Health-related quality of life and physical recovery after a critical illness: a multi-centre randomised controlled trial of a home-based physical rehabilitation program

Follow-up program after intensive care unit discharge

INTRODUCTION

Patient follow-up after intensive care unit (ICU) discharge allows the early recognition of complications associated to post-intensive care syndrome (PICS). The aim of this project is to standardize outcome variables in a follow-up program for patients at risk of suffering PICS.

METHODS

The Rehabilitation and Patient Follow-up Committee of the Argentine Society of Intensive Care Medicine (Sociedad Argentina de Terapia Intensiva, SATI) requested the collaboration of different committees to design the present document. A thorough search of the literature on the issue, together with pre-scheduled meetings and web-based discussion encounters were carried out. After comprehensive evaluation, the recommendations according to the GRADE system included in the follow-up program were: frequency of controlled visits, appointed healthcare professionals, basic domains of assessment and recommended tools of evaluation, validated in Spanish, and entire duration of the program.

CONCLUSION

The measures herein suggested for patient follow-up after ICU discharge will facilitate a basic approach to diagnosis and management of the long-term complications associated to PICS.

Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study

INTRODUCTION

A substantial number of patients discharged from intensive care units (ICUs) subsequently die without leaving hospital. It is unclear how many of these deaths are preventable. Ward-based management following discharge from ICU is an area that patients and healthcare staff are concerned about. The primary aim of REFLECT (Recovery Following Intensive Care Treatment) is to develop an intervention plan to reduce in-hospital mortality rates in patients who have been discharged from ICU.

METHODS AND ANALYSIS

REFLECT is a multicentre mixed-methods exploratory study examining ward care delivery to adult patients discharged from ICU. The study will be made up of four substudies. Medical notes of patients who were discharged from ICU and subsequently died will be examined using a retrospective case records review (RCRR) technique. Patients and their relatives will be interviewed about their post-ICU care, including relatives of patients who died in hospital following ICU discharge. Staff involved in the care of patients post-ICU discharge will be interviewed about the care of this patient group. The medical records of patients who survived their post-ICU stay will also be reviewed using the RCRR technique. The analyses of the substudies will be both descriptive and use a modified grounded theory approach to identify emerging themes. The evidence generated in these four substudies will form the basis of the intervention development, which will take place through stakeholder and clinical expert meetings.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the Wales Research and Ethics Committee 4 (17/WA/0107). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ISRCTN14658054.

Changes in health-related quality of life after discharge from an intensive care unit: a systematic review

Quality of life after critical illness is becoming increasingly important as survival improves. Various measures have been used to study the quality of life of patients discharged from intensive care. We systematically reviewed validated measures of quality of life and their results. We searched PubMed, CENTRAL, CINAHL, Web of Science and Open Grey for studies of quality of life, measured after discharge from intensive care. We categorised studied populations as: general; restricted to level-3 care or critical care beyond 5 days; and septic patients. We included quality of life measured at any time after hospital discharge. We identified 48 studies. Thirty-one studies used the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and 19 used the EuroQol-5D (EQ-5D); eight used both and nine used alternative validated measures. Follow-up rates ranged from 26-100%. Quality of life after critical care was worse than for age- and sex-matched populations. Quality of life improved for one year after hospital discharge. The aspects of life that improved most were physical function, physical role, vitality and social function. However, these domains were also the least likely to recover to population norms as they were more profoundly affected by critical illness.

Development of an ICU discharge instrument predicting psychological morbidity: a multinational study

Purpose

To develop an instrument for use at ICU discharge for prediction of psychological problems in ICU survivors.

Methods

Multinational, prospective cohort study in ten general ICUs in secondary and tertiary care hospitals in Sweden, Denmark and the Netherlands. Adult patients with an ICU stay ≥ 12 h were eligible for inclusion. Patients in need of neurointensive care, with documented cognitive impairment, unable to communicate in the local language, without a home address or with more than one limitation of therapy were excluded. Primary outcome was psychological morbidity 3 months after ICU discharge, defined as Hospital Anxiety and Depression Scale (HADS) subscale score ≥ 11 or Post-traumatic Stress Symptoms Checklist-14 (PTSS-14) part B score > 45.

Results

A total of 572 patients were included and 78% of patients alive at follow-up responded to questionnaires. Twenty percent were classified as having psychological problems post-ICU. Of 18 potential risk factors, four were included in the final prediction model after multivariable logistic regression analysis: symptoms of depression [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.10–1.50], traumatic memories (OR 1.44, 95% CI 1.13–1.82), lack of social support (OR 3.28, 95% CI 1.47–7.32) and age (age-dependent OR, peak risk at age 49–65 years). The area under the receiver operating characteristics curve (AUC) for the instrument was 0.76 (95% CI 0.70–0.81).

Conclusions

We developed an instrument to predict individual patients’ risk for psychological problems 3 months post-ICU, http://www.imm.ki.se/biostatistics/calculators/psychmorb/. The instrument can be used for triage of patients for psychological ICU follow-up.

Trial registration

The study was registered at clinicaltrials.gov, NCT02679157.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5467-3) contains supplementary material, which is available to authorized users.

Measuring Outcomes After Critical Illness

Outcomes after critical illness remain poorly understood. Conceptual models developed by other disciplines can serve as a framework by which to increase knowledge about outcomes after critical illness. This article reviews 3 models to understand the distinct but interrelated content of outcome domains, to review the components of functional status, and to describe how injuries and illnesses relate to disabilities and impairments afterward.

Lessons learnt during the implementation of a web-based triage tool for Dutch intensive care follow-up clinics

OBJECTIVES

Screening for symptoms of postintensive care syndrome is based on a long list of questionnaires, filled out by the intensive care unit (ICU) survivor and manually reviewed by the health professional. This is an inefficient and time-consuming process. The aim of this study was to evaluate the feasibility of a web-based triage tool and to compare the outcomes from web-based questionnaires to those from paper-based questionnaires.

DESIGN

A mixed-methods study.

SETTING

Nine Dutch ICU follow-up clinics.

PARTICIPANTS

221 ICU survivors and 14 health professionals.

INTERVENTIONS

A web-based triage tool was implemented by nine ICU follow-up clinics. End users, that is, health professionals were interviewed in order to evaluate the feasibility of the triage tool. ICU survivors were invited to fill out web-based questionnaires 3 months after hospital discharge.

PRIMARY OUTCOMES

Outcomes of the questionnaires were merged with clinical data from a national quality registry to assess the differences in outcomes between paper-based and web-based questionnaires.

RESULTS

221 ICU survivors received an invitation to fill out questionnaires, 93 (42.1%) survivors did not respond to the invitation. Respondents to the web-based questionnaires (n=54) were significantly younger and had a significantly longer ICU stay than those who preferred the paper-based questionnaires (n=74). The prevalence of mental, physical and nutritional problems was high, although comparable between the groups. Health professionals' interviews revealed that the software was complex to use (n=8) and although emailing survivors is very convenient, not all survivors have an email address (n=7).

CONCLUSIONS

Web-based screening software has major benefits compared with paper-based screening. However, implementation has shown to be rather difficult and there are important barriers to consider. Although different in age, the health status is comparable between the users of the web-based questionnaire and paper-based questionnaire.

Evaluating the impact of a home-based rehabilitation service on older people and their caregivers: a matched-control quasi-experimental study

Introduction

Previous studies evaluating home-based rehabilitation service (HBRS) merely focused on the period immediately after the patients’ discharge from hospitals. The present study focuses on HBRS that covers clients who have not been recently hospitalized. HBRS aims to meet older clients’ rehabilitation needs and support their caregivers in the community. This study intended to evaluate the impact of HBRS on the older clients’ health outcomes and hospital services utilization, and caregivers’ strain in providing care for clients.

Methods

This study used a matched-control quasi-experimental design with a 3-month follow-up to evaluate HBRS. The health outcome measures used for the older clients included Elderly Mobility Scale, Timed Up and Go test, Modified Barthel Index, Lawton’s Instrumental Activities of Daily Living Scale, Mini-Mental State Examination, and World Health Organization Quality of Life Scale, Short Form, Hong Kong version (WHOQOL-BREF [HK]). Meanwhile, the Caregiver Strain Index was used to measure the caregivers’ caregiving strain. Data on clients’ hospital services utilization 3 and 6 months before and after the study were also collected and evaluated.

Results

The final sample consisted of 122 pairs of older clients and caregivers who live in a community in Hong Kong. In the follow-up after 3 months, the intervention group showed immensely substantial improvements across all the health outcome measures compared with the control group. The intervention group also demonstrated substantial reduction in the clients’ hospital services utilization compared with the control group. However, no significant differences in the clients’ hospital services utilization exist between the two groups in the follow-up after 6 months.

Conclusion

HBRS of this study is an effective intervention service to improve health outcomes and reduce hospital services utilization among older people living in the community. Moreover, HBRS of this study was effective in reducing the caregivers’ caregiving strain.

Physical Rehabilitation Core Outcomes In Critical illness (PRACTICE): protocol for development of a core outcome set

Background

Existing data on physical rehabilitation interventions in critical illness are challenged by outcome heterogeneity that limits data synthesis and translation of research findings into clinical practice. This protocol describes the PRACTICE study to develop a core outcome set (COS) for trials of physical rehabilitation interventions delivered across the continuum of a patient’s recovery from the intensive care unit until reintegration in the community following hospital discharge.

Methods

Mixed methods will be used including: systematic reviews of quantitative and qualitative literature; qualitative interviews with patients and caregivers; a modified Delphi consensus process with researcher, clinician and patient/caregiver stakeholder groups; and consensus meetings for ratification of findings, resolving uncertainty, or developing an action plan for COS implementation.

Discussion

The PRACTICE COS will inform relevant stakeholders about important outcomes regarding physical rehabilitation in critical illness, and may enhance the future design and conduct of trials in this area.

Trial registration

COMET database (www.comet-initiative.org/, Record ID 288, 01/03/13). PROSPERO database (CRD42014008908, CRD42017078549).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2678-4) contains supplementary material, which is available to authorized users.

Appetite during the recovery phase of critical illness: a cohort study

BACKGROUND/OBJECTIVES

Reduced appetite is a recognised physiological symptom in survivors of critical illness. While reduced appetite has been reported by patients after intensive care unit (ICU) discharge, quantification using visual analogue scales (VAS) has not been previously performed, and follow-up duration has been limited. We aimed to describe appetite scores in ICU survivors during the first 3 months after ICU discharge and explore association with systemic inflammation.

SUBJECTS/METHODS

Secondary analysis of data collected in a complex rehabilitation intervention trial (RECOVER). A subgroup of 193 patients provided specific consent for inclusion in the blood sampling sub-study during consent for the main study. We studied appetite using a VAS; serum C-reactive protein (CRP); interleukin-1β and interleukin-6 (IL-1β and IL-6); and hand-grip strength.

RESULTS

Median (interquartile range) score on 0-10 appetite VAS was 4.3 (2.0-6.5) 1 week after ICU discharge, improving to 7.1 (4.6-8.9) by 3 months (mean difference 1.7 (0.9-2.4), p < 0.01). Number of days spent in an acute hospital following an intensive care stay was associated with poorer appetite scores (p = 0.03). CRP concentration and appetite were significantly associated at 1 week after ICU discharge (p = 0.01), but not at 3 months after ICU discharge (p = 0.67).

CONCLUSIONS

ICU survivors experience reduced appetite during the acute recovery phase of critical illness that could impact on nutritional recovery and this was associated with CRP concentration 1 week after ICU discharge.

Changes in biopsychosocial outcomes for a mixed cohort of ICU survivors

Background

Prolonged inflammation and infection associated with being critically ill and the ensuing physical inactivity has proven negative effects on the recovery of physical function, psychological health and reintegration into society for intensive care unit (ICU) survivors. Limited evidence is available on changes in biopsychosocial outcomes for South Africans recovering from an episode of critical illness.

Objectives

To determine changes in biopsychosocial outcomes for a mixed cohort of ICU survivors in hospital and at 1 month and 6 months after discharge.

Method

A prospective, observational, longitudinal study was conducted. Severity of illness, mechanical ventilation (MV) duration and ICU and hospital length of stay (LOS) were recorded. Physical function in ICU test-scored (PFIT-s) was performed at discharge from ICU and hospital. At 1 month and 6 months, peripheral muscle strength, exercise endurance, health-related quality of life (HRQOL), depression status and return to work were assessed. Descriptive and inferential statistics were used.

Results

Participants (n = 24) had a median age of 51.5 years, majority were male (n = 19; 79%) and most were employed before admission (n = 20; 83%). At 6 months, 11 participants (n = 11) were part of the final sample. Median PFIT-s changed significantly (0.3 points; p = 0.02) between ICU and hospital discharge. Peripheral muscle strength improved significantly for upper and lower limbs over 6 months (p = 0.00–0.03) but change in median 6-minute walk test distance (65m) was not significantly different. Significant improvements occurred in mean Medical Outcomes Short Form-36 (SF-36) physical health component scores (8.8 ± 7.6; p = 0.00). Mean SF-36 mental health component scores had a strong negative relationship with MV duration (r = −0.7; p = 0.01), LOS (r = −0.56; p = 0.04) and Patient Health Questionnaire 9 scores (r = −0.72; p = 0.01). Six participants (55%) returned to employment.

Conclusion

Clinically important improvements in biopsychosocial outcomes related to physical function and social factors were observed. Limitations in mental aspects of HRQOL were present at 6 months and some reported mild depressive symptoms.

Clinical implications

Intensive care unit survivors with a history of prolonged MV duration and hospital LOS who exhibit limitations in mental HRQOL, and signs of depressive symptoms should be referred to a psychologist for evaluation.

Supervised exercise rehabilitation in survivors of critical illness: A randomised controlled trial

Objectives

To investigate the impact of a six-week supervised exercise programme on cardiopulmonary fitness, balance, muscle strength and anxiety and depression in patients who have been discharged home from hospital following an intensive care unit length of stay of greater than 48 h. To investigate patients' perceptions of a six-week supervised exercise programme delivered at three months post hospital discharge.

Design

A single centre parallel, randomised controlled trial.

Setting

Outpatient department of a university teaching hospital in the UK.

Participants

Sixty adult survivors of critical illness, at three months post-hospital discharge.

Intervention

A six-week individually prescribed and supervised exercise program, with associated advice to home exercise modification. Twice weekly exercise sessions were individualised to participant's functional status and included cardiopulmonary, balance and strengthening exercises. Follow up at seven weeks, six months and 12 months.

Outcome measures

Six-Minute Walk Test, BERG balance test, grip strength and Hospital Anxiety and Depression Scale. A pre-designed survey was used to explore patient perceptions of the programme.

Results

Sixty participants (n = 30 received allocated programme in both control and treatment groups) were randomised. Loss to follow up resulted in n = 34 participants for intention to treat analysis at 12 months follow up (leaving n = 19 in control group, n = 15 in treatment group). Median participant age at enrolment was 62 years (interquartile range: 49-72), with a median intensive care unit length of stay of nine days (interquartile range: 4-17). No significant differences were found for the Six-Minute Walk Test at any time point (p > 0.05). Anxiety levels and balance were significantly improved in the treatment group at 12 months (p = 0.006 and p = 0.040, respectively).

Conclusions

Further research is needed into appropriate interventions and outcome measures, target patient populations and timing of such intervention post-hospital discharge.

Validity of a single PTSD checklist item to screen for insomnia in survivors of critical illness

BACKGROUND

There is no insomnia screening tool validated in intensive care unit (ICU) survivors.

OBJECTIVES

To examine the validity of a single item from the PTSD checklist-Civilian version (PCL-C) to detect insomnia by Insomnia Severity Index (ISI) METHODS: We performed a secondary analysis of data from a longitudinal investigation in 120 medical-surgical ICU survivors. At 1 year post-ICU, patients completed ISI, PCL-C, and Medical Short-Form 12 (SF-12) by telephone. A single PCL-C item rates difficulty initiating or maintaining sleep over the past month. We compared performance characteristics of this PCL-C item to ISI-defined insomnia (ISI ≥15).

RESULTS

A score of ≥3 on the PCL-C sleep item exhibited 91% sensitivity and 67% specificity for ISI-defined insomnia (ISI ≥ 15), and it demonstrated construct validity by correlation to related QOL indices.

CONCLUSIONS

A single PCL-C sleep item score ≥ 3 is a reasonable screen to identify insomnia symptoms in ICU survivors.

Mobile critical care recovery program (m-CCRP) for acute respiratory failure survivors: study protocol for a randomized controlled trial

BACKGROUND

Patients admitted to intensive care units (ICU) with acute respiratory failure (ARF) face chronic complications that can impede return to normal daily function. A mobile, collaborative critical care model may enhance the recovery of ARF survivors.

METHODS

The Mobile Critical Care Recovery Program (m-CCRP) study is a two arm, randomized clinical trial. We will randomize 620 patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation in a 1:1 ratio to one of two arms (310 patients per arm) - m-CCRP intervention versus attention control. Those in the intervention group will meet with a care coordinator after hospital discharge in predetermined intervals to aid in the recovery process. Baseline assessments and personalized goal setting will be used to develop an individualized care plan for each patient after discussion with an interdisciplinary team. The attention control arm will receive printed material and telephone reminders emphasizing mobility and management of chronic conditions. Duration of the intervention and follow-up is 12 months post-randomization. Our primary aim is to assess the efficacy of m-CCRP in improving the quality of life of ARF survivors at 12 months. Secondary aims of the study are to evaluate the efficacy of m-CCRP in improving function (cognitive, physical, and psychological) of ARF survivors and to determine the efficacy of m-CCRP in reducing acute healthcare utilization.

DISCUSSION

The proposed randomized controlled trial will evaluate the efficacy of a collaborative critical care recovery program in accomplishing the Institute of Healthcare Improvement's triple aims of better health, better care, at lower cost. We have developed a collaborative critical care model to promote ARF survivors' recovery from the physical, psychological, and cognitive impacts of critical illness. In contrast to a single disease focus and clinic-based access, m-CCRP represents a comprehensive, accessible, mobile, ahead of the curve intervention, focused on the multiple aspects of the unique recovery needs of ARF survivors.

TRIAL REGISTRATION

NCT03053245 , clinicaltrials.gov, registered February 1, 2017.

Long-term recovery following critical illness in an Australian cohort

BACKGROUND

Almost all data on 5-year outcomes for critical care survivors come from North America and Europe. The aim of this study was to investigate long-term mortality, physical function, psychological outcomes and health-related quality of life in a mixed intensive care unit cohort in Australia.

METHODS

This longitudinal study evaluated 4- to 5-year outcomes. Physical function (six-minute walk test) and health-related quality of life (Short Form 36 Version 2) were compared to 1-year outcomes and population norms. New psychological data (Center for Epidemiological Studies-Depression, Impact of Events Scale) was collected at follow-up.

RESULTS

Of the 150 participants, 66 (44%) patients were deceased by follow-up. Fifty-six survivors were included with a mean (SD) age of 64 (14.2). Survivors' mean (SD) six-minute walk distance increased between 1 and 4 to 5 years (465.8 m (148.9) vs. 507.5 m (118.2)) (mean difference = - 24.5 m, CI - 58.3, 9.2, p = 0.15). Depressive symptoms were low: median (IQR) score of 7.0 (1.0-15.0). The mean level of post-traumatic stress symptoms was low-median (IQR) score of 1.0 (0-11.0)-with only 9 (16%) above the threshold for potentially disordered symptoms. Short-Form 36 Physical and Mental Component Scores did not change between 1 and 4 to 5 years (46.4 (7.9) vs. 46.7 (8.1) and 48.8 (13) vs. 48.8 (11.1)) and were within a standard deviation of normal.

CONCLUSIONS

Outcomes of critical illness are not uniform across nations. Mortality was increased in this cohort; however, survivors achieved a high level of recovery for physical function and health-related quality of life with low psychological morbidity at follow-up.

TRIAL REGISTRATION

The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.

ICU-acquired weakness: should medical sovereignty belong to any specialist?

ICU-acquired weakness (ICUAW), including critical illness polyneuropathy, critical illness myopathy, and critical illness polyneuropathy and myopathy, is a frequent disabling disorder in ICU subjects. Research has predominantly been performed by intensivists, whose efforts have permitted the diagnosis of ICUAW early during an ICU stay and understanding of several of the pathophysiological and clinical aspects of this disorder. Despite important progress, the therapeutic strategies are unsatisfactory and issues such as functional outcomes and long-term recovery remain unclear. Studies involving multiple specialists should be planned to better differentiate the ICUAW types and provide proper functional outcome measures and follow-up. A more strict collaboration among specialists interested in ICUAW, in particular physiatrists, is desirable to plan proper care pathways after ICU discharge and to better meet the health needs of subjects with ICUAW.

Enhancing Recovery From Sepsis: A Review

Importance

Survival from sepsis has improved in recent years, resulting in an increasing number of patients who have survived sepsis treatment. Current sepsis guidelines do not provide guidance on posthospital care or recovery.

Observations

Each year, more than 19 million individuals develop sepsis, defined as a life-threatening acute organ dysfunction secondary to infection. Approximately 14 million survive to hospital discharge and their prognosis varies. Half of patients recover, one-third die during the following year, and one-sixth have severe persistent impairments. Impairments include development of an average of 1 to 2 new functional limitations (eg, inability to bathe or dress independently), a 3-fold increase in prevalence of moderate to severe cognitive impairment (from 6.1% before hospitalization to 16.7% after hospitalization), and a high prevalence of mental health problems, including anxiety (32% of patients who survive), depression (29%), or posttraumatic stress disorder (44%). About 40% of patients are rehospitalized within 90 days of discharge, often for conditions that are potentially treatable in the outpatient setting, such as infection (11.9%) and exacerbation of heart failure (5.5%). Compared with patients hospitalized for other diagnoses, those who survive sepsis (11.9%) are at increased risk of recurrent infection than matched patients (8.0%) matched patients (P < .001), acute renal failure (3.3% vs 1.2%, P < .001), and new cardiovascular events (adjusted hazard ratio [HR] range, 1.1-1.4). Reasons for deterioration of health after sepsis are multifactorial and include accelerated progression of preexisting chronic conditions, residual organ damage, and impaired immune function. Characteristics associated with complications after hospital discharge for sepsis treatment are not fully understood but include both poorer presepsis health status, characteristics of the acute septic episode (eg, severity of infection, host response to infection), and quality of hospital treatment (eg, timeliness of initial sepsis care, avoidance of treatment-related harms). Although there is a paucity of clinical trial evidence to support specific postdischarge rehabilitation treatment, experts recommend referral to physical therapy to improve exercise capacity, strength, and independent completion of activities of daily living. This recommendation is supported by an observational study involving 30 000 sepsis survivors that found that referral to rehabilitation within 90 days was associated with lower risk of 10-year mortality compared with propensity-matched controls (adjusted HR, 0.94; 95% CI, 0.92-0.97, P < .001).

Conclusions and Relevance

In the months after hospital discharge for sepsis, management should focus on (1) identifying new physical, mental, and cognitive problems and referring for appropriate treatment, (2) reviewing and adjusting long-term medications, and (3) evaluating for treatable conditions that commonly result in hospitalization, such as infection, heart failure, renal failure, and aspiration. For patients with poor or declining health prior to sepsis who experience further deterioration after sepsis, it may be appropriate to focus on palliation of symptoms.

Fifty Years of Research in ARDS. Long-Term Follow-up after Acute Respiratory Distress Syndrome. Insights for Managing Medical Complexity after Critical Illness

Critical illness is not a discrete disease state or syndrome. It is the culmination of a multiplicity of heterogeneous disease states and their varied health trajectories leading to extreme illness that requires advanced life support in a distinct geographic location in the hospital. It is a marker of newly acquired or worsened medical complexity and multimorbidities. Fifty years ago, distinguished critical care colleagues identified a syndrome of severe lung injury that united a group of patients with disparate admitting diagnoses. Acute respiratory distress syndrome continues to represent an important, incremental insult and risk modifier of acute and longer-term outcome, but it does not solely define our patients or their outcomes in isolation. Over the next 50 years, our research and clinical agenda needs to sharpen our lens on the fundamental importance of our patients' pre-critical illness health status, their intrinsic susceptibilities to tissue injury, and their innate and varied resiliencies. We need to take responsibility for the contribution that we make to morbidity through our practice in the intensive care unit each day. Engagement in frank and transparent communication with our patients and their caregivers about the very real and morbid consequences of being this sick is essential. We must enforce explicit consent about the morbidity of innovative, experimental, or high-risk medical and surgical procedures and ensure that our ongoing level of treatment aligns with patients' and caregivers' goals and values. Interprofessional and multidisciplinary collaboration is crucial to modify existing complex care pathways for our patients and their families to foster optimal rehabilitation and reintegration into the workplace and community.

Avaliação funcional de pacientes internados na Unidade de Terapia Intensiva adulto do Hospital Universitário de Canoas

RESUMO A sobrevida de pacientes críticos tem aumentado com o tempo. No entanto, a imobilidade e o tempo de internação estão contribuindo para o seu declínio funcional e da sua qualidade de vida. O objetivo do estudo foi avaliar a independência funcional dos pacientes internados na Unidade de Terapia Intensiva (UTI) Adulto do Hospital Universitário de Canoas. Pesquisa de coorte prospectiva executada de fevereiro a dezembro de 2016. Os pacientes foram avaliados quanto à capacidade funcional, força muscular, força de preensão palmar, mobilidade, equilíbrio e marcha. Foram avaliados 90 pacientes com média de idade de 59,6±16,1 anos, com predominância do gênero masculino (51,1%). A mediana do tempo de internação na UTI foi de 5 (3-9) dias, e de internação hospitalar de 13 (10-20) dias. Houve melhora significativa nos resultados de capacidade funcional (p<0,001), mobilidade (p=0,004) e equilíbrio (p=0,009). Os pacientes internados apresentaram um declínio funcional (com relação à normalidade) nos momentos avaliados. Entretanto, houve melhora nos valores até momento da alta hospitalar.

A tailored multicomponent program to reduce discomfort in critically ill patients: a cluster-randomized controlled trial

PURPOSE

Critically ill patients are exposed to stressful conditions and experience several discomforts. The primary objective was to assess whether a tailored multicomponent program is effective for reducing self-perceived discomfort.

METHODS

In a cluster-randomized two-arm parallel trial, 34 French adult intensive care units (ICUs) without planned interventions to reduce discomfort were randomized, 17 to the arm including a 6-month period of program implementation followed by a 6-month period without the program (experimental group), and 17 to the arm with an inversed sequence (control group). The tailored multicomponent program consisted of assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to healthcare teams, and site-specific tailored interventions. The primary outcome was the overall discomfort score derived from the 16-item IPREA questionnaire (0, minimal, 100, maximal overall discomfort) and the secondary outcomes were the discomfort scores of each IPREA item. IPREA was administered on the day of ICU discharge with a considered timeframe from the ICU admission until ICU discharge.

RESULTS

During a 1-month assessment period, 398 and 360 patients were included in the experimental group and the control group, respectively. The difference (experimental minus control) of the overall discomfort score between groups was - 7.00 (95% CI - 9.89 to - 4.11, p < 0.001). After adjustment (age, gender, ICU duration, mechanical ventilation duration, and type of admission), the program effect was still positive for the overall discomfort score (difference - 6.35, SE 1.23, p < 0.001) and for 12 out of 16 items.

CONCLUSIONS

This tailored multicomponent program decreased self-perceived discomfort in adult critically ill patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT02442934.

Critical Care Cycling Study (CYCLIST) trial protocol: a randomised controlled trial of usual care plus additional in-bed cycling sessions versus usual care in the critically ill

INTRODUCTION

In-bed cycling with patients with critical illness has been shown to be safe and feasible, and improves physical function outcomes at hospital discharge. The effects of early in-bed cycling on reducing the rate of skeletal muscle atrophy, and associations with physical and cognitive function are unknown.

METHODS AND ANALYSIS

A single-centre randomised controlled trial in a mixed medical-surgical intensive care unit (ICU) will be conducted. Adult patients (n=68) who are expected to be mechanically ventilated for more than 48 hours and remain in ICU for a further 48 hours from recruitment will be randomly allocated into either (1) a usual care group or (2) a group that receives usual care and additional in-bed cycling sessions. The primary outcome is change in rectus femoris cross-sectional area at day 10 in comparison to baseline measured by blinded assessors. Secondary outcome measures include muscle strength, incidence of ICU-acquired weakness, handgrip strength, time to achieve functional milestones (sitting out of bed, walking), Functional Status Score in ICU, ICU Mobility Scale, 6 min walk test 1 week post-ICU discharge, incidence of delirium and quality of life (EuroQol Five Dimensions questionnaire Five Levels scale). Quality of life assessments will be conducted post-ICU admission at day 10, 3 and 6 months after acute hospital discharge. Participants in the intervention group will complete an acceptability of intervention questionnaire.

ETHICS AND DISSEMINATION

Appropriate ethical approval from Metro South Health Human Research Ethics Committee has been attained. Results will be published in peer-reviewed publications and presented at scientific conferences to assist planning of future multicentre randomised controlled trials (if indicated) that will test in-bed cycling as an intervention to improve the physical, cognitive and health-related quality of life outcomes of patients with critical illness.

TRIAL REGISTRATION NUMBER

This trial has been prospectively registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12616000948493); Pre-results.

The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study

The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.

Follow-up after intensive care treatment: a questionnaire survey of intensive care aftercare in Denmark

BACKGROUND

Rehabilitation efforts after treatment in the intensive care unit (ICU) are termed intensive care aftercare. It includes both early in-hospital follow-up after ICU-discharge and late follow-up after hospital discharge. This study aims to investigate the current ICU-aftercare activities in Denmark.

METHODS

We conducted an electronic questionnaire survey, which was distributed by e-mail to the heads of all 31 general ICUs in Denmark. Specialized ICUs were not included. The questionnaire was divided into the following sections: early ICU-aftercare, late ICU-aftercare, future development and demographics.

RESULTS

Thirty-one ICUs were invited to participate. The response rate was 100%. Overall, 26 of 31 ICUs (84%) offered ICU-aftercare, with the following distribution: early ICU-aftercare (58%), late ICU-aftercare (57%) and both (29%). There were no significant associations between hospital size and provision of ICU-aftercare. For early ICU-aftercare, the most common eligibility criteria were based on ICU length of stay (LOS) (44%) and a decision based upon doctors' discretion (22%). Incidence of guidelines for early ICU-aftercare (44%) and checklists at patient contact (35%) were sparse. The most common early ICU-aftercare items were as follows: respiratory care (82%), tracheostomy care (59%) and nutritional care (59%). For late ICU-aftercare, the most common eligibility criterion was LOS (41%). Guidelines (71%), but not checklist at patient contact (35%), were more common. Most frequent late ICU-aftercare interventions were review of ICU-diaries (59%) and patient charts (53%).

CONCLUSION

Eighty-four per cent of Danish ICUs offered ICU-aftercare to their patients. There was an abundant heterogeneity of eligibility criteria and ICU-aftercare interventions.

Patients' Perceptions of an Exercise Program Delivered Following Discharge From Hospital After Critical Illness (the Revive Trial)

BACKGROUND

The REVIVE randomized controlled trial (RCT) investigated the effectiveness of an individually tailored (personalized) exercise program for patients discharged from hospital after critical illness. By including qualitative methods, we aimed to explore patients' perceptions of engaging in the exercise program.

METHODS

Patients were recruited from general intensive care units in 6 hospitals in Northern Ireland. Patients allocated to the exercise intervention group were invited to participate in this qualitative study. Independent semistructured interviews were conducted at 6 months after randomization. Interviews were audio-recorded, transcribed, and content analysis used to explore themes arising from the data.

RESULTS

Of 30 patients allocated to the exercise group, 21 completed the interviews. Patients provided insight into the physical and mental sequelae they experienced following critical illness. There was a strong sense of patients' need for the exercise program and its importance for their recovery following discharge home. Key facilitators of the intervention included supervision, tailoring of the exercises to personal needs, and the exercise manual. Barriers included poor mental health, existing physical limitations, and lack of motivation. Patients' views of outcome measures in the REVIVE RCT varied. Many patients were unsure about what would be the best way of measuring how the program affected their health.

CONCLUSIONS

This qualitative study adds an important perspective on patients' attitude to an exercise intervention following recovery from critical illness, and provides insight into the potential facilitators and barriers to delivery of the program and how programs should be evolved for future trials.

Self-Rated Health as a Predictor of Death after Two Years: The Importance of Physical and Mental Wellbeing Postintensive Care

INTRODUCTION

The objective of this study is, among half-year intensive care survivors, to determine whether self-assessment of health can predict two-year mortality.

METHODS

The study is a prospective cohort study based on the Procalcitonin and Survival Study trial. Half-year survivors from this 1200-patient multicenter intensive care trial were sent the SF-36 questionnaire. We used both a simple one-item question and multiple questions summarized as a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score. The responders were followed for vital status 730 days after inclusion. Answers were dichotomized into a low-risk and a high-risk group and hazard ratios (HR) with 95% confidence interval (CI) were calculated by Cox proportional hazard analyses.

CONCLUSION

We found that self-rated health measured by a single question was a strong independent predictor of two-year all-cause mortality (HR: 1.8; 95% CI: 1.1-3.0). The multi-item component scores of the SF-36 also predicted two-year mortality (PCS: HR: 2.9; 95% CI 1.7-5.0) (MCS: HR: 1.9; 95% CI 1.1-3.4). These results suggest that self-rated health questions could help in identifying patients at excess risk. Randomized controlled trials are needed to test whether our findings represent causality.

Functional Recovery in Patients With and Without Intensive Care Unit-Acquired Weakness

OBJECTIVE

The aim of this work was to compare the patient-reported functional health status with regard to physical, psychological, and social functioning of intensive care unit (ICU) survivors with and without ICU-acquired weakness (ICU-AW).

DESIGN

Single-center prospective study in ICU patients who were mechanically ventilated for more than 2 days and who survived to ICU discharge. Functional health status was assessed at 3, 6, and 12 months after ICU discharge, using the Sickness Impact Profile 68 (SIP68). The independent effect of ICU-AW on impaired functional status (SIP68 scores > 20) was analyzed using a multivariable logistic regression model.

RESULTS

A total of 133 patients were included, 60 with ICU-AW. Intensive care unit-acquired weakness was an independent predictor for impaired functional health status at 3 months after ICU discharge (odds ratio, 0.27; 95% confidence interval, 0.08-0.94; P = 0.04) but not at 6 and 12 months. Physical functioning was significantly more impaired in patients with ICU-AW at 3 and 12 months. Psychological functioning and social functioning were comparable between the groups, with little restrictions in psychological functioning, and severe long-lasting restrictions in social functioning.

CONCLUSIONS

The findings of this study urge the need to develop interdisciplinary rehabilitation interventions for ICU survivors, which should be continued after hospital discharge.

Does 6-Month Home Caregiver-Supervised Physiotherapy Improve Post-Critical Care Outcomes?: A Randomized Controlled Trial

OBJECTIVE

This study aims to determine whether a 6-month home physiotherapy program can improve outcomes in critical care survivors.

DESIGN

Forty-eight consecutive patients were randomized. The treatment group underwent 2 sessions/day of breathing retraining and bronchial hygiene, physical activity (mobilization, sit-to-stand gait, limb strengthening), and exercise re-conditioning whereas controls underwent standard care. Maximum inspiratory/expiratory pressures (MIP/MEP), forced volumes, blood gases, dyspnea, respiratory rate, disability, peripheral force measurements, perceived health status (Euroquol-5D), patient adherence/satisfaction, safety, and costs were assessed.

RESULTS

Outcomes of treatment versus controls: MIP 14 ± 17 vs. -0.2 ± 14 cm H2O, MEP 27 ± 27 vs. 6 ± 21 cm H2O both P < 0.03; in addition, quality of life (Euroquol-5D) (P = 0.04), FEV1 (P = 0.03), dyspnea (P = 0.002), and respiratory rate (P = 0.009) were significantly improved for treated cardiorespiratory patients only. Eighty-three percent of the treated patients were decannulated versus 14% of controls (P = 0.01). Compliance was high (74 ± 25%) and there were no side effects. The majority (87.4%) expressed satisfaction with the program. Treatment cost was 459&OV0556;/patient/month.

CONCLUSIONS

Carrying over regular bronchial hygiene techniques, physical activity, and exercise into the home after long critical care stays is safe and has a beneficial effect on respiratory muscles, decannulation, pulmonary function, and quality of life.

Prolonged acute care and post-acute care admission and recovery of physical function in survivors of acute respiratory failure: a secondary analysis of a randomized controlled trial

Background

The proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate.

Methods

We performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ≥4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score.

Results

Of the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4–29.8) points lower (p < 0.0001) than patients who were discharged to home. However, there was no difference in the rate at which physical function improved from 3 to 6 months for patients who required prolonged admission compared with those who returned home (p = 0.24 for interaction between prolonged admission and time). Adjusted for age, Acute Physiology and Chronic Health Evaluation II score, and sex, both groups had CS-PFP-10 scores that were 8.2 (CI 4.5–12.0) points higher at 6 months than at 3 months (p < 0.0001). For each additional year in patient age, CS-PFP-10 recovered 0.36 points slower (95% CI 0.12–0.61; p = 0.004).

Conclusions

Patients who require prolonged admission after acute respiratory failure have significantly lower physical functional performance than patients who return home. However, the rates of physical functional recovery between the two groups do not differ. The majority of survivors do not recover sufficiently to achieve functional independence by 6 months. Older age negatively influences the trajectory of functional recovery.

Trial registration

ClinicalTrials.gov, NCT01058421. Registered on 26 January 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1791-1) contains supplementary material, which is available to authorized users.

Factors Associated with Functional Recovery among Older Intensive Care Unit Survivors

RATIONALE

Most of the 1.4 million older adults who survive the intensive care unit (ICU) annually in the United States face increased disability, but little is known about those who achieve functional recovery.

OBJECTIVES

Our objectives were twofold: to evaluate the incidence and time to recovery of premorbid function within 6 months of a critical illness and to identify independent predictors of functional recovery among older ICU survivors.

METHODS

Potential participants included 754 persons aged 70 years or older who were evaluated monthly in 13 functional activities (1998-2012). The analytic sample included 218 ICU admissions from 186 ICU survivors. Functional recovery was defined as returning to a disability count less than or equal to the pre-ICU disability count within 6 months. Twenty-one potential predictors were evaluated for their associations with recovery.

MEASUREMENTS AND MAIN RESULTS

Functional recovery was observed for 114 (52.3%) of the 218 admissions. In multivariable analysis, higher body mass index (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.12) and greater functional self-efficacy (HR, 1.05; 95% CI, 1.02-1.08), a measure of confidence in performing various activities, were associated with recovery, whereas pre-ICU impairment in hearing (HR, 0.38; 95% CI, 0.22-0.66) and vision (HR, 0.59; 95% CI, 0.37-0.95) were associated with a lack of recovery.

CONCLUSIONS

Among older adults who survived an ICU admission with increased disability, pre-ICU hearing and vision impairment were strongly associated with poor functional recovery within 6 months, whereas higher body mass index and functional self-efficacy were associated with recovery. Future research is needed to evaluate whether interventions targeting these factors improve functional outcomes among older ICU survivors.

Five-Year Mortality and Hospital Costs Associated with Surviving Intensive Care

RATIONALE

Survivors of critical illness experience significant morbidity, but the impact of surviving the intensive care unit (ICU) has not been quantified comprehensively at a population level.

OBJECTIVES

To identify factors associated with increased hospital resource use and to ascertain whether ICU admission was associated with increased mortality and resource use.

METHODS

Matched cohort study and pre/post-analysis using national linked data registries with complete population coverage. The population consisted of patients admitted to all adult general ICUs during 2005 and surviving to hospital discharge, identified from the Scottish Intensive Care Society Audit Group registry, matched (1:1) with similar hospital control subjects. Five-year outcomes included mortality and hospital resource use. Confounder adjustment was based on multivariable regression and pre/post within-individual analyses.

MEASUREMENTS AND MAIN RESULTS

Of 7,656 ICU patients, 5,259 survived to hospital discharge (5,215 [99.2%] matched to hospital control subjects). Factors present before ICU admission (comorbidities/pre-ICU hospitalizations) were stronger predictors of hospital resource use than acute illness factors. In the 5 years after the initial hospital discharge, compared with hospital control subjects, the ICU cohort had higher mortality (32.3% vs. 22.7%; hazard ratio, 1.33; 95% confidence interval, 1.22-1.46; P < 0.001), used more hospital resources (mean hospital admission rate, 4.8 vs. 3.3/person/5 yr), and had 51% higher mean 5-year hospital costs ($25,608 vs. $16,913/patient). Increased resource use persisted after confounder adjustment (P < 0.001) and using pre/post-analyses (P < 0.001). Excess resource use and mortality were greatest for younger patients without significant comorbidity.

CONCLUSIONS

This complete, national study demonstrates that ICU survivorship is associated with higher 5-year mortality and hospital resource use than hospital control subjects, representing a substantial burden on individuals, caregivers, and society.

An Exploratory Study of Long-Term Outcome Measures in Critical Illness Survivors: Construct Validity of Physical Activity, Frailty, and Health-Related Quality of Life Measures

OBJECTIVE

Functional capacity is commonly impaired after critical illness. We sought to clarify the relationship between objective measures of physical activity, self-reported measures of health-related quality of life, and clinician reported global functioning capacity (frailty) in such patients, as well as the impact of prior chronic disease status on these functional outcomes.

DESIGN

Prospective outcome study of critical illness survivors.

SETTING

Community-based follow-up.

PATIENTS

Participants of the Musculoskeletal Ultrasound Study in Critical Care: Longitudinal Evaluation Study (NCT01106300), invasively ventilated for more than 48 hours and on the ICU greater than 7 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Physical activity levels (health-related quality of life [36-item short-form health survey] and daily step counts [accelerometry]) were compared to norm-based or healthy control scores, respectively. Controls for frailty (Clinical Frailty Score) were non-morbid, age- and gender-matched to survivors. Ninety-one patients were recruited on ICU admission: 41 were contacted for post-discharge assessment, and data were collected from 30 (14 female; mean age, 55.3 yr [95% CI, 48.3-62.3]; mean post-discharge, 576 d [95% CI, 539-614]). Patients' mean daily step count (5,803; 95% CI, 4,792-6,813) was lower than that in controls (11,735; 95% CI, 10,928-12,542; p < 0.001), and lower in those with preexisting chronic disease than without (2,989 [95% CI, 776-5,201] vs 7,737 [95% CI, 4,907-10,567]; p = 0.013). Physical activity measures (accelerometry, health-related quality of life, and frailty) demonstrated good construct validity across all three tools. Step variability (from SD) was highly correlated with daily steps (r = 0.67; p < 0.01) demonstrating a potential boundary constraint.

CONCLUSIONS

Subjective and objective measures of physical activity are all informative in ICU survivors. They are all reduced 18 months post-discharge in ICU survivors, and worse in those with pre-admission chronic disease states. Investigating interventions to improve functional capacity in ICU survivors will require stratification based on the presence of premorbidity.

Quality of Life Improves with Individualized Home-based Exercises in Critical Care Survivors

The Aim of the Study:

This study aims to determine the effect of individualized home-based exercise on the quality of life post-Intensive Care Unit (ICU) discharge.

Subjects:

Adult patients invasively mechanically ventilated for more than 48 h in medical ICU.

Methodology:

Thirty-five patients were enrolled prospectively in this study. They were interviewed to complete short form 36 (SF-36) version 2 questionnaire and were randomly allocated to control and experimental group by block randomization. The experimental group received individualized exercise information sheet and control group was asked to continue routine exercises done during their hospital stay. The experimental group also received a log book and weekly telephonic reminders. Patients were interviewed to complete the SF-36 through the telephone 4 weeks after hospital discharge.

Results:

Physical and mental components of the quality of life as measured by the SF-36 at the end of 4 weeks after hospital discharge showed a statistically significant difference (P < 0.05) in the experimental group.

Conclusion:

A well-structured individualized exercise program improves the quality of life of critically ill patients after discharge.

Physiotherapy management of intensive care unit-acquired weakness

[Hodgson CL, Tipping CJ (2016) Physiotherapy management of intensive care unit-acquired weakness.Journal of Physiotherapy63: 4-10].

Intensive care unit-acquired weakness

When critically ill, a severe weakness of the limbs and respiratory muscles often develops with a prolonged stay in the intensive care unit (ICU), a condition vaguely termed intensive care unit-acquired weakness (ICUAW). Many of these patients have serious nerve and muscle injury. This syndrome is most often seen in surviving critically ill patients with sepsis or extensive inflammatory response which results in increased duration of mechanical ventilation and hospital length of stay. Patients with ICUAW often do not fully recover and the disability will seriously impact on their quality of life. In this chapter we discuss the current knowledge on the pathophysiology and risk factors of ICUAW. Tools to diagnose ICUAW, how to separate ICUAW from other disorders, and which possible treatment strategies can be employed are also described. ICUAW is finally receiving the attention it deserves and the expectation is that it can be better understood and prevented.

Telerehabilitation Solution Conceptual Paper for Community-Based Exercise Rehabilitation of Patients Discharged After Critical Illness

A novel service oriented platform has been developed under the framework of the Telerehabilitation Service funded by the Cross Border Cooperation Programme Greece Cyprus 2007 – 2013 to support tele-supervised exercise rehabilitation for patients after hospitalization in intensive care units (ICU). The platform enables multiparty, interregional bidirectional audio/visual communication between clinical practitioners and post-ICU patients. It also enables patient group-based vital sign real time monitoring, patients’ clinical record bookkeeping, and individualized and group-based patient online exercise programs. The exercise programs intended for the service are based on successful cardiorespiratory rehabilitation programs, individualized and monitored by a multidisciplinary team. The eligibility study of former ICU patients to participate in such a service as well as a cost benefit analysis are presented to support the cost effectiveness of the telerehabilitation program in addition to the expected health benefits to a large proportion of former ICU patients.

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review

Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or 'usual care' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation

RATIONALE

Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design.

OBJECTIVES

To stratify patients for post-ICU disability and recovery to 1 year after critical illness.

METHODS

We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling.

MEASUREMENTS AND MAIN RESULTS

The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year.

CONCLUSIONS

ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

Physical declines occurring after hospital discharge in ARDS survivors: a 5-year longitudinal study

PURPOSE

Survivors of acute respiratory distress syndrome (ARDS) are at high risk for new or ongoing physical declines after hospital discharge. The objective of our study was to evaluate the epidemiology of physical declines over 5-year follow-up and identify patients at risk for decline.

METHODS

This multi-site prospective cohort study evaluated ARDS survivors who completed a physical status assessment at 3 or 6 months post-discharge. Three measures were evaluated: muscle strength (Medical Resource Council sumscore); exercise capacity [6-min walk test (6MWT)]; physical functioning [36-Item Short Form Health Survey (SF-36 survey)]. Patients were defined as "declined" if a comparison of their current and prior score showed a decrease that was greater than the Reliable Change Index-or if the patient died. Risk factors [pre-ARDS baseline status, intensive care unit (ICU) illness severity, and other intensive care variables] were evaluated using longitudinal, generalized linear regression models for each measure.

RESULTS

During the follow-up of 193 ARDS survivors (55 % male; median age 49 years), 166 (86 %) experienced decline in ≥1 physical measure (including death) and 133 (69 %) experienced a physical decline (excluding death). For all measures, age was a significant risk factor [odds ratios (OR) 1.34-1.69 per decade; p < 0.001]. Pre-ARDS comorbidity (Charlson Index) was independently associated with declines in strength and exercise capacity (OR 1.10 and 1.18, respectively; p < 0.02), and organ failure [maximum daily Sequential Organ Failure Assessment (SOFA) score in ICU] was associated with declines in strength (OR 1.06 per 1 point of SOFA score; p = 0.02).

CONCLUSIONS

Over the follow-up period, the majority of ARDS survivors experienced a physical decline, with older age and pre-ICU comorbidity being important risk factors for this decline.