Family-Administered Delirium Screening Improves Satisfaction Among ICU Caregivers A Prospective Cohort Study

Family-Administered Delirium Screening Improves Satisfaction Among ICU Caregivers A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Family-Administered Delirium Screening Improves Satisfaction Among ICU Caregivers A Prospective Cohort Study Charlotte C Ellberg, Megan Trieu, Atul Malhotra, Robert L Owens, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7616641/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Jan, 2026 Read the published version in Intensive Care Medicine → Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: Family caregivers experience distress when their loved one is in the ICU, particularly in the setting of delirium. Limited English proficiency (LEP) may worsen this experience and contribute to long-term psychological burden. Yet caregivers with LEP are rarely included in ICU research. Whether caregiver engagement using linguistically tailored delirium assessments improves satisfaction remains unknown. Methods: We conducted a prospective cohort study of patient-caregiver dyads in two academic ICUs. Caregivers were assigned to: 1) FAM-CAM group, in which caregivers completed daily FAM-CAM delirium assessments, or 2) control group with no FAM-CAM exposure. All caregivers completed the Family Satisfaction in the ICU-24 (FS-ICU-24) after 3 days. Outcomes included overall satisfaction and subdomains of decision-making and care (0–100 scale). Independent t-tests compared satisfaction by language, FAM-CAM exposure, and patient delirium status. Results: Among 120 dyads, 63 caregivers preferred English and 57 Spanish. English-speaking caregivers reported higher decision-making satisfaction than Spanish-speakers (90.8 vs 85.6, p < 0.05). FAM-CAM exposure improved overall satisfaction across language groups (91.9 vs 84.4, p < 0.01). Patient delirium was linked to lower caregiver satisfaction, but FAM-CAM engagement mitigated this effect, with higher scores among exposed caregivers(90.9 vs 80.3, p < 0.05). Conclusions: English-speaking caregivers reported higher satisfaction scores than Spanish-speaking caregivers. Engagement with FAM-CAM improved satisfaction across language groups and mitigated the negative impact of delirium, supporting its potential to enhance caregiver engagement and promote equity in the ICU. Communication Barriers Healthcare disparities Caregivers Critical Care Delirium Figures Figure 1 Figure 2 Figure 3 Figure 4 Take Home Message To our knowledge, this is the first U.S. ICU study to evaluate satisfaction with ICU care in English and Spanish-speaking families. Spanish-speaking caregivers, often excluded from clinical trials, reported lower satisfaction with care than English-speaking caregivers. Engagement with FAM-CAM improved satisfaction across both groups. As an easy-to-complete, scalable tool, FAM-CAM offers a novel approach to improving caregiver experience and reducing language-based disparities in ICU care. Introduction The intensive care unit (ICU) is a uniquely challenging environment for both patients and their caregivers. Caregivers in the ICU frequently witness distressing events that contribute to substantial psychological burden, including anxiety and depression [1–4]. Complications of critical illness, including delirium, immobility, and sedation, can worsen this distress [1,5]. Among these factors, delirium, a syndrome of acute brain dysfunction, plays a particularly important role [6,7]. For caregivers, delirium is especially distressing to witness, and contributes to confusion and uncertainty about their loved one’s condition [6,7]. It has also been linked to lower satisfaction with care, which is associated with greater caregiver psychological distress, poor patient outcomes, and the development of Post-Intensive Care Syndrome-Family (PICS-F), a long-term sequalae characterized by depression, anxiety, and post-traumatic stress symptoms among caregivers [8–11]. These adverse effects have prompted growing interest in strategies to mitigate caregiver distress, with caregiver engagement receiving considerable attention as a potential approach, largely due to its demonstrated benefits in delirium care [12]. However, the impact of such engagement on caregiver satisfaction and psychological outcomes have been mixed [13]. Despite a growing interest in caregiver engagement, caregivers with limited English proficiency (LEP) have been largely overlooked, as they are often excluded from U.S. ICU trials evaluating engagement tools and caregiver satisfaction [13,14]. While LEP is associated with low patient satisfaction and mistrust in the healthcare team across multiple care settings, its impact on the caregiver experience in the ICU remains underexplored [15,16]. Because caregiver satisfaction is closely tied to psychological well-being, evaluating the caregiver experience in diverse populations is essential, as caregivers with LEP may be at high risk for low satisfaction, psychological distress, and the development of PICS-F [17]. Our prior work demonstrated that standard delirium screening with the commonly used Confusion Assessment Method for the ICU (CAM-ICU) [7] was unreliable in Spanish-speaking patients with LEP, whereas caregiver-administered tools like the Family Confusion Assessment Method (FAM-CAM) and its Spanish-language adaptation, reduced language-based disparities and improved delirium detection [18]. However, whether these tools also enhance caregiver satisfaction through meaningful engagement remains unknown. In this study, we sought to: (1) evaluate differences in caregiver satisfaction across language groups, and (2) assess whether caregiver engagement via the English or Spanish-language FAM-CAM improved satisfaction with ICU care. We hypothesized that Spanish-speaking caregivers with LEP would report lower satisfaction than English-speaking caregivers, and that caregiver engagement using FAM-CAM would improve satisfaction across both language groups. We further hypothesized that caregiver satisfaction would be lower in the presence of patient delirium than in its absence, and that caregiver engagement would mitigate this effect. Methods Study Design, Participants, Enrollment This was a prospective non-randomized observational cohort study conducted in two mixed ICUs at a tertiary academic health center between August 2024 and January 2025. The parent study was designed to evaluate the accuracy of delirium screening among English and Spanish-speaking ICU patients enrolled on a 1:1 ratio based on patient language preference. The current analysis represents a secondary aim of that study, leveraging the same cohort to evaluate the impact of caregiver engagement via FAM-CAM on caregiver satisfaction. Sample size was determined by the parent study rather than formal power calculations for satisfaction outcomes. Although we specified a priori hypotheses, this analysis was not independently powered. Patient-caregiver dyads were enrolled within 72 hours of ICU admission. Patients were eligible if ≥18 years old and preferred English or Spanish. Exclusion criteria included prior moderate-to-severe neurocognitive impairment, inability to complete CAM-ICU due to significant visual/hearing deficits, or admission for active seizure, hepatic encephalopathy, or alcohol withdrawal. Caregivers were eligible if ≥18 years old, preferred English or Spanish, and were actively involved in the patient's care. They were excluded if not physically present during the study or were non-family members. Eligible patients were identified via the electronic health record (EHR) and approached by research staff. Caregivers were identified through the patient, EHR, or clinical team and approached separately. In the parent study, patients could participate even if their caregiver declined. However, this caregiver-focused arm only included dyads in which both patients and caregivers consented. All study procedures were approved by the UC San Diego IRB (IRB #810463), and verbal consent was obtained from patients (or their proxies) and caregivers. Study Procedures At enrollment, all participants completed a demographic questionnaire and self-reported their English proficiency. In the parent study, all patients underwent delirium assessments using CAM-ICU, the most widely used tool for delirium detection in the ICU [7]. As part of usual ICU care, delirium screening was conducted daily by bedside providers. In parallel, trained bilingual research staff conducted additional assessments in the patient’s preferred language using either the original English-language CAM-ICU or the cross-culturally adapted and validated Spanish-language version [19]. The parent study also evaluated the diagnostic accuracy of the caregiver-administered FAM-CAM and its cross-culturally adapted Spanish-language version [18,20]. As part of this broader study, a separate arm was designed to evaluate whether caregiver engagement using these tools impacted caregiver satisfaction. To answer this question, dyads were assigned to either an intervention or control group based on the day of the week in which they were enrolled. Dyads enrolled Monday through Wednesday were assigned to the intervention group, while dyads enrolled Thursday or Friday were assigned to the control group. The trial flow diagram is detailed in Figure 1 . All delirium assessments, including FAM-CAM and Spanish-FAM, were conducted for three consecutive days or until ICU discharge, whichever occurred first. On the final study day, all caregivers completed the Family Satisfaction in the ICU-24 (FS-ICU-24) questionnaire, a validated instrument available in both English and Spanish [21,22]. The FS-ICU-24 includes 24 Likert-scale items and is made up of two domains: (1) satisfaction with care (14-items), which assesses perceived symptom management, compassion, and attention to family needs; and (2) satisfaction with decision-making (10-items), which evaluates quality of physician communication, adequacy of information, and inclusion in care decisions [21,22]. Outcomes The primary outcome of the study was caregiver satisfaction with ICU care, measured using the FS-ICU-24 questionnaire. The FS-ICU-24 generates three scores: overall satisfaction, satisfaction with care, and satisfaction with decision-making. Statistical Analyses Statistical analyses were performed using IBM SPSS Statistics. Dyads were stratified by caregiver preferred language (English versus Spanish). FS-ICU-24 scores were converted from a Likert scale to a 0-100 scale, with higher scores indicating greater satisfaction. We used independent sample t-tests to compare caregiver satisfaction by language group (English versus Spanish), intervention group (FAM-CAM exposure versus no exposure), and patient delirium status (CAM-ICU positive versus negative). We also performed subgroup analyses to evaluate whether FAM-CAM exposure improved FS-ICU scores within each language group and within delirium versus non-delirium groups. Finally, we assessed for baseline demographic and clinical differences between English and Spanish-speaking caregivers and patients, as well as between the intervention and control groups using chi-square tests for categorical variables and t-tests for continuous variables. No significant differences were identified, so outcome comparisons were conducted using unadjusted independent sample t-tests. Results Participants Of the 132 patient-caregiver dyads who initially agreed to enroll, 12 caregivers (7 English-speaking and 5 Spanish-speaking) declined to complete the FS-ICU-24, most often citing feeling overwhelmed or having time constraints. Thus, the final analytic cohort included 120 patient-caregiver dyads. Among these dyads, 63 (53%) caregivers were English-speakers and 57 (47%) were Spanish-speakers with limited English proficiency. The mean caregiver age was 54 (standard deviation [SD], 18) years old for English-speakers and 53 (12) years old for Spanish-speakers. Most caregivers were female (38 [60%] English-speakers and 40 [70%] Spanish-speakers) and the most common caregiver relationship to the patient was spouse (28 [44%] English vs. 23 [42%] Spanish) ( Table 1). In the English-speaking caregiver group, the mean patient age was 62 (15) years old, and 31 patients (49%) were female. In the Spanish-speaking caregiver group, the mean patient age was 60 (15) years old, and 22 patients (39%) were female. There were no statistically significant differences in patient or caregiver characteristics between the two groups, including age, sex, illness severity (as measured by APACHE II score), or mortality ( Table 1). Patient-caregiver dyads were also categorized by intervention (FAM-CAM exposed vs not exposed) and there were similarly no significant differences in patient or caregiver demographics or clinical characteristics between these groups ( Supplementary Table 1) . Impact of Caregiver Language on Satisfaction with Care Among English‑speaking caregivers, mean FS‑ICU‑24 scores were 93.3 (12.8) for overall satisfaction, 90.8 (15.1) for decision‑making, and 93.1 (12.9) for satisfaction with care. Among Spanish‑speaking caregivers, scores were 88.2 (14.1) for overall satisfaction, 85.6 (18.5) for decision‑making, and 89.9 (12.1) for satisfaction with care. Spanish‑speaking caregivers reported lower satisfaction across all FS‑ICU‑24 domains compared with English‑speaking caregivers ( Figure 2 ). The largest difference was in the decision‑making domain, which was significantly lower among Spanish‑speaking caregivers (p<0.05), while overall satisfaction and care were lower but did not reach statistical significance (p=0.06 and p=0.10 respectively). Impact of FAM-CAM on Satisfaction with Care Caregivers exposed to the FAM‑CAM intervention reported higher FS‑ICU‑24 scores across all domains compared with caregivers in the non‑intervention group ( Figure 3 ). Among English‑speaking caregivers, those exposed to FAM‑CAM reported a mean overall satisfaction score of 93.9 (8.7) versus 85.4 (21.8) in the non‑intervention group. Satisfaction with decision‑making was 93.1 (10.8) versus 81.9 (24.4), and satisfaction with care was 94.4 (10.1) versus 88.1 (20.31). Among Spanish‑speaking caregivers, those exposed to FAM‑CAM reported an overall satisfaction score of 89.6 (14.1) versus 83.5 (13.6) in the non‑intervention group. Decision‑making satisfaction was 86.7 (18.8) versus 82.1 (17.8), and satisfaction with care was 91.7 (12.0) versus 84.6 (11.5). In the combined cohort, FAM‑CAM exposure was associated with significantly higher satisfaction across all domains (p<0.05). When stratified by caregiver language, English‑speaking caregivers demonstrated the largest improvement in decision‑making satisfaction (p<0.05), while Spanish‑speaking caregivers experienced the greatest improvement in satisfaction with care (p<0.05) ( Figure 3) . Impact of Delirium on Satisfaction with Care A total of 70 patients (58%) experienced delirium at least once during the 3‑day assessment period. Caregivers of patients with delirium reported lower satisfaction scores across all FS‑ICU‑24 domains. Mean overall satisfaction was 88.8 (15.7), satisfaction with decision‑making was 86.6 (19.8), and satisfaction with care was 90.4 (13.7). Caregivers of patients without delirium reported higher scores with mean overall satisfaction 92.3 (9.5), decision‑making 90.7 (11.5), and satisfaction with care 93.5 (10.8). Although satisfaction scores trended lower among caregivers of patients with delirium, the differences in overall satisfaction (p = 0.08), decision‑making (p = 0.10), and care (p = 0.09) were not statistically significant. Impact of FAM-CAM on Satisfaction with Care by Delirium Status FAM‑CAM exposure was associated with higher FS-ICU-24 scores among caregivers of both delirious and non‑delirious patients, with the greatest benefit observed among caregivers of patients with delirium ( Figure 4 ). Among caregivers of patients with delirium, those exposed to FAM‑CAM reported a mean overall satisfaction of 90.9 (12.9) compared with 80.3 (22.4) for those not exposed. Decision‑making satisfaction was 88.7 (17.7) versus 78.6 (25.9), and satisfaction with care was 92.61 (10.7) versus 81.5 (20.2). Among caregivers of patients without delirium, those exposed to FAM-CAM reported a mean overall satisfaction of 93.3 (9.6) compared to 89.3 (8.8) for those not exposed. Decision‑making satisfaction was 92.2 (10.7) versus 85.8 (13.0), and satisfaction with care was 94.1 (11.7) versus 91.8 (7.4). These results demonstrate that FAM‑CAM substantially improved family satisfaction when patients were delirious across all domains (p<0.05), while improvements in non‑delirious patients were more modest and not statistically significant. Discussion In this study, we evaluated differences in caregiver satisfaction based on language preference, caregiver engagement, and patient delirium status. First, we found that Spanish‑speaking caregivers with LEP reported lower satisfaction across all FS‑ICU‑24 domains compared to English‑speaking caregivers. Second, caregivers who were engaged in the care of their loved ones with FAM-CAM had higher satisfaction across both language groups. Lastly, although delirium was associated with lower satisfaction, the use of FAM‑CAM mitigated this effect. To our knowledge, this is the first U.S. study to evaluate quantitatively language‑based differences in caregiver satisfaction in the ICU and to demonstrate that a culturally and linguistically tailored tool can improve satisfaction among diverse families. Caregiver satisfaction is shaped by several factors reflected by two FS-ICU-24 domains: 1) care (e.g., support, trust, and perceived competence of the medical team) and 2) decision-making (e.g., clarity/consistency of information provided and caregiver inclusion) [21,23–25]. Among Spanish-speaking caregivers, the most significant improvement after FAM-CAM implementation was in the care domain, likely because the tool’s linguistic and cultural tailoring helped overcome barriers to comprehension and engagement. By creating a structured opportunity for caregivers to participate in their loved one’s care, the FAM-CAM may have fostered a sense of usefulness and strengthened partnership with the medical team, both central components of the care domain. In contrast, improvements in the decision-making domain were more modest, likely reflecting persistent communication barriers that the FAM-CAM could not address. For example, caregivers with LEP often rely on certified medical interpreters during complex care discussions, but interpreters are not always available in real-time [25]. Even when present, interpreter-mediated conversations can still feel constrained, limiting caregivers’ opportunities to ask questions, express concerns, and engage in the back-and-forth dialogue that is necessary for shared decision-making [25]. These persistent communication barriers likely explain the smaller benefit we observed in the decision-making domain. Nonetheless, the observed improvements highlight the value of culturally adapted tools in engaging a historically underrepresented families in ICU care. Importantly, FAM-CAM improved satisfaction across both language groups, with combined analyses showing significant improvement across all domains. In contrast, prior ICU interventions have shown mixed or modest results. The PARTNER trial, a nurse-led, multicomponent family support program did not significantly improve caregiver satisfaction [26], while the FICUS trial, an interprofessional intervention with a dedicated family liaison, achieved a modest, but statistically significant ~2 point increase on the FS-ICU-24 scale [27]. Similarly, a national collaborative of 63 ICUs that implemented multiple strategies (e.g., open visitation, caregiver diaries), saw only ~1-2 point improvements [28]. One reason for these modest effects may be that these interventions emphasized structured updates and emotional support rather than consistent and active caregiver engagement, which may be more important for improving satisfaction. Meanwhile, FAM-CAM is an easy-to-scale, resource-efficient tool that repeatedly engages caregivers in delirium assessments, allowing for real-time input into patient status. Additionally, this tool is low cost, does not require additional staff, and takes only 2-3 minutes for caregivers to complete. This approach allows for active caregiver participation, strengthening trust and partnership in the care domain, while also encouraging inclusion in the decision-making domain. Although statistical significance was not reached in every domain when stratified by language, the magnitude of improvement (~6–8 points) exceeded that of prior interventions, highlighting FAM-CAMs clinical relevance and need for confirmation in larger, randomized trials. FAM-CAM also appeared to mitigate the adverse effects of patient delirium on caregiver satisfaction. Delirium is well known to contribute to caregiver distress, in addition to low satisfaction with care [8,11], though its impact on standardized measures like FS-ICU-24 is less well characterized. In our study, caregivers of patients with delirium reported lower satisfaction scores across all domains, though differences were not statistically significant. Notably, among these caregivers, those engaged with FAM-CAM reported significantly higher FS-ICU scores than those who were not. A possible explanation is that participating in delirium assessments helped caregivers better understand their loved one’s own fluctuating mental status. This greater understanding may have increased their confidence in clinical decisions and provided a meaningful sense of contribution. Improving caregiver satisfaction has implications that extend beyond the ICU. Low caregiver satisfaction is a recognized risk factor for PICS-F, a condition with long-lasting effects on caregivers’ mental and physical health that persist well after their loved one’s ICU admission [5,29]. Caregiver satisfaction is also closely tied to patient outcomes, as caregivers distress has been associated with higher rehospitalization rates, accelerated patient functional decline, and lower patient quality of life [2,30]. Consistent with these findings, a secondary analysis of the MIND-USA trial involving 148 patient-caregiver dyads demonstrated that caregiver burden predicted worse patient outcomes at both 3 and 12-month post-ICU stay [2]. However, the prevalence and impact of PICS‑F in caregivers with LEP remains largely unknown, as this population is frequently underrepresented in clinical trials, including in MIND-USA. Our findings raise concern that language-based disparities in satisfaction may place caregivers with LEP at particularly high risk for PICS-F. Future studies should evaluate this risk, and if disparities are confirmed, develop targeted culturally-appropriate interventions to improve outcomes for caregivers and patients. This study has several limitations. First, the sample size was small, particularly in the non-intervention sub-group, which may have resulted in greater variability in FS-ICU-24. Because this analysis was a secondary aim of a parent study, it was not independently powered to detect differences in caregiver satisfaction. Nonetheless, the fact that consistent differences were observed across groups despite limited power suggests these findings are meaningful and merit confirmation in larger studies. Second, FS‑ICU‑24 scores in our study were generally high across all groups, exceeding the mean scores reported in prior studies (~75–80 [27]). These elevated scores may reflect a strong baseline culture of family engagement in our ICU, including routine inclusion of caregivers in daily rounds. Additionally, these scores may also have been influenced by timing of the FS-ICU-24 assessment, which was administered early in the ICU course, potentially preceding the strain of a prolonged ICU stay. Third, a subset of caregivers (n=12) declined to complete the FS-ICU-24 after enrollment, most often citing feeling overwhelmed, which may have introduced bias by underrepresenting caregivers with lower satisfaction. However, the high completion rate among enrolled caregivers suggests an accurate representation of the ICU caregiver population. Despite these limitations, we feel our findings provide meaningful insight into language-based disparities in caregiver satisfaction and demonstrate the potential of FAM-CAM to improve the caregiver experience in the ICU. Conclusion In this study, Spanish-speaking caregivers reported lower satisfaction with ICU care than English-speaking caregivers. Engagement with FAM-CAM improved satisfaction across both language groups and mitigated the negative impact of patient delirium. These findings highlight the potential of FAM-CAM as a scalable, caregiver engagement tool to improve the ICU experience for diverse caregiver populations. Declarations Conflict of Interest The authors declare that they have no financial or non-financial competing interests relevant to this work, and no funding was received to support this study. Ethics Approval The study protocol was approved by the University of California San Diego Institutional Review Board (IRB #810463). All human studies were performed in accordance with the ethical standards of the IRB and with the 1964 Declaration of Helsinki and its later amendments. Author Contributions All authors approved the final version of this manuscript. Acknowledgements We are deeply grateful to the patients, caregivers, and ICU staff who participated in this study and made it possible. We are especially appreciative to the Hospital Elder Life Program, LLC, for granting permission to use the Family Confusion Assessment Method (FAM-CAM). 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Available from: http://dx.doi.org/10.1097/CCM.0000000000004009 Shirasaki K, Hifumi T, Nakanishi N, Nosaka N, Miyamoto K, Komachi MH, et al. Postintensive care syndrome family: A comprehensive review. Acute Med Surg [Internet]. 2024;11:e939. Available from: http://dx.doi.org/10.1002/ams2.939 Stall NM, Kim SJ, Hardacre KA, Shah PS, Straus SE, Bronskill SE, et al. Association of informal caregiver distress with health outcomes of community-dwelling dementia care recipients: A systematic review. J Am Geriatr Soc [Internet]. 2019;67:609–17. Available from: http://dx.doi.org/10.1111/jgs.15690 Table Table 1. Demographic and Clinical Characteristics of Patient-Caregiver Dyads by Caregiver Preferred Language English-speaking Caregivers (n=63) Spanish-speaking Caregivers (n=57) Caregiver Characteristics Age (mean, SD) 54 (18) 53 (12) Biological Sex (n, %) Female 38 (60) 40 (70) Relationship to Patient (n, %) Spouse 28 (44) 23 (42) Parent (patient is child) 19 (30) 22 (38) Child 10 (16) 5 (8) Sibling 6 (10) 7 (12) Patient Characteristics Age 62 (15) 60 (15) Biological Sex (n, %) Female 31 (49) 22 (39) Patient Preferred Language (n, %) English 56 (88) 4 (7) Spanish 7 (12) 53 (93) Mechanical Ventilation (n, %) 25 (40) 25 (44) APACHE II Score (mean, SD) 20 (7) 19 (7) ICU LOS (median, IQR) 10 (9) 8 (10) Mortality (n, %) 16 (27) 16 (28) Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; ICU, intensive care unit; LOS, length of stay Supplementary Files Supplementary.docx STROBEChecklist.docx Cite Share Download PDF Status: Published Journal Publication published 08 Jan, 2026 Read the published version in Intensive Care Medicine → Version 1 posted Editorial decision: Major revisions 15 Oct, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers invited by journal 19 Sep, 2025 Editor assigned by journal 17 Sep, 2025 First submitted to journal 16 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7616641","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":517682515,"identity":"4190c221-9992-4733-8b6c-e51c3056d22d","order_by":0,"name":"Charlotte C Ellberg","email":"","orcid":"","institution":"University of California San Diego","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"C","lastName":"Ellberg","suffix":""},{"id":517682516,"identity":"a8263b7a-77e3-4713-b334-6d8e7e8af183","order_by":1,"name":"Megan Trieu","email":"","orcid":"","institution":"University of California San 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01:01:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":140912,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-7616641/v1/bc7a997b596396fa618b41c2.docx"},{"id":92681574,"identity":"4040e984-4716-4af4-bbfa-1d1e0c95e040","added_by":"auto","created_at":"2025-10-03 01:09:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":33957,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7616641/v1/838969b77812e595a9684927.docx"}],"financialInterests":"","formattedTitle":"Family-Administered Delirium Screening Improves Satisfaction Among ICU Caregivers A Prospective Cohort Study","fulltext":[{"header":"Take Home Message","content":"\u003cp\u003eTo our knowledge, this is the first U.S. ICU study to evaluate satisfaction with ICU care in English and Spanish-speaking families. Spanish-speaking caregivers, often excluded from clinical trials, reported lower satisfaction with care than English-speaking caregivers. Engagement with FAM-CAM improved satisfaction across both groups. As an easy-to-complete, scalable tool, FAM-CAM offers a novel approach to improving caregiver experience and reducing language-based disparities in ICU care.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe intensive care unit (ICU) is a uniquely challenging environment for both patients and their caregivers. Caregivers in the ICU frequently witness distressing events that contribute to substantial psychological burden, including anxiety and depression\u0026nbsp;[1\u0026ndash;4]. Complications of critical illness, including delirium, immobility, and sedation, can worsen this distress\u0026nbsp;[1,5]. Among these factors, delirium, a syndrome of acute brain dysfunction, plays a particularly important role\u0026nbsp;[6,7]. For caregivers, delirium is especially distressing to witness, and contributes to confusion and uncertainty about their loved one\u0026rsquo;s condition\u0026nbsp;[6,7]. It has also been linked to lower satisfaction with care, which is associated with greater caregiver psychological distress, poor patient outcomes, and the development of Post-Intensive Care Syndrome-Family (PICS-F), a long-term sequalae characterized by depression, anxiety, and post-traumatic stress symptoms among caregivers\u0026nbsp;[8\u0026ndash;11]. These adverse effects have prompted growing interest in strategies to mitigate caregiver distress, with caregiver engagement receiving considerable attention as a potential approach, largely due to its demonstrated benefits in delirium care\u0026nbsp;[12]. However, the impact of such engagement on caregiver satisfaction and psychological outcomes have been mixed\u0026nbsp;[13].\u003c/p\u003e\n\u003cp\u003eDespite a growing interest in caregiver engagement, caregivers with limited English proficiency (LEP) have been largely overlooked, as they are often excluded from U.S. ICU trials evaluating engagement tools and caregiver satisfaction [13,14]. While LEP is associated with low patient satisfaction and mistrust in the healthcare team across multiple care settings, its impact on the caregiver experience in the ICU remains underexplored [15,16]. Because caregiver satisfaction is closely tied to psychological well-being, evaluating the caregiver experience in diverse populations is essential, as caregivers with LEP may be at high risk for low satisfaction, psychological distress, and the development of PICS-F [17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur prior work demonstrated that standard delirium screening with the commonly used Confusion Assessment Method for the ICU (CAM-ICU) [7] was unreliable in Spanish-speaking patients with LEP, whereas caregiver-administered tools like the Family Confusion Assessment Method (FAM-CAM) and its Spanish-language adaptation, reduced language-based disparities and improved delirium detection [18]. However, whether these tools also enhance caregiver satisfaction through meaningful engagement remains unknown. In this study, we sought to: (1) evaluate differences in caregiver satisfaction across language groups, and (2) assess whether caregiver engagement via the English or Spanish-language FAM-CAM improved satisfaction with ICU care. We hypothesized that Spanish-speaking caregivers with LEP would report lower satisfaction than English-speaking caregivers, and that caregiver engagement using FAM-CAM would improve satisfaction across both language groups. We further hypothesized that caregiver satisfaction would be lower in the presence of patient delirium than in its absence, and that caregiver engagement would mitigate this effect.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design, Participants, Enrollment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis was a prospective non-randomized observational cohort study conducted in two mixed ICUs at a tertiary academic health center between August 2024 and January 2025. The parent study was designed to evaluate the accuracy of delirium screening among English and Spanish-speaking ICU patients enrolled on a 1:1 ratio based on patient language preference. The current analysis represents a secondary aim of that study, leveraging the same cohort to evaluate the impact of caregiver engagement via FAM-CAM on caregiver satisfaction. Sample size was determined by the parent study rather than formal power calculations for satisfaction outcomes. Although we specified a priori hypotheses, this analysis was not independently powered.\u003c/p\u003e\n\u003cp\u003ePatient-caregiver dyads were enrolled within 72 hours of ICU admission. Patients were eligible if \u0026ge;18 years old and preferred English or Spanish. Exclusion criteria included prior moderate-to-severe neurocognitive impairment, inability to complete CAM-ICU due to significant visual/hearing deficits, or admission for active seizure, hepatic encephalopathy, or alcohol withdrawal. Caregivers were eligible if \u0026ge;18 years old, preferred English or Spanish, and were actively involved in the patient\u0026apos;s care. They were excluded if not physically present during the study or were non-family members.\u003c/p\u003e\n\u003cp\u003eEligible patients were identified via the electronic health record (EHR) and approached by research staff. Caregivers were identified through the patient, EHR, or clinical team and approached separately. In the parent study, patients could participate even if their caregiver declined. However,\u0026nbsp;this caregiver-focused arm only included dyads in which both patients and caregivers consented. All study procedures were approved by the UC San Diego IRB (IRB #810463), and verbal consent was obtained from patients (or their proxies) and caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy Procedures\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt enrollment, all participants completed a demographic questionnaire and self-reported their English proficiency. In the parent study, all patients underwent delirium assessments using CAM-ICU, the most widely used tool for delirium detection in the ICU [7]. As part of usual ICU care, delirium screening was conducted daily by bedside providers. In parallel, trained bilingual research staff conducted additional assessments in the patient\u0026rsquo;s preferred language using either the original English-language CAM-ICU or the cross-culturally adapted and validated Spanish-language version [19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe parent study also evaluated the diagnostic accuracy of the caregiver-administered FAM-CAM and its cross-culturally adapted Spanish-language version [18,20]. As part of this broader study, a separate arm was designed to evaluate whether caregiver engagement using these tools impacted caregiver satisfaction. To answer this question, dyads were assigned to either an intervention or control group based on the day of the week in which they were enrolled. Dyads enrolled Monday through Wednesday were assigned to the intervention group, while dyads enrolled Thursday or Friday were assigned to the control group. The trial flow diagram is detailed in \u003cu\u003eFigure 1\u003c/u\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll delirium assessments, including FAM-CAM and Spanish-FAM, were conducted for three consecutive days or until ICU discharge, whichever occurred first. On the final study day, all caregivers completed the Family Satisfaction in the ICU-24 (FS-ICU-24) questionnaire, a validated instrument available in both English and Spanish [21,22]. The FS-ICU-24 includes 24 Likert-scale items and is made up of two domains: (1) satisfaction with care (14-items), which assesses perceived symptom management, compassion, and attention to family needs; and (2) satisfaction with decision-making (10-items), which evaluates quality of physician communication, adequacy of information, and inclusion in care decisions [21,22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOutcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome of the study was caregiver satisfaction with ICU care, measured using the FS-ICU-24 questionnaire. The FS-ICU-24 generates three scores: overall satisfaction, satisfaction with care, and satisfaction with decision-making.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analyses\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics. Dyads were stratified by caregiver preferred language (English versus Spanish). FS-ICU-24 scores were converted from a Likert scale to a 0-100 scale, with higher scores indicating greater satisfaction. We used independent sample t-tests to compare caregiver satisfaction by language group (English versus Spanish), intervention group (FAM-CAM exposure versus no exposure), and patient delirium status (CAM-ICU positive versus negative). We also performed subgroup analyses to evaluate whether FAM-CAM exposure improved FS-ICU scores within each language group and within delirium versus non-delirium groups. Finally, we assessed for baseline demographic and clinical differences between English and Spanish-speaking caregivers and patients, as well as between the intervention and control groups using chi-square tests for categorical variables and t-tests for continuous variables. No significant differences were identified, so outcome comparisons were conducted using unadjusted independent sample t-tests.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipants \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf the 132 patient-caregiver dyads who initially agreed to enroll, 12 caregivers (7 English-speaking and 5 Spanish-speaking) declined to complete the FS-ICU-24, most often citing feeling overwhelmed or having time constraints. Thus, the final analytic cohort included 120 patient-caregiver dyads. Among these dyads, 63 (53%) caregivers were English-speakers and 57 (47%) were Spanish-speakers with limited English proficiency. The mean caregiver age was 54 (standard deviation [SD], 18) years old for English-speakers and 53 (12) years old for Spanish-speakers. Most caregivers were female (38 [60%] English-speakers and 40 [70%] Spanish-speakers) and the most common caregiver relationship to the patient was spouse (28 [44%] English vs. 23 [42%] Spanish) (\u003cu\u003eTable 1).\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIn the English-speaking caregiver group, the mean patient age was 62 (15) years old, and 31 patients (49%) were female. In the Spanish-speaking caregiver group, the mean patient age was 60 (15) years old, and 22 patients (39%) were female. There were no statistically significant differences in patient or caregiver characteristics between the two groups, including age, sex, illness severity (as measured by APACHE II score), or mortality (\u003cu\u003eTable 1).\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePatient-caregiver dyads were also categorized by intervention (FAM-CAM exposed vs not exposed) and there were similarly no significant differences in patient or caregiver demographics or clinical characteristics between these groups (\u003cu\u003eSupplementary Table 1)\u003c/u\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImpact of Caregiver Language on Satisfaction with Care \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong English‑speaking caregivers, mean FS‑ICU‑24 scores were 93.3 (12.8) for overall satisfaction, 90.8 (15.1) for decision‑making, and 93.1 (12.9) for satisfaction with care. Among Spanish‑speaking caregivers, scores were 88.2 (14.1) for overall satisfaction, 85.6 (18.5) for decision‑making, and 89.9 (12.1) for satisfaction with care. Spanish‑speaking caregivers reported lower satisfaction across all FS‑ICU‑24 domains compared with English‑speaking caregivers (\u003cu\u003eFigure 2\u003c/u\u003e). The largest difference was in the decision‑making domain, which was significantly lower among Spanish‑speaking caregivers (p\u0026lt;0.05), while overall satisfaction and care were lower but did not reach statistical significance (p=0.06 and p=0.10 respectively).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImpact of FAM-CAM on Satisfaction with Care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCaregivers exposed to the FAM‑CAM intervention reported higher FS‑ICU‑24 scores across all domains compared with caregivers in the non‑intervention group (\u003cu\u003eFigure 3\u003c/u\u003e). \u003c/p\u003e\n\u003cp\u003eAmong English‑speaking caregivers, those exposed to FAM‑CAM reported a mean overall satisfaction score of 93.9 (8.7) versus 85.4 (21.8) in the non‑intervention group. Satisfaction with decision‑making was 93.1 (10.8) versus 81.9 (24.4), and satisfaction with care was 94.4 (10.1) versus 88.1 (20.31). Among Spanish‑speaking caregivers, those exposed to FAM‑CAM reported an overall satisfaction score of 89.6 (14.1) versus 83.5 (13.6) in the non‑intervention group. Decision‑making satisfaction was 86.7 (18.8) versus 82.1 (17.8), and satisfaction with care was 91.7 (12.0) versus 84.6 (11.5).\u003c/p\u003e\n\u003cp\u003eIn the combined cohort, FAM‑CAM exposure was associated with significantly higher satisfaction across all domains (p\u0026lt;0.05). When stratified by caregiver language, English‑speaking caregivers demonstrated the largest improvement in decision‑making satisfaction (p\u0026lt;0.05), while Spanish‑speaking caregivers experienced the greatest improvement in satisfaction with care (p\u0026lt;0.05) (\u003cu\u003eFigure 3)\u003c/u\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImpact of Delirium on Satisfaction with Care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 70 patients (58%) experienced delirium at least once during the 3‑day assessment period. Caregivers of patients with delirium reported lower satisfaction scores across all FS‑ICU‑24 domains. Mean overall satisfaction was 88.8 (15.7), satisfaction with decision‑making was 86.6 (19.8), and satisfaction with care was 90.4 (13.7). Caregivers of patients without delirium reported higher scores with mean overall satisfaction 92.3 (9.5), decision‑making 90.7 (11.5), and satisfaction with care 93.5 (10.8). Although satisfaction scores trended lower among caregivers of patients with delirium, the differences in overall satisfaction (p = 0.08), decision‑making (p = 0.10), and care (p = 0.09) were not statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImpact of FAM-CAM on Satisfaction with Care by Delirium Status\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFAM‑CAM exposure was associated with higher FS-ICU-24 scores among caregivers of both delirious and non‑delirious patients, with the greatest benefit observed among caregivers of patients with delirium (\u003cu\u003eFigure 4\u003c/u\u003e). Among caregivers of patients with delirium, those exposed to FAM‑CAM reported a mean overall satisfaction of 90.9 (12.9) compared with 80.3 (22.4) for those not exposed. Decision‑making satisfaction was 88.7 (17.7) versus 78.6 (25.9), and satisfaction with care was 92.61 (10.7) versus 81.5 (20.2).\u003c/p\u003e\n\u003cp\u003eAmong caregivers of patients without delirium, those exposed to FAM-CAM reported a mean overall satisfaction of 93.3 (9.6) compared to 89.3 (8.8) for those not exposed. Decision‑making satisfaction was 92.2 (10.7) versus 85.8 (13.0), and satisfaction with care was 94.1 (11.7) versus 91.8 (7.4). These results demonstrate that FAM‑CAM substantially improved family satisfaction when patients were delirious across all domains (p\u0026lt;0.05), while improvements in non‑delirious patients were more modest and not statistically significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we evaluated differences in caregiver satisfaction based on language preference, caregiver engagement, and patient delirium status. First, we found that Spanish‑speaking caregivers with LEP reported lower satisfaction across all FS‑ICU‑24 domains compared to English‑speaking caregivers. Second, caregivers who were engaged in the care of their loved ones with FAM-CAM had higher satisfaction across both language groups. Lastly, although delirium was associated with lower satisfaction, the use of FAM‑CAM mitigated this effect. To our knowledge, this is the first U.S. study to evaluate quantitatively language‑based differences in caregiver satisfaction in the ICU and to demonstrate that a culturally and linguistically tailored tool can improve satisfaction among diverse families.\u003c/p\u003e\n\u003cp\u003eCaregiver satisfaction is shaped by several factors reflected by two FS-ICU-24 domains: 1) \u003cstrong\u003ecare \u003c/strong\u003e(e.g., support, trust, and perceived competence of the medical team) and 2) \u003cstrong\u003edecision-making \u003c/strong\u003e(e.g., clarity/consistency of information provided and caregiver inclusion) [21,23\u0026ndash;25]. Among Spanish-speaking caregivers, the most significant improvement after FAM-CAM implementation was in the \u003cem\u003ecare\u003c/em\u003e domain, likely because the tool\u0026rsquo;s linguistic and cultural tailoring helped overcome barriers to comprehension and engagement. By creating a structured opportunity for caregivers to participate in their loved one\u0026rsquo;s care, the FAM-CAM may have fostered a sense of usefulness and strengthened partnership with the medical team, both central components of the care domain. In contrast, improvements in the \u003cem\u003edecision-making\u003c/em\u003e domain were more modest, likely reflecting persistent communication barriers that the FAM-CAM could not address. For example, caregivers with LEP often rely on certified medical interpreters during complex care discussions, but interpreters are not always available in real-time [25]. Even when present, interpreter-mediated conversations can still feel constrained, limiting caregivers\u0026rsquo; opportunities to ask questions, express concerns, and engage in the back-and-forth dialogue that is necessary for shared decision-making [25]. These persistent communication barriers likely explain the smaller benefit we observed in the decision-making domain. Nonetheless, the observed improvements highlight the value of culturally adapted tools in engaging a historically underrepresented families in ICU care. \u003c/p\u003e\n\u003cp\u003eImportantly, FAM-CAM improved satisfaction across both language groups, with combined analyses showing significant improvement across all domains. In contrast, prior ICU interventions have shown mixed or modest results. The PARTNER trial, a nurse-led, multicomponent family support program did not significantly improve caregiver satisfaction [26], while the FICUS trial, an interprofessional intervention with a dedicated family liaison, achieved a modest, but statistically significant ~2 point increase on the FS-ICU-24 scale [27]. Similarly, a national collaborative of 63 ICUs that implemented multiple strategies (e.g., open visitation, caregiver diaries), saw only ~1-2 point improvements [28]. One reason for these modest effects may be that these interventions emphasized structured updates and emotional support rather than consistent and active caregiver engagement, which may be more important for improving satisfaction. Meanwhile, FAM-CAM is an easy-to-scale, resource-efficient tool that repeatedly engages caregivers in delirium assessments, allowing for real-time input into patient status. Additionally, this tool is low cost, does not require additional staff, and takes only 2-3 minutes for caregivers to complete. This approach allows for active caregiver participation, strengthening trust and partnership in the care domain, while also encouraging inclusion in the decision-making domain. Although statistical significance was not reached in every domain when stratified by language, the magnitude of improvement (~6\u0026ndash;8 points) exceeded that of prior interventions, highlighting FAM-CAMs clinical relevance and need for confirmation in larger, randomized trials. \u003c/p\u003e\n\u003cp\u003eFAM-CAM also appeared to mitigate the adverse effects of patient delirium on caregiver satisfaction. Delirium is well known to contribute to caregiver distress, in addition to low satisfaction with care [8,11], though its impact on standardized measures like FS-ICU-24 is less well characterized. In our study, caregivers of patients with delirium reported lower satisfaction scores across all domains, though differences were not statistically significant. Notably, among these caregivers, those engaged with FAM-CAM reported significantly higher FS-ICU scores than those who were not. A possible explanation is that participating in delirium assessments helped caregivers better understand their loved one\u0026rsquo;s own fluctuating mental status. This greater understanding may have increased their confidence in clinical decisions and provided a meaningful sense of contribution.\u003c/p\u003e\n\u003cp\u003eImproving caregiver satisfaction has implications that extend beyond the ICU. Low caregiver satisfaction is a recognized risk factor for PICS-F, a condition with long-lasting effects on caregivers\u0026rsquo; mental and physical health that persist well after their loved one\u0026rsquo;s ICU admission [5,29]. Caregiver satisfaction is also closely tied to patient outcomes, as caregivers distress has been associated with higher rehospitalization rates, accelerated patient functional decline, and lower patient quality of life [2,30]. Consistent with these findings, a secondary analysis of the MIND-USA trial involving 148 patient-caregiver dyads demonstrated that caregiver burden predicted worse patient outcomes at both 3 and 12-month post-ICU stay [2]. However, the prevalence and impact of PICS‑F in caregivers with LEP remains largely unknown, as this population is frequently underrepresented in clinical trials, including in MIND-USA. Our findings raise concern that language-based disparities in satisfaction may place caregivers with LEP at particularly high risk for PICS-F. Future studies should evaluate this risk, and if disparities are confirmed, develop targeted culturally-appropriate interventions to improve outcomes for caregivers and patients. \u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, the sample size was small, particularly in the non-intervention sub-group, which may have resulted in greater variability in FS-ICU-24. Because this analysis was a secondary aim of a parent study, it was not independently powered to detect differences in caregiver satisfaction. Nonetheless, the fact that consistent differences were observed across groups despite limited power suggests these findings are meaningful and merit confirmation in larger studies. Second, FS‑ICU‑24 scores in our study were generally high across all groups, exceeding the mean scores reported in prior studies (~75\u0026ndash;80 [27]). These elevated scores may reflect a strong baseline culture of family engagement in our ICU, including routine inclusion of caregivers in daily rounds. Additionally, these scores may also have been influenced by timing of the FS-ICU-24 assessment, which was administered early in the ICU course, potentially preceding the strain of a prolonged ICU stay. Third, a subset of caregivers (n=12) declined to complete the FS-ICU-24 after enrollment, most often citing feeling overwhelmed, which may have introduced bias by underrepresenting caregivers with lower satisfaction. However, the high completion rate among enrolled caregivers suggests an accurate representation of the ICU caregiver population. Despite these limitations, we feel our findings provide meaningful insight into language-based disparities in caregiver satisfaction and demonstrate the potential of FAM-CAM to improve the caregiver experience in the ICU. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, Spanish-speaking caregivers reported lower satisfaction with ICU care than English-speaking caregivers. Engagement with FAM-CAM improved satisfaction across both language groups and mitigated the negative impact of patient delirium. These findings highlight the potential of FAM-CAM as a scalable, caregiver engagement tool to improve the ICU experience for diverse caregiver populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no financial or non-financial competing interests relevant to this work, and no funding was received to support this study.\u003c/p\u003e\n\u003ch2\u003eEthics Approval\u003c/h2\u003e\n\u003cp\u003eThe study protocol was approved by the University of California San Diego Institutional Review Board (IRB #810463). All human studies were performed in accordance with the ethical standards of the IRB and with the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003ch2\u003eAuthor Contributions\u003c/h2\u003e\n\u003cp\u003eAll authors approved the final version of this manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe are deeply grateful to the patients, caregivers, and ICU staff who participated in this study and made it possible. We are especially appreciative to the Hospital Elder Life Program, LLC, for granting permission to use the Family Confusion Assessment Method (FAM-CAM). Finally, we acknowledge the support and mentorship provided by colleagues in the Division of Pulmonary, Critical Care, and Sleep Medicine at the University of California, San Diego.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAyenew T, Gete M, Gedfew M, Getie A, Afenigus AD, Edmealem A, et al. 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Available from: http://dx.doi.org/10.1164/ajrccm.2025.211.abstracts.a5261\u003c/li\u003e\n\u003cli\u003eHiser SL, Fatima A, Ali M, Needham DM. Post-intensive care syndrome (PICS): recent updates. J Intensive Care [Internet]. 2023;11:23. Available from: http://dx.doi.org/10.1186/s40560-023-00670-7\u003c/li\u003e\n\u003cli\u003eLobo-Valbuena B, S\u0026aacute;nchez-Roca MD, Regal\u0026oacute;n-Mart\u0026iacute;n MP, Torres-Morales J, Enciso-Calder\u0026oacute;n V. Interprofessional intervention in the prevention of PICS and PICS-F. Enferm Intensiva (Engl ) [Internet]. 2025;36:500528. Available from: http://dx.doi.org/10.1016/j.enfie.2025.500528\u003c/li\u003e\n\u003cli\u003eKhan BA, Perkins AJ, Gao S, Hui SL, Campbell NL, Farber MO, et al. The Confusion Assessment Method for the ICU-7 delirium severity scale: A novel delirium severity instrument for use in the ICU. Crit Care Med [Internet]. 2017;45:851\u0026ndash;7. 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A systematic review of the impact of patient-physician non-English language concordance on quality of care and outcomes. J Gen Intern Med [Internet]. 2019;34:1591\u0026ndash;606. Available from: https://pubmed.ncbi.nlm.nih.gov/31147980/\u003c/li\u003e\n\u003cli\u003eLehman R, Moriarty H. Limited English Proficiency and Outcomes in the Intensive Care Unit: An Integrated Review. J Transcult Nurs [Internet]. 2024;35:226\u0026ndash;36. Available from: http://dx.doi.org/10.1177/10436596241229485\u003c/li\u003e\n\u003cli\u003eNaef R, von Felten S, Ernst J. Factors influencing post-ICU psychological distress in family members of critically ill patients: a linear mixed-effects model. Biopsychosoc Med [Internet]. 2021;15:4. Available from: http://dx.doi.org/10.1186/s13030-021-00206-1\u003c/li\u003e\n\u003cli\u003eFuentes AL, Ellberg C, Jimenez G, Reyes PA, Rodriguez A, Mu\u0026ntilde;oz Pineda JA, et al. 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Available from: http://dx.doi.org/10.1111/j.1532-5415.2012.04200.x\u003c/li\u003e\n\u003cli\u003eWall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med [Internet]. 2007;35:271\u0026ndash;9. Available from: http://dx.doi.org/10.1097/01.CCM.0000251122.15053.50\u003c/li\u003e\n\u003cli\u003ePadilla-Fortunatti C, Rojas-Silva N, Molina-Mu\u0026ntilde;oz Y, Avenda\u0026ntilde;o-Jara S. Cultural adaptation and psychometric properties of the Chilean-Spanish version of the Family Satisfaction in the Intensive Care Unit - 24 questionnaire. Med Intensiva [Internet]. 2023;47:140\u0026ndash;8. Available from: http://dx.doi.org/10.1016/j.medine.2022.07.019\u003c/li\u003e\n\u003cli\u003eGm\u0026uuml;nder M, Gessler N, Buser S, Feuz U, Fayyaz J, Jachmann A, et al. Caregivers with limited language proficiency and their satisfaction with paediatric emergency care related to the use of professional interpreters: a mixed methods study. BMJ Open [Internet]. 2024;14:e077716. Available from: http://dx.doi.org/10.1136/bmjopen-2023-077716\u003c/li\u003e\n\u003cli\u003eKarliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res [Internet]. 2007;42:727\u0026ndash;54. Available from: http://dx.doi.org/10.1111/j.1475-6773.2006.00629.x\u003c/li\u003e\n\u003cli\u003evan Lent LGG, Yilmaz NG, Goosen S, Burgers J, Giani S, Schouten BC, et al. Effectiveness of interpreters and other strategies for mitigating language barriers: A systematic review. Patient Educ Couns [Internet]. 2025;136:108767. Available from: http://dx.doi.org/10.1016/j.pec.2025.108767\u003c/li\u003e\n\u003cli\u003eWhite DB, Angus DC, Shields A-M, Buddadhumaruk P, Pidro C, Paner C, et al. A randomized trial of a family-support intervention in intensive care units. N Engl J Med [Internet]. 2018;378:2365\u0026ndash;75. Available from: http://dx.doi.org/10.1056/nejmoa1802637\u003c/li\u003e\n\u003cli\u003eNaef R, Jeitziner M-M, Riguzzi M, von Felten S, Verweij L, Rufer M, et al. Nurse-led family support intervention for families of critically ill patients: The FICUS cluster randomized clinical trial: The FICUS cluster randomized clinical trial. JAMA Intern Med [Internet]. 2025; Available from: http://dx.doi.org/10.1001/jamainternmed.2025.3406\u003c/li\u003e\n\u003cli\u003eKleinpell R, Zimmerman J, Vermoch KL, Harmon LA, Vondracek H, Hamilton R, et al. Promoting family engagement in the ICU: Experience from a national collaborative of 63 ICUs: Experience from a national collaborative of 63 ICUs. Crit Care Med [Internet]. 2019;47:1692\u0026ndash;8. Available from: http://dx.doi.org/10.1097/CCM.0000000000004009\u003c/li\u003e\n\u003cli\u003eShirasaki K, Hifumi T, Nakanishi N, Nosaka N, Miyamoto K, Komachi MH, et al. Postintensive care syndrome family: A comprehensive review. Acute Med Surg [Internet]. 2024;11:e939. Available from: http://dx.doi.org/10.1002/ams2.939\u003c/li\u003e\n\u003cli\u003eStall NM, Kim SJ, Hardacre KA, Shah PS, Straus SE, Bronskill SE, et al. Association of informal caregiver distress with health outcomes of community-dwelling dementia care recipients: A systematic review. J Am Geriatr Soc [Internet]. 2019;67:609\u0026ndash;17. Available from: http://dx.doi.org/10.1111/jgs.15690\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Demographic and Clinical Characteristics of \u0026nbsp; Patient-Caregiver Dyads by Caregiver Preferred Language\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEnglish-speaking\u0026nbsp;\u003cbr\u003e\u0026nbsp;Caregivers\u003c/p\u003e\n \u003cp\u003e(n=63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSpanish-speaking\u003cbr\u003e\u0026nbsp;Caregivers\u003c/p\u003e\n \u003cp\u003e(n=57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAge (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBiological Sex (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRelationship to Patient (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Spouse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Parent (patient is child)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Sibling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBiological Sex (n, %)\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003ePatient Preferred Language (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; English\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Spanish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMechanical Ventilation (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAPACHE II Score (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eICU LOS (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMortality (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eAbbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; ICU, intensive care unit; LOS, length of stay\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"intensive-care-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"icme","sideBox":"Learn more about [Intensive Care Medicine](http://link.springer.com/journal/134)","snPcode":"134","submissionUrl":"https://www.editorialmanager.com/icme/default2.aspx","title":"Intensive Care Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Communication Barriers, Healthcare disparities, Caregivers, Critical Care, Delirium","lastPublishedDoi":"10.21203/rs.3.rs-7616641/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7616641/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003eFamily caregivers experience distress when their loved one is in the ICU, particularly in the setting of delirium. Limited English proficiency (LEP) may worsen this experience and contribute to long-term psychological burden. Yet caregivers with LEP are rarely included in ICU research. Whether caregiver engagement using linguistically tailored delirium assessments improves satisfaction remains unknown.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe conducted a prospective cohort study of patient-caregiver dyads in two academic ICUs. Caregivers were assigned to: 1) FAM-CAM group, in which caregivers completed daily FAM-CAM delirium assessments, or 2) control group with no FAM-CAM exposure. All caregivers completed the Family Satisfaction in the ICU-24 (FS-ICU-24) after 3 days. Outcomes included overall satisfaction and subdomains of decision-making and care (0\u0026ndash;100 scale). Independent t-tests compared satisfaction by language, FAM-CAM exposure, and patient delirium status.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eAmong 120 dyads, 63 caregivers preferred English and 57 Spanish. English-speaking caregivers reported higher decision-making satisfaction than Spanish-speakers (90.8 vs 85.6, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). FAM-CAM exposure improved overall satisfaction across language groups (91.9 vs 84.4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Patient delirium was linked to lower caregiver satisfaction, but FAM-CAM engagement mitigated this effect, with higher scores among exposed caregivers(90.9 vs 80.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eEnglish-speaking caregivers reported higher satisfaction scores than Spanish-speaking caregivers. Engagement with FAM-CAM improved satisfaction across language groups and mitigated the negative impact of delirium, supporting its potential to enhance caregiver engagement and promote equity in the ICU.\u003c/p\u003e","manuscriptTitle":"Family-Administered Delirium Screening Improves Satisfaction Among ICU Caregivers A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 01:01:41","doi":"10.21203/rs.3.rs-7616641/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revisions","date":"2025-10-15T21:59:30+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-09-22T05:10:46+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-19T13:40:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-17T05:38:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Intensive Care Medicine","date":"2025-09-16T15:45:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"intensive-care-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"icme","sideBox":"Learn more about [Intensive Care Medicine](http://link.springer.com/journal/134)","snPcode":"134","submissionUrl":"https://www.editorialmanager.com/icme/default2.aspx","title":"Intensive Care Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6a0f14cf-315b-4e4f-b08d-3928b0a6b81f","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:04:33+00:00","versionOfRecord":{"articleIdentity":"rs-7616641","link":"https://doi.org/10.1007/s00134-025-08260-x","journal":{"identity":"intensive-care-medicine","isVorOnly":false,"title":"Intensive Care Medicine"},"publishedOn":"2026-01-08 15:58:37","publishedOnDateReadable":"January 8th, 2026"},"versionCreatedAt":"2025-10-03 01:01:41","video":"","vorDoi":"10.1007/s00134-025-08260-x","vorDoiUrl":"https://doi.org/10.1007/s00134-025-08260-x","workflowStages":[]},"version":"v1","identity":"rs-7616641","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7616641","identity":"rs-7616641","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}