Health-related quality of life as a prognostic factor of survival in critically ill patients

Nursing workload and patient-focused outcomes in intensive care: A systematic review

The aim of this systematic review was to examine the association of nursing workload on patient outcomes in intensive care units. The primary outcome measure was patient mortality, with adverse events (AE), the secondary outcome measures. Electronic search of databases including MEDLINE, CINAHL, Cochrane, EMCARE, Scopus, and Web of Science were performed. Studies were excluded if they were in non-ICU settings, pediatric, neonatal populations, or if the abstract/full text was unavailable. Risk of bias was assessed by the ROBINS-I tool. After screening 4129 articles, 32 studies were identified as meeting inclusion criteria. The majority of included studies were assessed as having a moderate risk of bias. The nursing activities score (NAS) was the most frequently used tool to assess nursing workload. Our systematic review identified that higher nursing workload was associated with patient-focused outcomes, including increased mortality and AE in the intensive care setting. The varied approaches of measuring and reporting nursing workload make it difficult to translate the findings of the impact of nursing workload on patient outcomes in intensive care settings.

Can a Dyadic Resiliency Program Improve Quality of Life in Cognitively Intact Dyads of Neuro-ICU Survivors and Informal Caregivers? Results from a Pilot RCT

BACKGROUND

Neuro-ICU hospitalization for an acute neurological illness is often traumatic and associated with heightened emotional distress and reduced quality of life (QoL) for both survivors and their informal caregivers (i.e., family and friends providing unpaid care). In a pilot study, we previously showed that a dyadic (survivor and caregiver together) resiliency intervention (Recovering Together [RT]) was feasible and associated with sustained improvement in emotional distress when compared with an attention placebo educational control. Here we report on changes in secondary outcomes assessing QoL.

METHODS

Survivors (n = 58) and informal caregivers (n = 58) completed assessments at bedside and were randomly assigned to participate together as a dyad in the RT or control intervention (both 6 weeks, two in-person sessions at bedside and four sessions via live video post discharge). We measured QoL domain scores (physical health, psychological, social relations, and environmental), general QoL, and QoL satisfaction using the World Health Organization Quality of Life Abbreviated Instrument at baseline, post treatment, and 3 months' follow-up. We conducted mixed model analyses of variance with linear contrasts to estimate (1) within-group changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up and (2) between-group differences in changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up.

RESULTS

We found significant within-group improvements from baseline to post treatment among RT survivors for physical health QoL (mean difference 1.73; 95% confidence interval [CI] 0.39-3.06; p = 0.012), environmental QoL (mean difference 1.29; 95% CI 0.21-2.36; p = 0.020), general QoL (mean difference 0.55; 95% CI 0.13-0.973; p = 0.011), and QoL satisfaction (mean difference 0.87; 95% CI 0.36-1.37; p = 0.001), and those improvements sustained through the 3-month follow-up. We found no significant between-group improvements for survivors or caregivers from baseline to post treatment or from post treatment to 3 months' follow-up for any QoL variables (i.e., domains, general QoL, and QoL satisfaction together).

CONCLUSIONS

In this pilot study, we found improved QoL among survivors, but not in caregivers, who received RT and improvements sustained over time. These RT-related improvements were not significantly greater than those observed in the control. Results support a fully powered randomized controlled trial to allow for a definitive evaluation of RT-related effects among dyads of survivors of acute brain injury and their caregivers.

Improvement of quality of life (QOL) between 1 and 3-4 years after traumatic brain injury (TBI) in ICU patients

BACKGROUND

Evaluation of changes in quality of life (QOL) in ICU patients several years after traumatic brain injury (TBI) is not well documented.

METHODS

A prospective cohort study was conducted in all patients with TBI admitted between 2004 and 2008 to the ICU of Regional Hospital of Malaga (Spain). Functional status was evaluated by Glasgow Outcome Scale (GOS) and QOL by PAECC (Project for the Epidemiologic Analysis of Critical Care patients) questionnaire between 0 (normal QOL) to 29 points (worst QOL).

RESULTS

A total of 531 patients. Median(Quartile1,Quartile 3) age: 35 (22, 56) years. After 3-4 years, 175 died (33%). Survivor QOL was deteriorated (median total PAECC score: 5 (0, 11) points) although 75.76% of patients who survived showed good functional situation (GOS normal or mild dysfunction). An improvement in QOL scores between 1 and 3-4 years was observed (median PAECC score differences between 3-4 years and 1 year: - 1(- 4, 0) points). QOL score improved during this interval of time: 62.6% of patients. Change in QOL was related by multivariate analysis to admission cranial-computed tomography scan (Marshall's classification), age, and Injury Severity Score (ISS), with the biggest improvement seen in younger patients and with more severe ISS. Basic physiological activities were maintained in the majority of patients. Subjective aspects and working activities improved between 1 and 3-4 years but with a high proportion still impaired in these items after 3-4 years.

CONCLUSIONS

ICU patients with TBI after 1 year show improvement in QOL between 1 and 3-4 years, with the biggest improvement in QOL seen in younger patients and in those with more severe ISS.

Demographic Shifts, Case Mix, Activity, and Outcome for Elderly Patients Admitted to Adult General ICUs in England, Wales, and Northern Ireland

OBJECTIVES

Major increases in the proportion of elderly people in the population are predicted worldwide. These population increases, along with improving therapeutic options and more aggressive treatment of elderly patients, will have major impact on the future need for healthcare resources, including critical care. Our objectives were to explore the trends in admissions, resource use, and risk-adjusted hospital mortality for older patients, admitted over a 20-year period between 1997 and 2016 to adult general ICUs in England, Wales, and Northern Ireland.

DESIGN

RETROSPECTIVE ANALYSIS OF NATIONAL CLINICAL AUDIT DATABASE.

SETTING

The Intensive Care National Audit & Research Centre Case Mix Programme Database, the national clinical audit for adult general ICUs in England, Wales, and Northern Ireland.

PATIENTS

All adult patients 16 years old or older admitted to adult general ICUs contributing data to the Case Mix Programme Database between January 1, 1997, and December 31, 2016.

MEASUREMENTS AND MAIN RESULTS

The annual number, trends, and outcomes for patients across four age bands (16-64, 65-74, 75-84, and 85+ yr) admitted to ICUs contributing to the Case Mix Programme Database from 1997 to 2016 were examined. Case mix, activity, and outcome were described in detail for the most recent cohort of patients admitted in 2015-2016. Between 1997 to 2016, the annual number of admissions to ICU of patients in the older age bands increased disproportionately, with increases that could not be explained solely by general U.K. demographic shifts. The risk-adjusted acute hospital mortality decreased significantly within each age band over the 20-year period of the study. Although acute severity at ICU admission was comparable with that of the younger age group, apart from cardiovascular and renal dysfunction, older patients received less organ support. Older patients stayed longer in hospital post-ICU discharge, and hospital mortality increased with age, but the majority of patients surviving to hospital discharge returned home.

CONCLUSIONS

Over the past two decades, elderly patients have been more commonly admitted to ICU than can be explained solely by the demographic shift. Importantly, as with the wider population, outcomes in elderly patients admitted to ICU are improving over time, with most patients returning home.

Long-term survival after intensive care: A retrospective cohort study

Background Limited data exist on long-term survival of patients requiring admission to intensive care units (ICUs). The aim of this study was to investigate long-term survival of ICU patients in Iceland and assess changes over a 15-year period. Methods Data were collected on age, gender, admission cause, length of stay, comorbidities, mechanical ventilation and survival of patients 18 years and older admitted to the ICUs in Landspitali during 2002-2016. Long-term survival of patients surviving more than 30 days from admission was estimated and its predictors assessed with Cox regression analysis. Long-term survival was compared to the survival of an age- and gender-matched reference group from the general population. Results Of 15 832 ICU admissions, 55% was medical, 38% was surgical and 7% was due to trauma. The 5-year survival of medical, surgical and trauma patients was 66%, 76% and 92% respectively. Significant survival differences were found between admission subgroups. Higher age and comorbidity burden was related to decreased survival in all patient groups. After correcting for age, gender, comorbidities, length of ICU stay and mechanical ventilation, patient survival improved during the study period only for patients admitted for infections. There was a high variability in the estimated time point where the ICU admission had no residual effect on survival. Conclusions Long-term survival of ICU patients is substantially decreased compared to the general population, but varies based on admission causes. Improved long-term survival of patients admitted with infections could be explained by earlier detection and improved treatment of septic shock.

Short- and long-term prognosis of critically-ill patients referred to the ICU from the Emergency Department of a tertiary hospital

BACKGROUND AND OBJECTIVE

A frequent source of critically-ill patients admitted to the ICU is the Emergency Department. It is essential to analyse the short-term prognosis of these patients, but also their evolution after their discharge from the hospital, since this is one of the major concerns of these patients. The aim of this study is to describe the epidemiological characteristics of patients admitted to the ICU from the Emergency Department and to analyse their outcome.

PATIENTS AND METHOD

This consisted of an observational prospective cohorts study which included 269 Emergency Department patients consecutively admitted to the ICU over an 18-month period. Factors associated with hospital mortality were presented as an odds ratio (OR) and factors associated with long-term mortality were presented as a hazard ratio (HR). A P-value lower than .05 was accepted as significant. The overall survival was analysed on the basis of the Kaplan-Meier curves.

RESULTS

Hospital mortality was 15%, ICU complications where the variables with the greatest impact on short-term mortality: acute renal failure (OR 22.7) and respiratory distress syndrome (OR 51.2). After hospital discharge, the cumulative mortality at 12, 24 and 36 months was 6, 11 and 15%, respectively. The degree of functional dependence (HR 3.7), cancer (HR 3.4) and arrhythmias (HR 2.4) were factors related to long-term mortality.

CONCLUSIONS

The short-term outcome of ICU patients is related to age and comorbidity, but more significantly to the characteristics of the acute illness. However, the long-term outcome is more closely associated with the patients' characteristics.

Relationship between quality-of-life after 1-year follow-up and severity of traumatic brain injury assessed by computerized tomography

PURPOSE

This paper studies the relationship between computed tomography (CT) scan on admission, according to Marshall's tomographic classification, and quality-of-life (QoL) after 1 year in patients admitted to the Intensive Care Unit (ICU) with traumatic brain injury (TBI).

METHODS

This study used validated scales including the Glasgow Outcome Scale and the PAECC (Project for the Epidemiologic Analysis of Critical Care Patients) QoL questionnaire.

RESULTS

We enrolled 531 patients. After 1 year, 171 patients (32.2%) had died (missing data = 6.6%). Good recovery was seen in 22.7% of the patients, while 20% presented moderate disability. The PAECC score after 1 year was 9.43 ± 8.72 points (high deterioration). Patients with diffuse injury I had a mean of 5.08 points vs 7.82 in those with diffuse injury II, 11.76 in those with diffuse injury III and 19.29 in those with diffuse injury IV (p < 0.001). Multivariate analysis found that QoL after 1 year was associated with CT Marshall classification, depth of coma, age, length of stay, spinal injury and tracheostomy.

CONCLUSIONS

Patients with TBI had a high mortality rate 1 year after admission, deterioration in QoL and significant impairment of functional status, although more than 40% were normal or self-sufficient. QoL after 1 year was strongly related to cranial CT findings on admission.

Our paper 20 years later: 1-year survival and 6-month quality of life after intensive care

INTRODUCTION

In the early 1990s, the in-hospital mortality rate of intensive care unit (ICU) patients dropped, and interest in the quality of life (QOL) of ICU survivors increased. In 1996, we published a study to investigate 1-year survival after hospital discharge and 6-month QOL after intensive care. Now, we compare our previous results with those reported in the recent literature to appraise any changes, and new knowledge in the area.

RESULTS

The 1-year survival of ICU patients after hospital discharge is substantial, lower than in the general population, and different among subgroups. Some studies showed a reduction in QOL at 6 months, as in our study, while others showed an improvement. Different results seem to be related mainly to the case mix. Studies on different types of patients found long-term cognitive impairment in ICU survivors, possibly not disease specific. The proportions of patients with neuropsychological morbidities such as posttraumatic stress disorder, anxiety, and depression, described after our study, did not show any change over time.

CONCLUSIONS

Differences between studies on long-term survival and QOL do not allow conclusions to be drawn about change over time. No change was found in neuropsychological morbidities. However, a lack of change may not be viewed negatively, because critically ill patients who survive ICU today may be at higher risk for poor long-term outcome than in the past due to the higher severity of their illness and the more aggressive treatments received. Future studies may provide understanding of the relationships between psychiatric symptoms, cognitive impairment, functional disability, and QOL.

Outcome and quality of life of elderly critically ill patients: an Italian prospective observational study

The demand of critical care admissions to intensive care unit (ICU) is projected to rise in the next decade. The aim of this study was to evaluate short and long-term mortality and quality of life (QoL) of elderly patients (80 years and older) admitted to two ICUs for medical conditions, abdominal surgery (planned and unplanned) and orthopedic surgery for hip fractures, over a 6-year period. Three months and one year after ICU discharge, patients or family members were contacted by telephone to obtain follow-up information using the EuroQoL questionnaire. The data were compared with an age-matched of the Italian population. Two hundred eighty-eight patients were included in the study. ICU mortality of medical (14.8%) and unplanned surgical patients (26.4%) was higher than that of planned surgical (5.0%) and orthopedic patients (2.5%), as was hospital mortality (27.7% vs. 50.0% vs. 5.0% vs. 14.3%). Three months and 12 months mortality rates after ICU discharge were 40.7% and 61.1% in medical patients, 70.5% and 76.4% in unplanned surgical patients, 20.0% and 30.0% in planned surgical patients, 36.2% and 46.2% in orthopedic patients. QoL measures revealed that, one year after ICU discharge, medical and orthopedic patients had significantly more severe problems vis-à-vis mobility, self-care and activity than abdominal surgical patients and control population. Type of admission was the independent risk factor associated with ICU and long-term mortality, whereas age 90 year and older was associated with long-term mortality. Orthopedic surgery for hip fractures seems to influence QoL similar to medical diseases.

Health-related quality of life in Australian survivors of critical illness

OBJECTIVE

To document health-related quality of life of an Australian sample of intensive care unit survivors 6 months after intensive care unit discharge and compare this with preadmission health-related quality of life, health-related quality of life of national population norms, and international samples of intensive care unit survivors.

DESIGN

Prospective observational single-center study.

SETTING

Eighteen-bed medical-surgical tertiary intensive care unit of an Australian metropolitan hospital.

PATIENTS

Of the 122 eligible patients, 100 were recruited (intensive care unit length of stay >48 hrs, age >18 yrs, not imminently at risk of death) and the final sample comprised 67 patients, age (median [interquartile range], 61 yrs [49-73 yrs]), 60% male admitted to the intensive care unit for a median [interquartile range] 101 hrs (68-149 hrs). Normative age- and sex-matched Australian Short-Form 36 data from the Australian Bureau of Statistics, selected international cohorts of intensive care unit survivors, and their respective national age-matched normative data were included for comparison.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven participants provided responses to questions rating health-related quality of life (Australian Short-Form 36) at preadmission (on admission to the intensive care unit or through retrospective recall as soon as able) and 6 months after intensive care unit discharge. Ten additional participants were unable to provide study data without proxy input and were excluded from analysis. Participants reported clinically meaningful improvements in bodily pain (p = .001), social functioning (p = .03), role-emotional domains of the Short-Form 36 (p = .04), and mental component summary score (p = .01) at 6 months after intensive care unit discharge, mostly attributable to the patients undergoing cardiac surgery, whereas remaining Short-Form 36 domains showed no difference between preadmission and 6 months (p > .05). Participants reported clinically meaningful decrements in preadmission Short-Form 36 data compared with the Australian normative population with role-physical (p < .001) and physical functioning (p < .001) most affected at follow-up. Health-related quality of life in this sample was comparable with international samples of intensive care unit survivors.

CONCLUSIONS

Although the majority of health-related quality of life domains did not differ between preadmission and 6-month follow-up, participants reported significant and clinically meaningful improvements in pain and mental health at follow-up. Critical illness survivors' health-related quality of life remained within 1 sd of Australian norms at follow-up and physical function health-related quality of life was most affected. Health-related quality of life in these Australian survivors of the intensive care unit was comparable with international survivors 6 months after intensive care unit admission.

The effect of diabetes on mortality in critically ill patients: a systematic review and meta-analysis

Introduction

Critically ill patients with diabetes are at increased risk for the development of complications, but the impact of diabetes on mortality is unclear. We conducted a systematic review and meta-analysis to determine the effect of diabetes on mortality in critically ill patients, making a distinction between different ICU types.

Methods

We performed an electronic search of MEDLINE and Embase for studies published from May 2005 to May 2010 that reported the mortality of adult ICU patients. Two reviewers independently screened the resultant 3,220 publications for information regarding ICU, in-hospital or 30-day mortality of patients with or without diabetes. The number of deaths among patients with or without diabetes and/or mortality risk associated with diabetes was extracted. When only crude survival data were provided, odds ratios (ORs) and standard errors were calculated. Data were synthesized using inverse variance with ORs as the effect measure. A random effects model was used because of anticipated heterogeneity.

Results

We included 141 studies comprising 12,489,574 patients, including 2,705,624 deaths (21.7%). Of these patients, at least 2,327,178 (18.6%) had diabetes. Overall, no association between the presence of diabetes and mortality risk was found. Analysis by ICU type revealed a significant disadvantage for patients with diabetes for all mortality definitions when admitted to the surgical ICU (ICU mortality: OR [95% confidence interval] 1.48 [1.04 to 2.11]; in-hospital mortality: 1.59 [1.28 to 1.97]; 30-day mortality: 1.62 [1.13 to 2.34]). In medical and mixed ICUs, no effect of diabetes on all outcomes was found. Sensitivity analysis showed that the disadvantage in the diabetic surgical population was attributable to cardiac surgery patients (1.77 [1.45 to 2.16], P < 0.00001) and not to general surgery patients (1.21 [0.96 to 1.53], P = 0.11).

Conclusions

Our meta-analysis shows that diabetes is not associated with increased mortality risk in any ICU population except cardiac surgery patients.

Challenges and possible solutions for long-term follow-up of patients surviving critical illness

INTRODUCTION

Surviving critical illness can be life-changing and present new healthcare challenges for patients after discharge from hospital. Optimisation of recovery, rather than mere survival, is an important goal of intensive care. Observational studies have identified decreased quality of life and increased healthcare needs for survivors but loss to follow-up can be high with possible selection bias. Patients in need of support may therefore not be included in study results or allocated appropriate follow up support.

AIM

To examine the frequency and reasons patients admitted to general ICUs who survive critical illness are excluded from study participation or lost to follow-up and consider the possible implications and solutions.

METHOD

The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies (2006-2010) were included if they described follow-up of survivors from general ICUs.

RESULTS

Ten studies were reviewed. Of the 3269 eligible patients, 14% died after hospital discharge, 27% declined, and 22% were lost to follow-up. Reasons for loss to follow-up included no response, inability to contact the patient, too ill or admitted to another facility.

CONCLUSION

The most appropriate method of care follow-up has yet to be established but is likely to involve an eclectic model that tailors service provision to support individual patient needs. Identifying methods to minimise loss to follow-up may enhance interpretation of patients' recovery, lead to improvements in clinical practice and inform healthcare service decisions and policy.

Quality of life after intensive care: a systematic review of the literature

OBJECTIVES

To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life.

DATA SOURCES

EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files.

DATA EXTRACTION

Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients.

DATA SYNTHESIS

Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting.

CONCLUSIONS

Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.