SPECIAL ARTICLE

A Clinical Pathway to Standardize Care of Children

With Delirium in Pediatric Inpatient Settings
Gabrielle H. Silver, MD,a,* Julia A. Kearney, MD,b,* Sonali Bora, MD,c Claire De Souza, MD,d Lisa Giles, MD,e Sophia Hrycko, MD,f Willough Jenkins, MD, FRCPSC,g
Nasuh Malas, MD,h Lisa Namerow, MD,i Roberto Ortiz-Aguayo, MD,j Ruth Russell, MD,k Maryland Pao, MD,l Sigita Plioplys, MD,m Khyati Brahmbhatt, MD,n
PATHWAYS FOR CLINICAL CARE WORKGROUP

ABSTRACT Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has
lacked a consistent approach for detection and management. A clinical pathway (CP) was developed
to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of
a
NewYork-Presbyterian/Weill inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings
Cornell Medical Center, Weill
with validated tools is feasible and effective in reducing delirium and improving outcomes; however,
Cornell Medicine, Cornell
University, New York, New York; multidisciplinary coordination is required for implementation. The workgroup, composed of
b
Memorial Sloan Kettering international experts in child and adolescent consultation psychiatry, reviewed the literature and
Cancer Center, New York, New
York; cChildren’s Healthcare of developed a flowchart for feasible screening and management of pediatric delirium. When evidence
d
Atlanta, Atlanta, Georgia; was lacking, expert consensus was reached; stakeholder feedback was included to create the final
Hospital for Sick Children,
University of Toronto, Toronto, pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1)
Ontario, Canada; eDepartments “Prevention and Identification of Pediatric Delirium” emphasizes the need for systematic preventive
of Pediatrics and Psychiatry,
School of Medicine, The
measures and screening, and (2) “Diagnosis and Management of Pediatric Delirium” recommends
University of Utah, Salt Lake City, an urgent and ongoing search for the underlying causes to reverse the syndrome while providing
Utah; fDepartment of Psychiatry,
symptomatic management focused on comfort and safety. Detailed accompanying documents
University of Ottawa, Ottawa,
Ontario, Canada; gDepartment of explain the supporting literature and the rationale for recommendations and provide resources such
Psychiatry, School of Medicine, as screening tools and implementation guides. Additionally, the role of the child and adolescent
University of California, San
Diego, La Jolla, California; consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is
h
Division of Child and Adolescent discussed.
Psychiatry, Departments of
Psychiatry and Pediatrics, C.S.
Mott Children’s Hospital, Medical
School, University of Michigan,
Ann Arbor, Michigan; iInstitute of
Living and Hartford Hospital,
School of Medicine, University of
Connecticut, Hartford, www.hospitalpediatrics.org
Connecticut; jChildren’s Hospital DOI:https://doi.org/10.1542/hpeds.2019-0115
of Philadelphia, Philadelphia, Copyright © 2019 by the American Academy of Pediatrics
Pennsylvania; kMcGill University
Health Centre and Montreal Address correspondence to Gabrielle H. Silver, MD, NewYork-Presbyterian/Weill Cornell Medical Center, 470 West End Ave, Suite 1AA, New
Children’s Hospital, Montréal, York, NY 10024. E-mail: dr.gabriellesilver@gmail.com
Canada; lNational Institute of
Mental Health, National
HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).
Institutes of Health, Bethesda, FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Maryland; mDepartment of
Psychiatry and Behavioral FUNDING: Supported by the Abramson Fund of the American Academy of Child and Adolescent Psychiatry and the Intramural Research
Sciences, Ann and Robert H. Program (ZIA MH002922-10) of the National Institute of Mental Health of the National Institutes of Health.
Lurie Children’s Hospital of POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Chicago, Northwestern
University, Chicago, Illinois; and Drs Silver and Kearney organized and led pathway development, drafted sections and assembled the initial manuscript, and coordinated
n
Department of Psychiatry, all edits and revisions; Drs Bora, De Souza, Giles, Hryko, Jenkins, Malas, Namerow, Ortiz-Aguayo, and Russell participated in pathway
Langley Porter Psychiatric development, drafted sections of the initial manuscript, and reviewed and revised edits; Drs Pao and Plioplys conceptualized and
Institute, Weill Institute for designed the overall pathway project and critically reviewed the manuscript; Dr Brahmbhatt conceptualized and designed the overall
Neurosciences, Benioff Children’s pathway project, participated in pathway development, drafted sections of the initial manuscript, and reviewed and revised edits; and
Hospital, University of California,
all authors approved the final manuscript as submitted.
San Francisco, San Francisco,
California *Contributed equally as co-first authors

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Delirium is a well-described syndrome of
acute brain dysfunction1 associated with
underlying physical illness. It involves an
acute change in baseline awareness, and
onset of altered behavior or cognition, with
a fluctuating course.2 Current
pathophysiologic models explain delirium
symptoms as the result of disturbances
within the neuroendocrine and
inflammatory pathways triggered by an
underlying physiologic disturbance, such as
a systemic or neurologic medical condition,
or iatrogenic causes, such as use of
sedatives, substance intoxication, or
withdrawal.2–4 Current understanding of
pediatric delirium is extrapolated from
robust adult literature and supported by
expanding pediatric literature.5–10
Delirium can occur in any setting but is
most prevalent in the inpatient setting,
predominately in the critical care setting,
because of worsening clinical disease and
exposure to pharmacologic agents that can
exacerbate delirium, such as
benzodiazepines or anticholinergics.10–15
Prevalence rates are ∼20% to 44% in PICU
settings, according to US studies.16–20 The
inpatient environment can confer risks for
the development of delirium due to noise
and overstimulation, causing frequent
disruptions in rest and sleep.21 Validated
screening tools have recently become
available and are feasible for implementation
in detecting pediatric delirium. Tools include
the Pediatric Confusion Assessment Method
for the ICU (pCAM-ICU), the Preschool
Confusion Assessment Method for the ICU
(psCAM-ICU), and the Cornell Assessment of
Pediatric Delirium (CAPD).17,18, 20, 22–25
Pediatric delirium can have significant
impacts on morbidity, mortality, and
financial costs. Delirium increases length of
stay in pediatric critical care settings and
length of mechanical ventilation by 2 to
3 days26 and is an independent predictor of
mortality (adjusted odds ratio 4.39; P ,
.001).16 Hospital costs of youth with delirium
are .4 times the cost of similar youth
without delirium ($18 832 vs $4803; P ,
.0001), with incremental increases in cost
seen with each day a child remains
delirious. Controlling for age, sex, severity of
illness, and pediatric critical care length of
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stay, delirium is associated with an 85%
increase in hospitalization costs.26 Beyond
short-term effects on hospital outcomes,
delirium studies in adults show significant
cognitive, emotional, and behavioral impacts
beyond the hospital stay.25,27–29 In a
systematic review and meta-analysis of
5280 adult patients with delirium, there was
an association between the presence of
delirium and a decline in cognitive
outcomes.30 Long-term outcome research in
pediatric delirium is needed. A significant
minority (nearly one-third) of pediatric
patients with delirium describe
posttraumatic stress symptoms up to
3 months after hospitalization.31 A recent
study of cognitive function in PICU survivors
did not find an association between
delirium and impaired cognition, although
the survivors did have lower IQ as a group
compared with the normal population, and
the study was limited by design, using
normative scales only and lacking controls
or baseline evaluations for subjects.32
Despite the negative outcomes associated
with pediatric delirium, there is a lack of
standardization of prevention, evaluation,
and management.33 For problems like
delirium, clinical pathways (CPs) can be an
effective means of standardizing care by
translating current literature and expert
consensus into clinical practice.34,35 Although
they have been increasingly used in
pediatric diseases ranging from community-
acquired pneumonia to cystic fibrosis, there
has been limited use of CPs to address
complex conditions at the interface of
pediatric medicine and psychiatry, such as
in the case of delirium.36–38 CP use has
resulted in decreased length of stay,
reduced health care use and costs, reduced
use of unnecessary diagnostic practices and
interventions, reduced recidivism, and
improved quality of care.36,39 They anchor
the interdisciplinary care teams, as well as
families, to aligned expectations and
principles for care. They also allow for
clinician judgment and do not provide a
rigid, overly prescriptive approach.40 Factors
that predict successful CP implementation
include high disease prevalence, significant
disease impact on patient outcomes, high
practice variability, and broad,
multidisciplinary care involvement.40
The goal of standardizing pediatric delirium
care in this way is to improve outcomes,
prevent delirium, decrease length of stay
and invasive interventions (such as
prolonged mechanical ventilation or
extended sedation use), reduce cost,
improve quality of life, and enhance patient,
family, and provider satisfaction with care.39
The current study describes the process
and content development of a CP for
inpatient pediatric delirium care developed
through evidence-based review, broad
stakeholder feedback, and expert
consensus by a representative group of
child and adolescent consultation-liaison
psychiatrists in the United States and
Canada.
METHODS
The Pathways for Clinical Care (PaCC)
Workgroup has described the overall
process of developing 3 pediatric
consultation-liaison CPs41,42 using an
established model for CP creation.43
Identifying the Need for a CP
Factors that may make a condition
appropriate for successful pathway
development include the following. (1)
Either high-volume, common conditions or if
low-volume condition is high risk: Delirium
meets both conditions when it is prevalent
in inpatient settings, namely critical care,
and when not as prevalent (general
pediatric hospitalized population), it may
indicate new-onset central nervous system
comorbidities or be a harbinger of critical
systemic complications (eg, sepsis). (2)
Strong evidence base: There is strong
evidence for screening and a fair evidence
base for management from adult research
with growing pediatric evidence. (3) High
variation in practice: This was affirmed by
the varied experiences the authors had
when implementing best practices for
pediatric delirium at their own institutions
and stakeholder feedback obtained from
multiinstitutional inpatient pediatric care
providers. A lack of standardized screening,
institutionally based patterns of prescribing
drugs (deemed either useful or taboo) for
pediatric patients with delirium, and even
cross-disciplinary differences in diagnostic
language and recognition of delirium
SILVER et al
further this as a compelling target for
standardization through pathway
development. (4) Traverses different
settings: Delirium, although most common
in critical care, often occurs in other
inpatient medical and surgical settings and
involves many disciplines caring for
1 patient. These factors all point to the
urgent need for a pathway for pediatric
delirium screening and management.
Assembling a Team of Experts
The subgroup coleaders has an established
clinical and research expertise in pediatric
delirium as authors of the CAPD and other
seminal peer-reviewed publications.* The
13 subgroup members practice in a variety
of consultation-liaison settings in 7 US
states and 2 Canadian provinces, work
mainly in medium or large academic acute
medical centers, and have some variation in
resources and practice patterns. All
members volunteered to participate in the
pathway development initiative.
Starting in 2016, the subgroup met regularly
over 2 years, primarily through
teleconferences (∼28 calls and 4 in-person
meetings). Work was conducted by
individual members and shared with the
group for discussion and consensus
generation. To establish a shared baseline
level of knowledge and understanding, the
coleaders facilitated telephone-based
training and dialogue on screening and
management of delirium based on a review
of the literature and the leaders’ previous
work.55–57 Ilana Waynik, MD, a pediatric
hospitalist and clinical educator with
expertise in CP generation, provided
ongoing guidance about pathway
development over the 2 years.
Compiling and Reviewing
Background Research
The literature on pediatric delirium was
compiled, reviewed, and used to inform and
structure steps in the pathway. Subgroup
members shared current practices,
guidelines, and protocols (as available)
from their individual institutions, which
further influenced the common,
foundational elements of the pathway. When
*Refs 10, 12, 13, 16, 17, 22, 26, and 44–54.
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evidence was limited, consensus
discussions by subgroup experts
contributed to elaboration of some pathway
recommendations.
Developing the CP
On the basis of literature review and
clinical consensus discussions, the
subgroup drafted an outline of the key
pathway steps and drafts of the pathway
documents. Feedback and revisions were
done iteratively at 3 key points with
different audiences: (1) The initial drafts
were shared with the members of the
larger PaCC Workgroup and Dr Waynik, the
CP expert, at a face-to-face workshop
retreat made possible by an American
Academy of Child and Adolescent
Psychiatry (AACAP) Abramson Fund grant
obtained for the initiative. (2) The pathway
was then presented and discussed at the
AACAP October 2017 Annual Meeting and
Member Services Forum in Washington,
District of Columbia. Audience responses
on language, format, and implementation
strategies informed further refinement
of the suite of documents.41 (3) Finally,
the pathway was shared with
multidisciplinary stakeholders
representing a range of fields, including
pediatric critical care, advanced practice
nursing, bedside nursing, physiotherapy,
and pharmacy, and a parent from
members’ hospitals by using a
questionnaire devised by the subgroup
to elicit feedback. Responses were
summarized, considered by members, and
incorporated into the pathway documents
if consistent with the pathway goals and
evidence base.
RESULTS
The products of the described consensus
process are a suite of complementary
documents including 2 flowcharts
(Figs 1 and 2) and two text documents:
“Introduction to the Delirium Pathway” and
“Guide to the Delirium Pathway”
(Supplemental Information). Many aspects
of the intervention are flexible to local
preferences and practice, which may vary
according to resources. The flowcharts
intentionally include detailed information on
nonpharmacologic prevention and
intervention so that these documents could
serve as stand-alone clinical or educational
resources with end-user ease in mind.
DISCUSSION
Delirium is a disabling and prevalent
condition among hospitalized children.
Increasing recognition of pediatric delirium
by clinicians reveals concerns about
appropriate assessment and treatment. To
promote a more standardized approach to
care, we present a consensus-driven,
evidence-based CP on the detection and
management of pediatric delirium in
inpatient settings.
When possible, empirical evidence was
included to inform each pathway
recommendation. When no evidence was
found, the rationale supporting the
inclusion of each consensus
recommendation is described in the guide.
Consensus discussions took into account
values and priorities such as patient safety,
illness prevention, early identification,
patient-centered care, family systems
interventions, and multidisciplinary and/or
team-based practice.
Given that inpatient care, and thus delirium
evaluation and management, is
multidisciplinary by nature, documents
were created with input from
multidisciplinary stakeholders and written
to acknowledge the different audiences,
such as nursing, physician specialists (eg,
critical care and neurology), rehabilitation,
pharmacy, and administration. This
inclusive approach recognizes that
successful implementation of a new CP
requires education, participation, and buy-in
from all relevant disciplines. The
complementary pathway documents were
designed to address the varying needs of
the stakeholder groups. For example, the
pathway flowchart is a simplified, easy-to-
read, bedside reference tool (Figs 1 and 2),
whereas the accompanying narrative,
“Guide to the Pathway” in the Supplemental
Information, presents a more
comprehensive, in-depth description of each
step and its underlying rationale.
The pathway is designed to provide an
overall guide, not a prescriptive
methodology, for pediatric institutions
911
FIGURE 1 Pediatric Delirium Pathway I: Prevention and Identification. OT, occupational therapy; PT, physical therapy.

912 SILVER et al

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FIGURE 2 Pediatric Delirium Pathway II: Diagnosis and Management. OT, occupational therapy; PT, physical therapy.

focused on improving delirium evaluation standardization of recommendations and have heterogeneous needs, resources, and
and management. It was challenging to potential for setting-specific customization populations, the pathway is amenable to
ensure the “best” balance between of recommendations. Because institutions modification and refinement by local care

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teams and institutional workgroups. The
pathway indicates when and where it is
recommended to engage psychiatry; when
and how this occurs may become setting
specific because of the availability of
consultation-liaison psychiatry in different
hospitals. Another example of adaptation
potential is the promotion of the use of
whichever validated delirium screening tool
best meets an institution’s needs.
Additionally, pathway elements may be
revised for discipline-specific policies (eg,
nursing policies may be written to include
parameters for bedside screening, and
environmental interventions nurses
can implement for prevention and
management).
Implementation of the pathway can be led
by leadership in child and adolescent
consultation-liaison psychiatrists, pediatric
intensivists or hospitalists, or pediatric
nurses and requires champions in all
disciplines. As child and adolescent
consultation-liaison psychiatrists, we
believe this clinical area offers a unique
leadership opportunity for members of our
field. Through the process of successful
implementation of the Pediatric Delirium
Pathway, the psychiatrist can offer valuable
expertise toward an education and training
program, the development of delirium order
sets, and the identification of quality metrics
for ongoing review and improvement.43 The
insights a psychiatrist brings to the
differential diagnosis of delirium, the
developmental presentation of symptoms in
children, and the appropriate use of
antipsychotics in medically ill children will
help ensure safe and meaningful
implementation of the pathway. An added
benefit of leading these initiatives in our
own institutions has been the fuller
integration of consult-liaison psychiatry
teams into the PICU and other medical units.
One limitation in the process of pathway
development was the lack of published
evidence for many recommendations.
Although the quality of evidence was
considered, a formal Preferred Reporting
Items for Systematic Reviews and Meta-
analysis systematic review was not completed
for this study. Another limitation is the lack of
a systematic, blinded approach to reach
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expert consensus for clinical management,
such as the Delphi method. Additionally,
because a review of quality metrics has not
yet been done, there is no assurance that
adherence to these recommendations
will bring improved outcomes for delirium
care.
Future steps for this pathway initiative
include the design of multiinstitutional
studies to examine implementation
processes and the impact on patient,
provider, and system outcomes. Examination
of rates of adherence to the pathway may
help us better understand barriers to and
facilitators of pathway implementation.
Studying outcomes such as changes in
delirium prevalence, sources of delirium,
delirium interventions used, length of stay,
morbidity, and mortality may help elucidate
the clinical benefits and drawbacks of
pathway implementation. Revisions to this
pathway based on emerging research are to
be expected and will require ongoing
collaboration between pediatrics, nursing,
and child and adolescent psychiatry. The
concept of CPs is still relatively new in
psychiatry, especially when it targets
psychiatric or behavioral problems in
hospital-based pediatric medical and/or
surgical contexts. This delirium pathway
represents a promising example of how
psychiatric CPs may promote improvement
of quality of care in inpatient pediatric
hospital settings.
CONCLUSIONS
We propose a CP representing a distillation
of current literature and expert consensus
in screening, evaluation, and management
of pediatric delirium. This pathway is
designed to be adapted to fit individual
institutions and foment a multidisciplinary
approach while encouraging consultation-
liaison child and adolescent psychiatry
leadership and integration. Ongoing
research regarding pathway
implementation, outcomes, and continued
process improvement is warranted.
Acknowledgments
In addition to the authors of this article, the
PaCC Workgroup includes Patricia Ibeziako,
MD, Lisa Horowitz, PhD, Andrea Chapman,
MD, Shanti Gooden, MD, Finza Latif, MD,
Petra Steinbuchel, MD, Khalid Afzal, MD, Kyle
Johnson, MD, Elizabeth Kowal, MD, and
Brian Kurtz, MD. The authors thank
graphic designer Kathleen Saminy for her
invaluable collaboration in this pathway
development.
REFERENCES
1. Schieveld JN, Janssen NJ, van Cauteren
YJ. On the Cornell Assessment for
Pediatric Delirium and both the
diagnostic and statistical manual, 5th
edition, and International Classification
of Diseases, 11th revision: quo vadis?*.
Crit Care Med. 2014;42(3):751–752
2. American Psychiatric Association. Desk
Reference to the Diagnostic Criteria
from DSM-5. Washington, DC: American
Psychiatric Association. 2013
3. Maldonado JR. Acute brain failure:
pathophysiology, diagnosis,
management, and sequelae of delirium.
Crit Care Clin. 2017;33(3):461–519
4. Cerejeira J, Batista P, Nogueira V, Vaz-
Serra A, Mukaetova-Ladinska EB. The
stress response to surgery and
postoperative delirium: evidence of
hypothalamic-pituitary-adrenal axis
hyperresponsiveness and decreased
suppression of the GH/IGF-1 Axis.
J Geriatr Psychiatry Neurol. 2013;26(3):
185–194
5. Cano Londoño EM, Mejía Gil IC, Uribe
Hernández K, et al. Delirium during the
first evaluation of children aged five to
14 years admitted to a paediatric critical
care unit. Intensive Crit Care Nurs. 2018;
45:37–43
6. Slooff VD, van den Dungen DK, van
Beusekom BS, et al. Monitoring
haloperidol plasma concentration and
associated adverse events in critically ill
children with delirium: first results of a
clinical protocol aimed to monitor
efficacy and safety. Pediatr Crit Care
Med. 2018;19(2):e112–e119
7. Patel AK, Bell MJ, Traube C. Delirium in
pediatric critical care. Pediatr Clin North
Am. 2017;64(5):1117–1132
8. Barnes SS, Grados MA, Kudchadkar SR.
Child psychiatry engagement in the
management of delirium in critically ill
SILVER et al
 children. Crit Care Res Pract. 2018;2018:
9135618
9. Alvarez RV, Palmer C, Czaja AS, et al.
Delirium is a common and early finding
in patients in the pediatric cardiac
intensive care unit. J Pediatr. 2018;195:
206–212
10. Mody K, Kaur S, Mauer EA, et al.
Benzodiazepines and development of
delirium in critically ill children:
estimating the causal effect. Crit Care
Med. 2018;46(9):1486–1491
11. Pandharipande PP, Ely EW, Arora RC,
et al. The intensive care delirium
research agenda: a multinational,
interprofessional perspective. Intensive
Care Med. 2017;43(9):1329–1339
12. Meyburg J, Dill ML, Traube C, Silver G,
von Haken R. Patterns of postoperative
delirium in children. Pediatr Crit Care
Med. 2017;18(2):128–133
13. Silver G, Traube C, Gerber LM, et al.
Pediatric delirium and associated risk
factors: a single-center prospective
observational study. Pediatr Crit Care
Med. 2015;16(4):303–309
14. Traube C, Ariagno S, Thau F, et al.
Delirium in hospitalized children with
cancer: incidence and associated risk
factors. J Pediatr. 2017;191:212–217
15. Nellis ME, Goel R, Feinstein S, Shahbaz S,
Kaur S, Traube C. Association between
transfusion of RBCs and subsequent
development of delirium in critically ill
children. Pediatr Crit Care Med. 2018;
19(10):925–929
16. Traube C, Silver G, Gerber LM, et al.
Delirium and mortality in critically ill
children: epidemiology and outcomes of
pediatric delirium. Crit Care Med. 2017;
45(5):891–898
17. Traube C, Silver G, Kearney J, et al.
Cornell Assessment of Pediatric
Delirium: a valid, rapid, observational
tool for screening delirium in the PICU*.
Crit Care Med. 2014;42(3):656–663
18. Smith HA, Boyd J, Fuchs DC, et al.
Diagnosing delirium in critically ill
children: validity and reliability of the
Pediatric Confusion Assessment Method
HOSPITAL PEDIATRICS Volume 9, Issue 11, November 2019
Downloaded from www.aappublications.org/news by guest on June 6, 2021
for the Intensive Care Unit. Crit Care
Med. 2011;39(1):150–157
19. Simone S, Edwards S, Lardieri A, et al.
Implementation of an ICU bundle: an
interprofessional quality improvement
project to enhance delirium
management and monitor delirium
prevalence in a single PICU. Pediatr Crit
Care Med. 2017;18(6):531–540
20. Smith HA, Gangopadhyay M, Goben CM,
et al. The preschool confusion
assessment method for the ICU: valid
and reliable delirium monitoring for
critically ill infants and children. Crit
Care Med. 2016;44(3):592–600
21. Kawai Y, Weatherhead JR, Traube C, et al.
Quality improvement initiative to reduce
pediatric intensive care unit noise
pollution with the use of a pediatric
delirium bundle. J Intensive Care Med.
2019;34(5):383–390
22. Silver G, Kearney J, Traube C, Hertzig M.
Delirium screening anchored in child
development: the Cornell Assessment for
Pediatric Delirium. Palliat Support Care.
2015;13(4):1005–1011
23. Brandenburg T, Chamberlain A, Chima R.
Effects of implementing delirium
screening in a pediatric intensive care
unit. Crit Care Med. 2016;44(12):379
24. Daoud A, Duff JP, Joffe AR; Alberta Sepsis
Network. Diagnostic accuracy of
delirium diagnosis in pediatric intensive
care: a systematic review. Crit Care.
2014;18(5):489
25. Brummel NE, Vasilevskis EE, Han JH,
Boehm L, Pun BT, Ely EW. Implementing
delirium screening in the ICU: secrets to
success. Crit Care Med. 2013;41(9):
2196–2208
26. Traube C, Mauer EA, Gerber LM, et al. Cost
associated with pediatric delirium in the
ICU. Crit Care Med. 2016;44(12):e1175–e1179
27. Colville G, Kerry S, Pierce C. Children’s
factual and delusional memories of
intensive care. Am J Respir Crit Care
Med. 2008;177(9):976–982
28. Girard TD, Jackson JC, Pandharipande
PP, et al. Delirium as a predictor of long-
term cognitive impairment in survivors
of critical illness. Crit Care Med. 2010;
38(7):1513–1520
29. Pandharipande PP, Girard TD, Jackson
JC, et al; BRAIN-ICU Study Investigators.
Long-term cognitive impairment after
critical illness. N Engl J Med. 2013;
369(14):1306–1316
30. Salluh JI, Wang H, Schneider EB, et al.
Outcome of delirium in critically ill
patients: systematic review and meta-
analysis. BMJ. 2015;350:h2538
31. Schieveld JN, Janssen NJ. Delirium in the
pediatric patient: on the growing
awareness of its clinical
interdisciplinary importance. JAMA
Pediatr. 2014;168(7):595–596
32. Meyburg J, Ries M, Zielonka M, et al.
Cognitive and behavioral consequences
of pediatric delirium: a pilot study.
Pediatr Crit Care Med. 2018;19(10):
e531–e537
33. Trogrlic Z, Ista E, Ponssen HH, et al.
Attitudes, knowledge and practices
concerning delirium: a survey among
intensive care unit professionals. Nurs
Crit Care. 2017;22(3):133–140
34. Grimshaw JM, Eccles MP, Lavis JN, Hill
SJ, Squires JE. Knowledge translation of
research findings. Implement Sci. 2012;
7(1):50
35. Francke AL, Smit MC, de Veer AJ,
Mistiaen P. Factors influencing the
implementation of clinical guidelines for
health care professionals: a systematic
meta-review. BMC Med Inform Decis
Mak. 2008;8(1):38
36. Kaiser SV, Rodean J, Bekmezian A, et al.
Effectiveness of pediatric asthma
pathways for hospitalized children: a
multicenter, national analysis. J Pediatr.
2018;197:165–171.e2
37. Dona D, Baraldi M, Brigadoi G, et al. The
impact of clinical pathways on antibiotic
prescribing for acute otitis media and
pharyngitis in the emergency
department. Pediatr Infect Dis J. 2018;
37(9):901–907
38. Singh SB, Shelton AU, Greenberg B,
Starner TD. Implementation of cystic
fibrosis clinical pathways improved
physician adherence to care
915
 guidelines. Pediatr Pulmonol. 2017;52(2):
175–181
39. Rotter T, Kinsman L, James E, et al.
Clinical pathways: effects on
professional practice, patient outcomes,
length of stay and hospital costs.
Cochrane Database Syst Rev. 2010;(3):
CD006632
40. Lawal AK, Rotter T, Kinsman L, et al. What
is a clinical pathway? Refinement of an
operational definition to identify clinical
pathway studies for a Cochrane
systematic review. BMC Med. 2016;14:35
41. Brahmbhatt KPS, Pao M, Ibeziako P,
Kearney J, Silver G, Horowitz L. Pathways
in clinical care: standardizing mental
health care in pediatric inpatient
settings. In: Proceedings from the
American Academy of Child and
Adolescent Psychiatry; October 7, 2017;
Washington, DC
42. Brahmbhatt K, Kurtz B, Afzal K, et al.
Suicide risk screening in pediatric
hospitals: clinical pathways to address a
global health crisis. Psychosomatics.
2019;60(1):1–9
43. Waynik I, Sekaran A, Bode R, Engel R. A
path to successful pathway
development. In: Proceedings from the
Pediatric Hospital Medicine Annual
Conference; July 28–31, 2016; Chicago, IL
44. Gangopadhyay M, Smith H, Pao M, et al.
Development of the Vanderbilt
assessment for delirium in infants and
children to standardize pediatric
916
Downloaded from www.aappublications.org/news by guest on June 6, 2021
delirium assessment by psychiatrists.
Psychosomatics. 2017;58(4):355–363
45. Groves A, Traube C, Silver G. Detection
and management of delirium in the
neonatal unit: a case series. Pediatrics.
2016;137(3):e20153369
46. Joyce C, Witcher R, Herrup E, et al.
Evaluation of the safety of quetiapine in
treating delirium in critically ill children:
a retrospective review. J Child Adolesc
Psychopharmacol. 2015;25(9):666–670
47. Patel AK, Biagas KV, Clarke EC, et al.
Delirium in children after cardiac
bypass surgery. Pediatr Crit Care Med.
2017;18(2):165–171
48. Silver GH, Kearney JA, Kutko MC, Bartell
AS. Infant delirium in pediatric critical
care settings. Am J Psychiatry. 2010;
167(10):1172–1177
49. Silver G, Traube C, Kearney J, et al.
Detecting pediatric delirium:
development of a rapid observational
assessment tool. Intensive Care Med.
2012;38(6):1025–1031
50. Silver G, Kearney J, Traube C, Atkinson
TM, Wyka KE, Walkup J. Pediatric
delirium: evaluating the gold standard.
Palliat Support Care. 2015;13(3):513–516
51. Traube C, Augenstein J, Greenwald B,
LaQuaglia M, Silver G. Neuroblastoma
and pediatric delirium: a case series.
Pediatr Blood Cancer. 2014;61(6):
1121–1123
52. Traube C, Silver G, Reeder RW, et al.
Delirium in critically ill children: an
international point prevalence study. Crit
Care Med. 2017;45(4):584–590
53. Traube C, Silver G. Iatrogenic
withdrawal syndrome or undiagnosed
delirium? Crit Care Med. 2017;45(6):
e622–e623
54. Traube C, Silver G. Identify delirium,
then investigate for underlying
etiology. Pediatr Crit Care Med. 2018;
19(1):86–87
55. Kearney J, Martini DR, Fuchs C,
Gangopadhyay M, Silver G, Chapman G.
Pediatric delirium: current practice and
new directions. In: Proceedings from the
American Academy of Child and
Adolescent Psychiatry (AACAP) 61st
Annual Meeting; August 4–11, 2014; San
Diego, CA
56. Silver G, Kearney J. Detecting and
diagnosing pediatric delirium with the
application of standardized clinical
tools: the how and the why. In:
Proceedings from the Academy of Child
and Adolescent Psychiatry 62nd Annual
Meeting; October 30, 2015; San Antonio,
TX
57. Silver G, Fuchs C, Kearney J,
Gangopadhyay M, Nagle A. The
inconsolable child clinical assessment
and standardized tools for
differentiating anxiety, pain, sleep
problems and delirium in infants and
small children. In: Proceedings from the
Journal of the American Academy of
Child and Adolescent Psychiatry; October
1, 2016; New York, NY
SILVER et al
A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric
Inpatient Settings
Gabrielle H. Silver, Julia A. Kearney, Sonali Bora, Claire De Souza, Lisa Giles,
Sophia Hrycko, Willough Jenkins, Nasuh Malas, Lisa Namerow, Roberto
Ortiz-Aguayo, Ruth Russell, Maryland Pao, Sigita Plioplys, Khyati Brahmbhatt and
PATHWAYS FOR CLINICAL CARE WORKGROUP
Hospital Pediatrics 2019;9;909
DOI: 10.1542/hpeds.2019-0115 originally published online October 29, 2019;

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A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric
Inpatient Settings
Gabrielle H. Silver, Julia A. Kearney, Sonali Bora, Claire De Souza, Lisa Giles,
Sophia Hrycko, Willough Jenkins, Nasuh Malas, Lisa Namerow, Roberto
Ortiz-Aguayo, Ruth Russell, Maryland Pao, Sigita Plioplys, Khyati Brahmbhatt and
PATHWAYS FOR CLINICAL CARE WORKGROUP
Hospital Pediatrics 2019;9;909
DOI: 10.1542/hpeds.2019-0115 originally published online October 29, 2019;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://hosppeds.aappublications.org/content/9/11/909

Data Supplement at:

http://hosppeds.aappublications.org/content/suppl/2019/10/23/hpeds.2019-0115.DCSupplemental

Hospital Pediatrics is an official journal of the American Academy of Pediatrics. Hospital

Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345
Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics.
All rights reserved. Print ISSN: 1073-0397.

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