed that impaired arousal was associated with 30‐day mortality, but their study was conducted in 469 older stroke patients, limiting the study's external validity to a more general patient population.[33] Our data advance the current stage of knowledge; we observed a similar relationship between impaired arousal and 6‐month mortality in a much broader clinical population who were predominantly not critically ill regardless of delirium status. Additionally, most of our impaired arousal cohort had a RASS of 1, indicating that even subtle abnormalities portended adverse outcomes.

In addition to long‐term prognosis, the presence of impaired arousal has immediate clinical implications. Using arousal scales like the RASS can serve as a way for healthcare providers to succinctly communicate the patient's mental status in a standardized manner during transitions of care (eg, emergency physician to inpatient team). Regardless of which clinical setting they are in, older acutely ill patients with an impaired arousal may also require close monitoring, especially if the impairment is acute. Because of its close relationship with delirium, these patients likely have an underlying acute medical illness that precipitated their impaired arousal.

Understanding the true clinical significance of impaired arousal in the absence of delirium requires further study. Because of the fluctuating nature of delirium, it is possible that these patients may have initially been delirious and then became nondelirious during the psychiatrist's evaluation. Conversely, it is also possible that these patients may have eventually transitioned into delirium at later point in time; the presence of impaired arousal alone may be a precursor to delirium. Last, these patients may have had subsyndromal delirium, which is defined as having 1 or more delirium symptoms without ever meeting full DSM‐IV‐TR criteria for delirium.[34] Patients with subsyndromal delirium have poorer outcomes, such as prolonged hospitalizations, and higher mortality than patients without delirium symptoms.[34]

Additional studies are also needed to further clarify the impact of impaired arousal on nonmortality outcomes such as functional and cognitive decline. The prognostic significance of serial arousal measurements also requires further study. It is possible that patients whose impaired arousal rapidly resolves after an intervention may have better prognoses than those who have persistent impairment. The measurement of arousal may have additional clinical applications in disease prognosis models. The presence of altered mental status is incorporated in various disease‐specific risk scores such as the CURB‐65 or Pneumonia Severity Index for pneumonia,[35, 36] and the Pulmonary Embolism Severity Index for pulmonary embolism.[37] However, the definition of altered mental status is highly variable; it ranges from subjective impressions that can be unreliable to formal cognitive testing, which can be time consuming. Arousal scales such as the RASS may allow for more feasible, reliable, and standardized assessment of mental status. Future studies should investigate if incorporating the RASS would improve the discrimination of these disease‐severity indices.

This study has several notable limitations. We excluded patients with a RASS of 4 and 5, which represented comatose patients. This exclusion, however, likely biased our findings toward the null. We enrolled a convenience sample that may have introduced selection bias. However, our enrolled cohort was similar to all potentially eligible patients who presented to the emergency department during the study period. We also attempted to mitigate this selection bias by using multivariable regression and adjusting for factors that may have confounded the relationship between RASS and 6‐month mortality. This study was performed at a single, urban, academic hospital and enrolled patients who were aged 65 years and older. Our findings may not be generalizable to other settings and to those who are under 65 years of age. Because 406 patients received a psychiatric evaluation, this limited the number of covariates that could be incorporated into the multivariable model to evaluate if impaired arousal in the absence of delirium is associated with 6‐month mortality. To minimize residual confounding, we used the inverse weighted propensity score, but we acknowledge that this bias may still exist. Larger studies are needed to clarify the relationships between arousal, delirium, and mortality.

CONCLUSION

In conclusion, impaired arousal at initial presentation is an independent predictor for 6‐month mortality in a diverse group of acutely ill older patients, and this risk appears to be present even in the absence of delirium. Because of its ease of use and prognostic significance, it may be a useful vital sign for underlying brain dysfunction. Routine standardized assessment and communication of arousal during routine clinical care may be warranted.

Disclosures: Research reported in this publication was supported by the Vanderbilt Physician Scientist Development Award, Emergency Medicine Foundation, and National Institute on Aging of the National Institutes of Health under award number K23AG032355. This study was also supported by the National Center for Research Resources, grant UL1 RR024975‐01, and is now at the National Center for Advancing Translational Sciences, grant 2 UL1 TR000445‐06. Dr. Vasilevskis was supported in part by the National Institute on Aging of the National Institutes of Health under award number K23AG040157. Dr. Powers was supported by Health Resources and Services Administration Geriatric Education Centers, grant 1D31HP08823‐01‐00. Dr. Storrow was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K12HL1090 and the National Center for Advancing Translational Sciences under award number UL1TR000445. Dr. Ely was supported in part by the National Institute on Aging of the National Institutes of Health under award numbers R01AG027472 and R01AG035117, and a Veteran Affairs MERIT award. Drs. Vasilevskis, Schnelle, Dittus, Powers, and Ely were supported by the Veteran Affairs Geriatric Research, Education, and Clinical Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of Vanderbilt University, Emergency Medicine Foundation, National Institutes of Health, and Veterans Affairs. The funding agencies did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

J.H.H., E.W.E., J.F.S., A.B.S., and R.D.S. conceived the trial. J.H.H., E.W.E., A.B.S., J.F.S., R.D.S., A.S., and A.W. participated in the study design. J.H.H. and A.W. recruited patients and collected the data. J.H.H., A.J.G., and A.S. analyzed the data. All authors participated in the interpretation of results. J.H.H. drafted the manuscript, and all authors contributed to the critical review and revision of the manuscript.

The authors report no conflicts of interest.

Arousal is defined as the patient's overall level of responsiveness to the environment. Its assessment is standard of care in most intensive care units (ICUs) to monitor depth of sedation and underlying brain dysfunction. There has been recent interest in expanding the role of arousal assessment beyond the ICU. Specifically, the Veterans Affairs Delirium Working Group proposed that simple arousal assessment be a vital sign to quantify underlying brain dysfunction.[1] The rationale is that impaired arousal is closely linked with delirium,[2] and is an integral component of multiple delirium assessments.[3, 4, 5] Chester et al. observed that the presence of impaired arousal was 64% sensitive and 93% specific for delirium diagnosed by a psychiatrist.[2] Delirium is an under‐recognized public health problem that affects up to 25% of older hospitalized patients,[6, 7] is associated with a multitude of adverse outcomes such as death and accelerated cognitive decline,[8] and costs the US healthcare system an excess of $152 billion dollars.[9]

Most delirium assessments require the patient to undergo additional cognitive testing. The assessment of arousal, however, requires the rater to merely observe the patient during routine clinical care and can be easily integrated into the clinical workflow.[10] Because of its simplicity and brevity, assessing arousal alone using validated scales such as the Richmond Agitation‐Sedation Scale (RASS) may be a more appealing alternative to traditional, more complex delirium screening in the acute care setting. Its clinical utility would be further strengthened if impaired arousal was also associated with mortality, and conferred risk even in the absence of delirium. As a result, we sought to determine if impaired arousal at initial presentation in older acutely ill patients predicted 6‐month mortality and whether this relationship was present in the absence of delirium.

METHODS

RESULTS

A total of 1903 patients were screened, and 1084 patients met enrollment criteria (Figure 1). Of these, 1051 (97.0%) were non‐ICU patients. Patient characteristics of this cohort can be seen in Table 2. Enrolled patients and potentially eligible patients who presented to the emergency department during the enrollment window were similar in age, gender, and severity of illness, but enrolled patients were slightly more likely to have a chief complaint of chest pain and syncope (unpublished data).

Figure 1

Of those enrolled, 249 (23.0%) had an abnormal RASS at initial presentation, and their distribution can be seen in Figure 2. Within 6 months, patients with an abnormal RASS were more likely to die compared with patients with a RASS of 0 (23.7% vs 9.7%, P<0.001). The Kaplan‐Meier survival curves for all enrolled patients with impaired and normal RASS can be seen in Figure 3; the survival curve declined more slowly in patients with a normal RASS compared with those with an abnormal RASS.

Figure 2

Figure 3

Using Cox proportional hazards regression, the relationship between an abnormal RASS at initial presentation and 6‐month mortality persisted (HR: 1.73, 95% CI: 1.21‐2.49) after adjusting for age, sex, nonwhite race, comorbidity burden, severity of illness, dementia, functional dependence, nursing home residence, psychoactive medications given, and admission status. The interaction between an abnormal RASS and APS (severity of illness) had a P value of 0.52. The interaction between an abnormal RASS and benzodiazepine or opioid medication administration had a P value of 0.38. The interaction between an abnormal RASS and admission status had a P value of 0.57. This indicated that severity of illness, psychoactive medication administration, and admission status did not modify the relationship between an abnormal RASS and 6‐month mortality.

We analyzed a subset of 406 patients who received a psychiatrist's assessment to determine if an abnormal RASS was associated with 6‐month mortality regardless of delirium status using Cox proportional hazard regression weighted by the inverse of the propensity score. Patients with an abnormal RASS and no delirium were significantly associated with higher mortality compared to those with a normal RASS (HR: 2.20, 95% CI: 1.10‐4.41). Patients with an abnormal RASS with delirium also had an increased risk for 6‐month mortality (HR: 2.86, 95% CI: 1.29‐6.34).

All regression models were internally validated. There was no evidence of substantial overfitting or collinearity. The Schoenfeld residuals for each model were examined graphically and there was good model fit overall, and no significant outliers were observed.

DISCUSSION

Vital sign measurements are a fundamental component of patient care, and abnormalities can serve as an early warning signal of the patient's clinical deterioration. However, traditional vital signs do not include an assessment of the patient's brain function. Our chief finding is that impaired arousal at initial presentation, as determined by the nonphysician research staff, increased the risk of 6‐month mortality by 73% after adjusting for confounders in a diverse group of acutely ill older patients. This relationship existed regardless of severity of illness, administration of psychoactive medications, and admission status. Though impaired arousal is closely linked with delirium,[2, 24] which is another well‐known predictor of mortality,[11, 25, 26] the prognostic significance of impaired arousal appeared to extend beyond delirium. We observed that the relationship between 6‐month mortality and impaired arousal in the absence of delirium was remarkably similar to that observed with impaired arousal with delirium. Arousal can be assessed for by simply observing the patient during routine clinical care and can be performed by nonphysician and physician healthcare providers. Its assessment should be performed and communicated in conjunction with traditional vital sign measurements in the emergency department and inpatient settings.[1]

Most of the data linking impaired arousal to death have been collected in the ICU. Coma, which represents the most severe form of depressed arousal, has been shown to increase the likelihood of death regardless of underlying etiology.[27, 28, 29, 30, 31] This includes patients who have impaired arousal because they received sedative medications during mechanical ventilation.[32] Few studies have investigated the effect of impaired arousal in a non‐ICU patient population. Zuliani et al. observed that impaired arousal was associated with 30‐day mortality, but their study was conducted in 469 older stroke patients, limiting the study's external validity to a more general patient population.[33] Our data advance the current stage of knowledge; we observed a similar relationship between impaired arousal and 6‐month mortality in a much broader clinical population who were predominantly not critically ill regardless of delirium status. Additionally, most of our impaired arousal cohort had a RASS of 1, indicating that even subtle abnormalities portended adverse outcomes.

In addition to long‐term prognosis, the presence of impaired arousal has immediate clinical implications. Using arousal scales like the RASS can serve as a way for healthcare providers to succinctly communicate the patient's mental status in a standardized manner during transitions of care (eg, emergency physician to inpatient team). Regardless of which clinical setting they are in, older acutely ill patients with an impaired arousal may also require close monitoring, especially if the impairment is acute. Because of its close relationship with delirium, these patients likely have an underlying acute medical illness that precipitated their impaired arousal.

Understanding the true clinical significance of impaired arousal in the absence of delirium requires further study. Because of the fluctuating nature of delirium, it is possible that these patients may have initially been delirious and then became nondelirious during the psychiatrist's evaluation. Conversely, it is also possible that these patients may have eventually transitioned into delirium at later point in time; the presence of impaired arousal alone may be a precursor to delirium. Last, these patients may have had subsyndromal delirium, which is defined as having 1 or more delirium symptoms without ever meeting full DSM‐IV‐TR criteria for delirium.[34] Patients with subsyndromal delirium have poorer outcomes, such as prolonged hospitalizations, and higher mortality than patients without delirium symptoms.[34]

Additional studies are also needed to further clarify the impact of impaired arousal on nonmortality outcomes such as functional and cognitive decline. The prognostic significance of serial arousal measurements also requires further study. It is possible that patients whose impaired arousal rapidly resolves after an intervention may have better prognoses than those who have persistent impairment. The measurement of arousal may have additional clinical applications in disease prognosis models. The presence of altered mental status is incorporated in various disease‐specific risk scores such as the CURB‐65 or Pneumonia Severity Index for pneumonia,[35, 36] and the Pulmonary Embolism Severity Index for pulmonary embolism.[37] However, the definition of altered mental status is highly variable; it ranges from subjective impressions that can be unreliable to formal cognitive testing, which can be time consuming. Arousal scales such as the RASS may allow for more feasible, reliable, and standardized assessment of mental status. Future studies should investigate if incorporating the RASS would improve the discrimination of these disease‐severity indices.

This study has several notable limitations. We excluded patients with a RASS of 4 and 5, which represented comatose patients. This exclusion, however, likely biased our findings toward the null. We enrolled a convenience sample that may have introduced selection bias. However, our enrolled cohort was similar to all potentially eligible patients who presented to the emergency department during the study period. We also attempted to mitigate this selection bias by using multivariable regression and adjusting for factors that may have confounded the relationship between RASS and 6‐month mortality. This study was performed at a single, urban, academic hospital and enrolled patients who were aged 65 years and older. Our findings may not be generalizable to other settings and to those who are under 65 years of age. Because 406 patients received a psychiatric evaluation, this limited the number of covariates that could be incorporated into the multivariable model to evaluate if impaired arousal in the absence of delirium is associated with 6‐month mortality. To minimize residual confounding, we used the inverse weighted propensity score, but we acknowledge that this bias may still exist. Larger studies are needed to clarify the relationships between arousal, delirium, and mortality.

CONCLUSION

In conclusion, impaired arousal at initial presentation is an independent predictor for 6‐month mortality in a diverse group of acutely ill older patients, and this risk appears to be present even in the absence of delirium. Because of its ease of use and prognostic significance, it may be a useful vital sign for underlying brain dysfunction. Routine standardized assessment and communication of arousal during routine clinical care may be warranted.

Disclosures: Research reported in this publication was supported by the Vanderbilt Physician Scientist Development Award, Emergency Medicine Foundation, and National Institute on Aging of the National Institutes of Health under award number K23AG032355. This study was also supported by the National Center for Research Resources, grant UL1 RR024975‐01, and is now at the National Center for Advancing Translational Sciences, grant 2 UL1 TR000445‐06. Dr. Vasilevskis was supported in part by the National Institute on Aging of the National Institutes of Health under award number K23AG040157. Dr. Powers was supported by Health Resources and Services Administration Geriatric Education Centers, grant 1D31HP08823‐01‐00. Dr. Storrow was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K12HL1090 and the National Center for Advancing Translational Sciences under award number UL1TR000445. Dr. Ely was supported in part by the National Institute on Aging of the National Institutes of Health under award numbers R01AG027472 and R01AG035117, and a Veteran Affairs MERIT award. Drs. Vasilevskis, Schnelle, Dittus, Powers, and Ely were supported by the Veteran Affairs Geriatric Research, Education, and Clinical Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of Vanderbilt University, Emergency Medicine Foundation, National Institutes of Health, and Veterans Affairs. The funding agencies did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

J.H.H., E.W.E., J.F.S., A.B.S., and R.D.S. conceived the trial. J.H.H., E.W.E., A.B.S., J.F.S., R.D.S., A.S., and A.W. participated in the study design. J.H.H. and A.W. recruited patients and collected the data. J.H.H., A.J.G., and A.S. analyzed the data. All authors participated in the interpretation of results. J.H.H. drafted the manuscript, and all authors contributed to the critical review and revision of the manuscript.

The authors report no conflicts of interest.

Electronic cigarettes are increasingly prevalent battery‐operated devices that heat a solution to generate an inhalable nicotine‐containing aerosol.[1, 2] Despite a diverse array of devices on the market, the US Food and Drug Administration (FDA) has only recently proposed expanding its regulatory ability to include electronic cigarettes.[3] States, municipalities, and institutions have enacted variable regulations on electronic nicotine delivery systems.[4, 5] Advocates of electronic cigarettes propose that they are a less‐toxic alternative to tobacco cigarettes, with potential for use as a nicotine replacement therapy (NRT).[6, 7, 8] Opponents argue that electronic cigarettes may undermine tobacco cessation goals and potentially expose nonusers to secondhand nicotine vapor.[9, 10]

Hospital providers frequently care for nicotine‐dependent patients.[11] We investigated inpatient healthcare providers' knowledge, perceptions, and experience with electronic cigarettes, with the goals of informing educational efforts and guiding policy decisions around hospital‐based use of electronic nicotine delivery systems.

METHODS

The study was conducted at a 183‐bed urban safety‐net medical center affiliated with a residency training program using a cross‐sectional survey to query a diverse array of inpatient providers (Table 1). Respondents who had not cared for an inpatient in the past 5 years were excluded. Surveys were designed based on prior literature, personal experience, and expert suggestions.[12] Surveys were disseminated in March 2014 via e‐mail, with embedded informed consent and a link that connected anonymously to the online survey (Qualtrics, Provo, UT). We did not collect unique identifiers and offered no incentive for participation. Data were downloaded to a secure database and analyzed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA) and GraphPad Prism version 6.04 (GraphPad Software, Inc., La Jolla, CA). The study was approved by the institutional review board.

RESULTS

DISCUSSION

Our study is the first to provide hospital‐based providers' experience and perspectives surrounding electronic cigarette use. The vast majority of participants reported familiarity with electronic cigarettes, consistent with prior findings.[13] Though electronic cigarettes have yet to achieve a use in the hospital setting, 19% of our respondents reported receiving requests from hospitalized patients to use these devices. With increasing patient demand for electronic cigarettes, hospitals will need to update their tobacco policies to include these novel devices as well as target educational efforts toward front‐line providers, such as nurses, who receive the majority of requests.

Participants perceived traditional cigarettes to be significantly more harmful than electronic cigarettes, while established forms of NRT were felt to be less harmful than electronic cigarettes (data not shown). Concern about the health effects of electronic cigarettes is further reflected in providers' hesitancy to view these devices as an NRT option in the hospital, reluctance to consider sharing a room with an electronic cigarette user, and near majority opinion that electronic cigarettes should be banned from healthcare settings altogether. Current regulation by the US Department of Transportation bans electronic cigarette use on airplanes, whereas a host of states currently ban electronic cigarette use in similarly enclosed spaces such as correctional facilities and commuter trains.[14] More knowledge is needed on the health effects of electronic cigarettes on the primary user, secondhand exposure range, and their potential to aid in short‐ and long‐term nicotine cessation before providers and hospitals can make an informed risk‐benefit analysis for appropriate inpatient use. As current or past tobacco users were more accepting of the use of electronic cigarettes in hospital settings, these providers' opinions should be sought for a unique understanding of the interplay between electronic cigarettes and the healthcare environment.

Concern over the unknown safety effects can also be seen in the overwhelming provider support for FDA regulation. Healthcare advocacy groups, such as the American Heart Association, the American Lung Association, and the Legacy Foundation already support federal regulation.[15, 16, 17] FDA regulation may lead to the ability to standardize device content, regulate purchasing and marketing requirements, and ensure that claims to health effects are supported by scientific evidence, though agency involvement may also slow the process of integration into hospital use. Perhaps reflective of the immediacy of the problem, nurses who receive the majority of requests for electronic cigarettes from patients are least likely to want FDA regulation. Until more is known, patients and staff may benefit from pairing vaporizing patients in shared rooms or providing users with designated inhaling spaces.

Nicotine addiction is a strong driving force and, due to a strict no‐smoking policy at our institution, we have witnessed patients making unsafe decisions to leave the hospital (in some cases against medical advice) in an effort to continue smoking. Patients may be starting to look toward electronic cigarettes as an NRT option that more closely satisfies nicotine cravings as well as the ritualistic and tactile components of cigarette use. Electronic cigarettes could have the potential to act as a harm reduction method for nicotine‐dependent inpatients by decreasing the nicotine‐withdrawal related impetus for unsafe hospital discharges. Institutions should take this into account when formulating new policy.

Our study has several limitations. First, it was a single‐center study that may not be representative of provider perspectives at other institutions. Second, the survey was a cross‐sectional sample, missing providers who did not receive the e‐mail during the enrollment period. Third, responses may not accurately reflect perspectives of smaller responding groups such as social workers. Fourth, the survey did not include all types of physicians who deal with smoking cessation, though internal and family medicine physicians provide the majority of care for hospitalized patients at our institution. Fifth, we recorded self‐reported familiarity with electronic cigarettes and did not formally test providers' knowledge of the subject.

Our study provides new perspectives and data on electronic cigarettes to inform future research as well as hospital and healthcare policy. Hospitals should educate patients and front‐line providers around the paucity of health information on these novel devices, while formulating policy that acknowledges patient demand for electronic cigarettes and their potential for cessation therapy and harm reduction. Further research should focus on the effects of nicotine vapor inhalation on patients, the consequences of secondhand nicotine vapor, and the potential for electronic nicotine delivery systems to act as a novel NRT for hospital use.

Electronic cigarettes are increasingly prevalent battery‐operated devices that heat a solution to generate an inhalable nicotine‐containing aerosol.[1, 2] Despite a diverse array of devices on the market, the US Food and Drug Administration (FDA) has only recently proposed expanding its regulatory ability to include electronic cigarettes.[3] States, municipalities, and institutions have enacted variable regulations on electronic nicotine delivery systems.[4, 5] Advocates of electronic cigarettes propose that they are a less‐toxic alternative to tobacco cigarettes, with potential for use as a nicotine replacement therapy (NRT).[6, 7, 8] Opponents argue that electronic cigarettes may undermine tobacco cessation goals and potentially expose nonusers to secondhand nicotine vapor.[9, 10]

Hospital providers frequently care for nicotine‐dependent patients.[11] We investigated inpatient healthcare providers' knowledge, perceptions, and experience with electronic cigarettes, with the goals of informing educational efforts and guiding policy decisions around hospital‐based use of electronic nicotine delivery systems.

METHODS

The study was conducted at a 183‐bed urban safety‐net medical center affiliated with a residency training program using a cross‐sectional survey to query a diverse array of inpatient providers (Table 1). Respondents who had not cared for an inpatient in the past 5 years were excluded. Surveys were designed based on prior literature, personal experience, and expert suggestions.[12] Surveys were disseminated in March 2014 via e‐mail, with embedded informed consent and a link that connected anonymously to the online survey (Qualtrics, Provo, UT). We did not collect unique identifiers and offered no incentive for participation. Data were downloaded to a secure database and analyzed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA) and GraphPad Prism version 6.04 (GraphPad Software, Inc., La Jolla, CA). The study was approved by the institutional review board.

RESULTS

DISCUSSION

Our study is the first to provide hospital‐based providers' experience and perspectives surrounding electronic cigarette use. The vast majority of participants reported familiarity with electronic cigarettes, consistent with prior findings.[13] Though electronic cigarettes have yet to achieve a use in the hospital setting, 19% of our respondents reported receiving requests from hospitalized patients to use these devices. With increasing patient demand for electronic cigarettes, hospitals will need to update their tobacco policies to include these novel devices as well as target educational efforts toward front‐line providers, such as nurses, who receive the majority of requests.

Participants perceived traditional cigarettes to be significantly more harmful than electronic cigarettes, while established forms of NRT were felt to be less harmful than electronic cigarettes (data not shown). Concern about the health effects of electronic cigarettes is further reflected in providers' hesitancy to view these devices as an NRT option in the hospital, reluctance to consider sharing a room with an electronic cigarette user, and near majority opinion that electronic cigarettes should be banned from healthcare settings altogether. Current regulation by the US Department of Transportation bans electronic cigarette use on airplanes, whereas a host of states currently ban electronic cigarette use in similarly enclosed spaces such as correctional facilities and commuter trains.[14] More knowledge is needed on the health effects of electronic cigarettes on the primary user, secondhand exposure range, and their potential to aid in short‐ and long‐term nicotine cessation before providers and hospitals can make an informed risk‐benefit analysis for appropriate inpatient use. As current or past tobacco users were more accepting of the use of electronic cigarettes in hospital settings, these providers' opinions should be sought for a unique understanding of the interplay between electronic cigarettes and the healthcare environment.

Concern over the unknown safety effects can also be seen in the overwhelming provider support for FDA regulation. Healthcare advocacy groups, such as the American Heart Association, the American Lung Association, and the Legacy Foundation already support federal regulation.[15, 16, 17] FDA regulation may lead to the ability to standardize device content, regulate purchasing and marketing requirements, and ensure that claims to health effects are supported by scientific evidence, though agency involvement may also slow the process of integration into hospital use. Perhaps reflective of the immediacy of the problem, nurses who receive the majority of requests for electronic cigarettes from patients are least likely to want FDA regulation. Until more is known, patients and staff may benefit from pairing vaporizing patients in shared rooms or providing users with designated inhaling spaces.

Nicotine addiction is a strong driving force and, due to a strict no‐smoking policy at our institution, we have witnessed patients making unsafe decisions to leave the hospital (in some cases against medical advice) in an effort to continue smoking. Patients may be starting to look toward electronic cigarettes as an NRT option that more closely satisfies nicotine cravings as well as the ritualistic and tactile components of cigarette use. Electronic cigarettes could have the potential to act as a harm reduction method for nicotine‐dependent inpatients by decreasing the nicotine‐withdrawal related impetus for unsafe hospital discharges. Institutions should take this into account when formulating new policy.

Our study has several limitations. First, it was a single‐center study that may not be representative of provider perspectives at other institutions. Second, the survey was a cross‐sectional sample, missing providers who did not receive the e‐mail during the enrollment period. Third, responses may not accurately reflect perspectives of smaller responding groups such as social workers. Fourth, the survey did not include all types of physicians who deal with smoking cessation, though internal and family medicine physicians provide the majority of care for hospitalized patients at our institution. Fifth, we recorded self‐reported familiarity with electronic cigarettes and did not formally test providers' knowledge of the subject.

Our study provides new perspectives and data on electronic cigarettes to inform future research as well as hospital and healthcare policy. Hospitals should educate patients and front‐line providers around the paucity of health information on these novel devices, while formulating policy that acknowledges patient demand for electronic cigarettes and their potential for cessation therapy and harm reduction. Further research should focus on the effects of nicotine vapor inhalation on patients, the consequences of secondhand nicotine vapor, and the potential for electronic nicotine delivery systems to act as a novel NRT for hospital use.

Electronic cigarettes are increasingly prevalent battery‐operated devices that heat a solution to generate an inhalable nicotine‐containing aerosol.[1, 2] Despite a diverse array of devices on the market, the US Food and Drug Administration (FDA) has only recently proposed expanding its regulatory ability to include electronic cigarettes.[3] States, municipalities, and institutions have enacted variable regulations on electronic nicotine delivery systems.[4, 5] Advocates of electronic cigarettes propose that they are a less‐toxic alternative to tobacco cigarettes, with potential for use as a nicotine replacement therapy (NRT).[6, 7, 8] Opponents argue that electronic cigarettes may undermine tobacco cessation goals and potentially expose nonusers to secondhand nicotine vapor.[9, 10]

Hospital providers frequently care for nicotine‐dependent patients.[11] We investigated inpatient healthcare providers' knowledge, perceptions, and experience with electronic cigarettes, with the goals of informing educational efforts and guiding policy decisions around hospital‐based use of electronic nicotine delivery systems.

METHODS

The study was conducted at a 183‐bed urban safety‐net medical center affiliated with a residency training program using a cross‐sectional survey to query a diverse array of inpatient providers (Table 1). Respondents who had not cared for an inpatient in the past 5 years were excluded. Surveys were designed based on prior literature, personal experience, and expert suggestions.[12] Surveys were disseminated in March 2014 via e‐mail, with embedded informed consent and a link that connected anonymously to the online survey (Qualtrics, Provo, UT). We did not collect unique identifiers and offered no incentive for participation. Data were downloaded to a secure database and analyzed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA) and GraphPad Prism version 6.04 (GraphPad Software, Inc., La Jolla, CA). The study was approved by the institutional review board.

RESULTS

DISCUSSION

Our study is the first to provide hospital‐based providers' experience and perspectives surrounding electronic cigarette use. The vast majority of participants reported familiarity with electronic cigarettes, consistent with prior findings.[13] Though electronic cigarettes have yet to achieve a use in the hospital setting, 19% of our respondents reported receiving requests from hospitalized patients to use these devices. With increasing patient demand for electronic cigarettes, hospitals will need to update their tobacco policies to include these novel devices as well as target educational efforts toward front‐line providers, such as nurses, who receive the majority of requests.

Participants perceived traditional cigarettes to be significantly more harmful than electronic cigarettes, while established forms of NRT were felt to be less harmful than electronic cigarettes (data not shown). Concern about the health effects of electronic cigarettes is further reflected in providers' hesitancy to view these devices as an NRT option in the hospital, reluctance to consider sharing a room with an electronic cigarette user, and near majority opinion that electronic cigarettes should be banned from healthcare settings altogether. Current regulation by the US Department of Transportation bans electronic cigarette use on airplanes, whereas a host of states currently ban electronic cigarette use in similarly enclosed spaces such as correctional facilities and commuter trains.[14] More knowledge is needed on the health effects of electronic cigarettes on the primary user, secondhand exposure range, and their potential to aid in short‐ and long‐term nicotine cessation before providers and hospitals can make an informed risk‐benefit analysis for appropriate inpatient use. As current or past tobacco users were more accepting of the use of electronic cigarettes in hospital settings, these providers' opinions should be sought for a unique understanding of the interplay between electronic cigarettes and the healthcare environment.

Concern over the unknown safety effects can also be seen in the overwhelming provider support for FDA regulation. Healthcare advocacy groups, such as the American Heart Association, the American Lung Association, and the Legacy Foundation already support federal regulation.[15, 16, 17] FDA regulation may lead to the ability to standardize device content, regulate purchasing and marketing requirements, and ensure that claims to health effects are supported by scientific evidence, though agency involvement may also slow the process of integration into hospital use. Perhaps reflective of the immediacy of the problem, nurses who receive the majority of requests for electronic cigarettes from patients are least likely to want FDA regulation. Until more is known, patients and staff may benefit from pairing vaporizing patients in shared rooms or providing users with designated inhaling spaces.

Nicotine addiction is a strong driving force and, due to a strict no‐smoking policy at our institution, we have witnessed patients making unsafe decisions to leave the hospital (in some cases against medical advice) in an effort to continue smoking. Patients may be starting to look toward electronic cigarettes as an NRT option that more closely satisfies nicotine cravings as well as the ritualistic and tactile components of cigarette use. Electronic cigarettes could have the potential to act as a harm reduction method for nicotine‐dependent inpatients by decreasing the nicotine‐withdrawal related impetus for unsafe hospital discharges. Institutions should take this into account when formulating new policy.

Our study has several limitations. First, it was a single‐center study that may not be representative of provider perspectives at other institutions. Second, the survey was a cross‐sectional sample, missing providers who did not receive the e‐mail during the enrollment period. Third, responses may not accurately reflect perspectives of smaller responding groups such as social workers. Fourth, the survey did not include all types of physicians who deal with smoking cessation, though internal and family medicine physicians provide the majority of care for hospitalized patients at our institution. Fifth, we recorded self‐reported familiarity with electronic cigarettes and did not formally test providers' knowledge of the subject.

Our study provides new perspectives and data on electronic cigarettes to inform future research as well as hospital and healthcare policy. Hospitals should educate patients and front‐line providers around the paucity of health information on these novel devices, while formulating policy that acknowledges patient demand for electronic cigarettes and their potential for cessation therapy and harm reduction. Further research should focus on the effects of nicotine vapor inhalation on patients, the consequences of secondhand nicotine vapor, and the potential for electronic nicotine delivery systems to act as a novel NRT for hospital use.