Preventing Chronic Critical Illness and Rehospitalization: A Focus on Sepsis

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Chronic critical illness in critically ill COVID-19 patients

OBJECTIVES

To evaluate the presence of chronic critical illness (CCI) in COVID-19 patients and compare clinical characteristics and prognosis of patients with and without CCI admitted to intensive care unit (ICU).

METHODS

It was a retrospective, observational study at a university hospital ICU. Patients were accepted as CCI if they had prolonged ICU stay (≥14 days) and got ≥1 score for cardiovascular sequential organ failure assessment (SOFA) score and ≥2 score in other parameters on day 14 of ICU admission which was described as persistent organ dysfunction.

RESULTS

131 of 397 (33%) patients met CCI criteria. CCI patients were older (p = 0.003) and frailer (p < 0.001). Their Acute Physiology and Chronic Health Evaluation (APACHE) II and SOFA scores were higher, PaO2/FiO2 ratio was lower (p < 0.001). Requirement of invasive mechanical ventilation (IMV), steroid use, and septic shock on admission were higher in the CCI group (p < 0.001). CCI patients had higher ICU and hospital mortality than other patients (54.2% vs. 19.9% and 55.7% vs. 22.6%, p < 0.001, respectively). Regression analysis revealed that IMV (OR: 8.40, [5.10-13.83], p < 0.001) and PaO2/FiO2 < 150 on admission (OR: 2.25, [1.36-3.71], p = 0.002) were independent predictors for CCI.

DISCUSSION

One-third of the COVID-19 patients admitted to the ICU were considered as CCI with significantly higher ICU and hospital mortality.

Evaluation of Incident 7-Day Infection and Sepsis Hospitalizations in an Integrated Health System

RATIONALE

Pre-hospital opportunities to predict infection and sepsis hospitalization may exist, but little is known about their incidence following common healthcare encounters.

OBJECTIVES

To evaluate the incidence and timing of infection and sepsis hospitalization within 7 days of living hospital discharge, emergency department discharge, and ambulatory visit settings.

METHODS

In each setting, we identified patients in clinical strata based on the presence of infection and severity of illness. We estimated number needed to evaluate values with hypothetical predictive model operating characteristics.

RESULTS

We identified 97,614,228 encounters including 1,117,702 (1.1 %) hospital discharges, 4,635,517 (4.7%) emergency department discharges, and 91,861,009 (94.1 %) ambulatory visits between 2012 and 2017. The incidence of 7-day infection hospitalization varied from 37,140 (3.3%) following inpatient discharge, 50,315 (1.1%) following emergency department discharge, and 277,034 (0.3%) following ambulatory visits. The incidence of 7-day infection hospitalization was increased for inpatient discharges with high readmission risk (10.0%), emergency department discharges with increased acute or chronic severity of illness (3.5% and 4.7%, respectively), and ambulatory visits with acute infection (0.7%). The timing of 7-day infection and sepsis hospitalizations differed across settings with an early rise following ambulatory visits, a later peak following emergency department discharges, and a delayed peak following inpatient discharge. Theoretical number needed to evaluate values varied by strata, but following hospital and emergency department discharge, were as low as 15 to 25.

CONCLUSIONS

Incident 7-day infection and sepsis hospitalizations following encounters in routine healthcare settings were surprisingly common and may be amenable to clinical predictive models.

Erste Evaluation eines Programms zur Frührehabilitation von Langzeitintensivpatient_innen

First evaluation of an early rehabilitation programm for chronically critically ill patients Abstract. Introduction: Chronically critically ill patients are an increasing challenge for teams in intensive care units due to the burden of symptoms and the consumption of resources. Structured multimodal concepts are recommended for nursing care and treatment. A local, interprofessional program for early rehabilitation aims to provide optimal care for patients through a systematic, proactive and holistic treatment process with a rehabilitative focus. The program consists of specific assessments and systematic coordination of interprofessional early rehabilitation. Problem and objective: Interprofessional collaboration requires mutual acceptance and good communication from those involved. The functioning of selected processes as well as the satisfaction of the professionals are topics of a first formative evaluation. Methods: The team evaluated descriptive quality data as well as self-generated structured questionnaires. Results: Specific adjustments were made to the treatment plan for 52 of 112 patients in the program. The assessments are easy to carry out and support systematic early rehabilitation. From the perspective of the professionals involved, both the interprofessional collaboration and their understanding for the patients improved. Discussion and transfer: The program optimizes treatment and promotes good interprofessional collaboration. The formative evaluation provides valuable information for future process changes such as the inclusion of patients as well as further disciplines and program development beyond the boundaries of the intensive care unit.

Immunological Endotyping of Chronic Critical Illness After Severe Sepsis

Improved management of severe sepsis has been one of the major health care accomplishments of the last two decades. Due to enhanced recognition and improved management of severe sepsis, in-hospital mortality has been reduced by up to 40%. With that good news, a new syndrome has unfortunately replaced in-hospital multi-organ failure and death. This syndrome of chronic critical illness (CCI) includes sepsis patients who survive the early "cytokine or genomic storm," but fail to fully recover, and progress into a persistent state of manageable organ injury requiring prolonged intensive care. These patients are commonly discharged to long-term care facilities where sepsis recidivism is high. As many as 33% of sepsis survivors develop CCI. CCI is the result, at least in part, of a maladaptive host response to chronic pattern-recognition receptor (PRR)-mediated processes. This maladaptive response results in dysregulated myelopoiesis, chronic inflammation, T-cell atrophy, T-cell exhaustion, and the expansion of suppressor cell functions. We have defined this panoply of host responses as a persistent inflammatory, immune suppressive and protein catabolic syndrome (PICS). Why is this important? We propose that PICS in survivors of critical illness is its own common, unique immunological endotype driven by the constant release of organ injury-associated, endogenous alarmins, and microbial products from secondary infections. While this syndrome can develop as a result of a diverse set of pathologies, it represents a shared outcome with a unique underlying pathobiological mechanism. Despite being a common outcome, there are no therapeutic interventions other than supportive therapies for this common disorder. Only through an improved understanding of the immunological endotype of PICS can rational therapeutic interventions be designed.

Sirtuin 2 expression levels may predict the progression of sepsis survivors to chronic critical illness

Background

Sirtuin 2 (SIRT2) is a conserved deacetylase that participates in the regulation of inflammation in sepsis. In this observational prospective study, we investigated the predictive value of the SIRT2 expression level in the development of chronic critical illness (CCI) in patients with sepsis.

Methods

A total of 128 critically ill patients with sepsis or septic shock were enrolled and assigned to the CCI group, rapid recovery (RAP) group, or early death group according to their clinical trajectories. Patients’ demographic and clinical information, as well as laboratory data, including C-reactive protein (CRP) level and total lymphocyte counts, were collected. Blood samples were obtained at admission and on days 1, 4, 7, 10, 14, and 21 (days 14 and 21 for the CCI group only). Peripheral blood mononuclear cells were isolated, and SIRT2 expression was measured by real-time polymerase chain reaction. Serum levels of interleukin (IL)-6 and IL-10 were measured by enzyme-linked immunosorbent assay.

Results

Our cohort included 37 CCI and 82 RAP patients, and 9 early death patients, who died within 14 days of intensive care unit (ICU) admission. Compared with the RAP group, CCI patients showed elevated CRP and IL-6 levels throughout the observation period, reflecting a sustained inflammatory response. However, decreases in total lymphocyte count and IL-10 expression in these patients were indicative of immunosuppression. SIRT2 mRNA level was lower in CCI and RAP patients compared with healthy controls at the initial stage of hospitalization, but increased starting on day 4 and continued to increase for the duration of hospitalization. By day 10, SIRT2 expression had almost returned to normal in RAP patients; however, in CCI patients, it continued to increase until the end of the observation period. A receiver-operating characteristic curve analysis showed that the expression level of SIRT2 at 10 days predicts the occurrence of CCI (P<0.05).

Conclusions

SIRT2 expression may be a useful marker for identifying sepsis survivors who are at risk of progressing to CCI.

Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.

Hierarchical analysis of factors associated with hospital readmissions for coronary heart disease: A case-control study

AIMS AND OBJECTIVES

To analyse, hierarchically, factors associated with hospital readmissions for acute coronary syndrome.

BACKGROUND

Hospital readmissions have risen, especially in patients with multiple comorbidities, which are most often chronic. The leading causes of hospital readmission include acute coronary syndrome, which is costly and often preventable. Determining clinical and nonclinical variables that increase the chances of readmission is important to assess and evaluate patients hospitalised for coronary heart diseases.

DESIGN

A case-control study whose dependent variable was hospital readmission for acute coronary syndrome.

METHODS

The study included 277 inpatients, of whom 132 were in their first hospitalisation and 145 had already been hospitalised for acute coronary syndrome. The independent variables for this hierarchical model were sociodemographic conditions, life habits, access to health services and physical health measures. Data were obtained by interviews, anthropometric measurements and patient records. Logistic regression analysis was performed using the stepwise technique, with Microsoft Excel and R version 3.2.3. The research was reported via strengthening the reporting of observational studies in epidemiology (STROBE).

RESULTS

In the final hierarchical logistic model, the following risk factors were associated with readmission for acute coronary syndrome: inadequate drug therapy adherence, stress, history of smoking for 30 years or more, and the lack of use of primary healthcare services.

CONCLUSIONS

Clinical and nonclinical variables are related to hospital readmission for acute coronary syndrome and can increase the chance of readmission by up to six times.

RELEVANCE TO CLINICAL PRACTICE

The predictive model can be used to avoid readmission for acute coronary syndrome, and it represents an advance in the prediction of the occurrence of the outcome. This implies the need for a reorientation of the network for postdischarge care in the first hospitalisation for acute coronary syndrome.