To measure the prevalence and incidence of delirium in older adults as they transition from the e... more To measure the prevalence and incidence of delirium in older adults as they transition from the emergency department (ED) to the inpatient ward, and to determine the association between delirium during early hospitalisation and subsequent clinical deterioration. Prospective cohort study. Urban tertiary care hospital in Bronx, New York. Adults aged 65 years or older admitted to the inpatient ward from the ED (n=260). Beginning in the ED, delirium was assessed daily for 3 days, using the Confusion Assessment Method for the Intensive Care Unit. (1) Clinical deterioration, defined as unanticipated intensive care unit (ICU) admission or in-hospital death (primary outcome); (2) decline in discharge status, defined as discharge to higher level of care, hospice or in-hospital death. 38 of 260 participants (15%) were delirious at least once during the first 3 days of hospitalisation. Of the 29 (11%) patients with delirium in the ED (ie, hospital day 1), delirium persisted into hospital day 2...
Abstract This paper describes a one-hop self-organized clustering (SOC) algorithm developed speci... more Abstract This paper describes a one-hop self-organized clustering (SOC) algorithm developed specifically for ultra-wideband (UWB) networks. Our research is motivated by the strict regulation of the transmit power of UWB devices, as imposed by US Federal Communications Commission (FCC). To comply with FCC power regulations and to maximize network capacity, we propose a heuristic clustering algorithm to form clusters that have the minimum total power emission subject to constraints on radio range and multiple ...
To measure the prevalence and incidence of delirium in older adults as they transition from the e... more To measure the prevalence and incidence of delirium in older adults as they transition from the emergency department (ED) to the inpatient ward, and to determine the association between delirium during early hospitalisation and subsequent clinical deterioration. Prospective cohort study. Urban tertiary care hospital in Bronx, New York. Adults aged 65 years or older admitted to the inpatient ward from the ED (n=260). Beginning in the ED, delirium was assessed daily for 3 days, using the Confusion Assessment Method for the Intensive Care Unit. (1) Clinical deterioration, defined as unanticipated intensive care unit (ICU) admission or in-hospital death (primary outcome); (2) decline in discharge status, defined as discharge to higher level of care, hospice or in-hospital death. 38 of 260 participants (15%) were delirious at least once during the first 3 days of hospitalisation. Of the 29 (11%) patients with delirium in the ED (ie, hospital day 1), delirium persisted into hospital day 2 in 72% (n=21), and persisted for all 3 days in 52% (n=15). In multivariate analyses, as little as 1 episode of delirium during the first 3 days was associated with increased odds of unanticipated ICU admission or in-hospital death (adjusted OR 8.07 (95% CI 1.91 to 34.14); p=0.005). Delirium that persisted for all 3 days was associated with a decline in discharge status, even after adjusting for factors such as severity of illness and baseline cognitive impairment (adjusted OR 4.70 (95% CI 1.41 to 15.63); p=0.012). Delirium during the first few days of hospitalisation was associated with poor outcomes in older adults admitted from the ED to the inpatient ward. These findings suggest the need for serial delirium monitoring that begins in the ED to identify a high-risk population that may benefit from closer follow-up and intervention.
Rationale: Although expert communication between ICU clinicians with patients or surrogates impro... more Rationale: Although expert communication between ICU clinicians with patients or surrogates improves patient- and family-centered outcomes, fellows in Critical Care Medicine do not feel adequately trained to conduct family meetings. Objective: We aimed to develop, implement, and evaluate a communication skills program that could be easily integrated into a U.S. critical care fellowship. Methods: We developed four simulation cases that provided communication challenges that critical care fellows commonly face. For each case, we developed a list of directly observable tasks that could be used by faculty to evaluate fellows during each simulation. We developed a didactic curriculum of lectures/case discussions on topics related to Palliative Care, End-of-Life Care, Communication Skills and Bioethics; this month-long curriculum began and ended with the fellows leading family meetings in up to two simulated cases with direct observation by faculty who were not blinded to the timing of the simulation. Our primary measures of effectiveness were the fellows' self-reported change in comfort with leading family meetings after the program was completed and the quality of the communication as measured by the faculty evaluators during the family meeting simulations at the end of the month. Measurement and Main Results: Over three years, 31 critical care fellows participated in the program, 28 of whom participated in 101 family meeting simulations with direct feedback by faculty facilitators. Our trainees showed high rates of information disclosure during the simulated family meetings. During the simulations done at the end of the month compared to those done at the beginning: our fellows showed significantly improved rates in: 1) verbalizing an agenda for the meeting (64% versus 41%, chi-squared 5.27, p=0.02); 2) summarizing what will be done for the patient (64% versus 39%, chi-squared 6.21, p=0.01) and 3) providing a follow-up plan (60% versus 37%, chi-squared 5.2, p=0.02) Over 95% of our participants (n=27) reported feeling "slightly" or "much" more comfortable with discussing foregoing life sustaining treatment and leading family discussions after the month-long curriculum. Conclusion: A communication skills program can be feasibly integrated into a critical care training program and is associated with improvements in fellows' skills and comfort with leading family meetings.
Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It ... more Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. These poor outcomes are not only independently associated with the development of delirium but are also associated with increasing delirium duration. Therefore, interventions should strive both to prevent the occurrence of ICU delirium and to limit its persistence. Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.
Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and n... more Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and nicotine withdrawal may increase delirium in these populations. This systematic review aims to determine whether active cigarette smoking increases the risk for delirium in hospitalized and intensive care unit (ICU) patients. A systematic search of English-, Spanish-, and French-language articles published from 1966 to April 2013 was performed. Studies were included if they measured cigarette smoking as a risk factor and delirium as an outcome in adult hospitalized or ICU patients. Methodologic quality of studies was assessed using both the validated Newcastle Ottawa Scale and an additional evidence-based quality rating scale. A total of 14 cohort studies of surgical and ICU populations were included in the review. No studies in non-ICU inpatients were identified. The incidence of delirium ranged from 9 to 52%, and the prevalence of active smokers ranged from 9 to 44%. The quality of asse...
To measure the prevalence and incidence of delirium in older adults as they transition from the e... more To measure the prevalence and incidence of delirium in older adults as they transition from the emergency department (ED) to the inpatient ward, and to determine the association between delirium during early hospitalisation and subsequent clinical deterioration. Prospective cohort study. Urban tertiary care hospital in Bronx, New York. Adults aged 65 years or older admitted to the inpatient ward from the ED (n=260). Beginning in the ED, delirium was assessed daily for 3 days, using the Confusion Assessment Method for the Intensive Care Unit. (1) Clinical deterioration, defined as unanticipated intensive care unit (ICU) admission or in-hospital death (primary outcome); (2) decline in discharge status, defined as discharge to higher level of care, hospice or in-hospital death. 38 of 260 participants (15%) were delirious at least once during the first 3 days of hospitalisation. Of the 29 (11%) patients with delirium in the ED (ie, hospital day 1), delirium persisted into hospital day 2...
Abstract This paper describes a one-hop self-organized clustering (SOC) algorithm developed speci... more Abstract This paper describes a one-hop self-organized clustering (SOC) algorithm developed specifically for ultra-wideband (UWB) networks. Our research is motivated by the strict regulation of the transmit power of UWB devices, as imposed by US Federal Communications Commission (FCC). To comply with FCC power regulations and to maximize network capacity, we propose a heuristic clustering algorithm to form clusters that have the minimum total power emission subject to constraints on radio range and multiple ...
To measure the prevalence and incidence of delirium in older adults as they transition from the e... more To measure the prevalence and incidence of delirium in older adults as they transition from the emergency department (ED) to the inpatient ward, and to determine the association between delirium during early hospitalisation and subsequent clinical deterioration. Prospective cohort study. Urban tertiary care hospital in Bronx, New York. Adults aged 65 years or older admitted to the inpatient ward from the ED (n=260). Beginning in the ED, delirium was assessed daily for 3 days, using the Confusion Assessment Method for the Intensive Care Unit. (1) Clinical deterioration, defined as unanticipated intensive care unit (ICU) admission or in-hospital death (primary outcome); (2) decline in discharge status, defined as discharge to higher level of care, hospice or in-hospital death. 38 of 260 participants (15%) were delirious at least once during the first 3 days of hospitalisation. Of the 29 (11%) patients with delirium in the ED (ie, hospital day 1), delirium persisted into hospital day 2 in 72% (n=21), and persisted for all 3 days in 52% (n=15). In multivariate analyses, as little as 1 episode of delirium during the first 3 days was associated with increased odds of unanticipated ICU admission or in-hospital death (adjusted OR 8.07 (95% CI 1.91 to 34.14); p=0.005). Delirium that persisted for all 3 days was associated with a decline in discharge status, even after adjusting for factors such as severity of illness and baseline cognitive impairment (adjusted OR 4.70 (95% CI 1.41 to 15.63); p=0.012). Delirium during the first few days of hospitalisation was associated with poor outcomes in older adults admitted from the ED to the inpatient ward. These findings suggest the need for serial delirium monitoring that begins in the ED to identify a high-risk population that may benefit from closer follow-up and intervention.
Rationale: Although expert communication between ICU clinicians with patients or surrogates impro... more Rationale: Although expert communication between ICU clinicians with patients or surrogates improves patient- and family-centered outcomes, fellows in Critical Care Medicine do not feel adequately trained to conduct family meetings. Objective: We aimed to develop, implement, and evaluate a communication skills program that could be easily integrated into a U.S. critical care fellowship. Methods: We developed four simulation cases that provided communication challenges that critical care fellows commonly face. For each case, we developed a list of directly observable tasks that could be used by faculty to evaluate fellows during each simulation. We developed a didactic curriculum of lectures/case discussions on topics related to Palliative Care, End-of-Life Care, Communication Skills and Bioethics; this month-long curriculum began and ended with the fellows leading family meetings in up to two simulated cases with direct observation by faculty who were not blinded to the timing of the simulation. Our primary measures of effectiveness were the fellows' self-reported change in comfort with leading family meetings after the program was completed and the quality of the communication as measured by the faculty evaluators during the family meeting simulations at the end of the month. Measurement and Main Results: Over three years, 31 critical care fellows participated in the program, 28 of whom participated in 101 family meeting simulations with direct feedback by faculty facilitators. Our trainees showed high rates of information disclosure during the simulated family meetings. During the simulations done at the end of the month compared to those done at the beginning: our fellows showed significantly improved rates in: 1) verbalizing an agenda for the meeting (64% versus 41%, chi-squared 5.27, p=0.02); 2) summarizing what will be done for the patient (64% versus 39%, chi-squared 6.21, p=0.01) and 3) providing a follow-up plan (60% versus 37%, chi-squared 5.2, p=0.02) Over 95% of our participants (n=27) reported feeling "slightly" or "much" more comfortable with discussing foregoing life sustaining treatment and leading family discussions after the month-long curriculum. Conclusion: A communication skills program can be feasibly integrated into a critical care training program and is associated with improvements in fellows' skills and comfort with leading family meetings.
Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It ... more Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. These poor outcomes are not only independently associated with the development of delirium but are also associated with increasing delirium duration. Therefore, interventions should strive both to prevent the occurrence of ICU delirium and to limit its persistence. Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.
Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and n... more Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and nicotine withdrawal may increase delirium in these populations. This systematic review aims to determine whether active cigarette smoking increases the risk for delirium in hospitalized and intensive care unit (ICU) patients. A systematic search of English-, Spanish-, and French-language articles published from 1966 to April 2013 was performed. Studies were included if they measured cigarette smoking as a risk factor and delirium as an outcome in adult hospitalized or ICU patients. Methodologic quality of studies was assessed using both the validated Newcastle Ottawa Scale and an additional evidence-based quality rating scale. A total of 14 cohort studies of surgical and ICU populations were included in the review. No studies in non-ICU inpatients were identified. The incidence of delirium ranged from 9 to 52%, and the prevalence of active smokers ranged from 9 to 44%. The quality of asse...
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Papers by Michelle Gong