Determinants of Health-Related Quality of Life After ICU: Importance of Patient Demographics, Previous Comorbidity, and Severity of Illness

Screening for post-intensive care syndrome: Validation of the Healthy Aging Brain Care Monitor Self-Report Chinese version

BACKGROUND

The Healthy Aging Brain Care Monitor Self-Report (HABC-M SR) is a tool to evaluate physical, mental and cognitive impairments. It has been validated in several countries for post-intensive care syndrome (PICS) assessment, but there is no Chinese version yet.

AIM

The aim of this study is to translate and cross-cultural adapt HABC-M SR, and validate its psychological properties among Chinese ICU survivors.

STUDY DESIGN

This is a cross-sectional study. the HABC-M SR was translated into Chinese and validated in intensive care unit survivors (n = 145). Measures of internal consistency, construct validity, concurrent validity, and content validity were evaluated.

RESULTS

A 19-item Chinese version of HABC-M SR was yielded, with good reliability (Cronbach's α = 0.92) and validity (the variance was 64.4%, overall content validity was 0.91, and correlation coefficients were 0.62-0.90).

CONCLUSIONS

The 19-item Chinese version HABC-M SR is a reliable and valid tool for PICS assessing and may be regarded as a standard measurement.

RELEVANCE TO CLINICAL PRACTICE

The Chinese version HABC-M SR may help in selecting PICS high-risk survivors for ICU follow-up interventions. The HABC-M SR can also be regarded as a standard specific PICS measurement, thus promote the comparability between studies and transformation of the clinical evidence.

Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors

INTRODUCTION

Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury.

METHODS

Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ​≥ ​3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors.

RESULTS

2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR ​= ​1.57; 95% CI ​= ​1.21, 2.03), and worse SF-12 mental (mean Δ ​= ​-1.43; 95% CI ​= ​-2.79, -0.09) and physical scores (mean Δ ​= ​-2.61; 95% CI ​= ​-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group.

CONCLUSIONS

Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

An Exploratory Analysis of Sociodemographic Factors Associated With Physical Functional Impairment in ICU Survivors

IMPORTANCE

Physical functional impairment is one of three components of postintensive care syndrome (PICS) that affects up to 60% of ICU survivors.

OBJECTIVES

To explore the prevalence of objective physical functional impairment among a diverse cohort of ICU survivors, both at discharge and longitudinally, and to highlight sociodemographic factors that might be associated with the presence of objective physical functional impairment.

DESIGN, SETTING, AND PARTICIPANTS

This was a secondary analysis of 37 patients admitted to the ICU in New Orleans, Louisiana, and Denver, Colorado between 2016 and 2019 who survived with longitudinal follow-up data.

MAIN OUTCOMES AND MEASURES

Our primary outcome of physical functional impairment was defined by handgrip strength and the short physical performance battery. We explored associations between functional impairment and sociodemographic factors that included race/ethnicity, sex, primary language, education status, and medical comorbidities.

RESULTS

More than 75% of ICU survivors were affected by physical functional impairment at discharge and longitudinally at 3- to 6-month follow-up. We did not see a significant difference in the proportion of patients with physical functional impairment by race/ethnicity, primary language, or education status. Impairment was relatively higher in the follow-up period among women, compared with men, and those with comorbidities. Among 18 patients with scores at both time points, White patients demonstrated greater change in handgrip strength than non-White patients. Four non-White patients demonstrated diminished handgrip strength between discharge and follow-up.

CONCLUSIONS AND RELEVANCE

In this exploratory analysis, we saw that the prevalence of objective physical functional impairment among ICU survivors was high and persisted after hospital discharge. Our findings suggest a possible relationship between race/ethnicity and physical functional impairment. These exploratory findings may inform future investigations to evaluate the impact of sociodemographic factors on functional recovery.

A randomized clinical trial to evaluate the effect of post-intensive care multidisciplinary consultations on mortality and the quality of life at 1 year

PURPOSE

Critical illness is associated with long-term increased mortality and impaired quality of life (QoL). We assessed whether multidisciplinary consultations would improve outcome at 12 months (M12) after intensive care unit (ICU) discharge.

METHODS

We performed an open, multicenter, parallel-group, randomized clinical trial. Eligible are patients discharged alive from ICU in 11 French hospitals between 2012 and 2018. The intervention group had a multidisciplinary face-to-face consultation involving an intensivist, a psychologist, and a social worker at ICU discharge and then at M3 and M6 (optional). The control group had standard post-ICU follow-up. A consultation was scheduled at M12 for all patients. The QoL was assessed using the EuroQol-5 Dimensions-5 Level (Euro-QoL-5D-5L) which includes five dimensions (mobility, self-care, usual activities, pain, and anxiety/depression), each ranging from 1 to 5 (1: no, 2: slight, 3: moderate, 4: severe, and 5: extreme problems). The primary endpoint was poor clinical outcome defined as death or severe-to-extreme impairment of at least one EuroQoL-5D-5L dimension at M12. The information was collected by a blinded investigator by phone. Secondary outcomes were functional, psychological, and cognitive status at M12 consultation.

RESULTS

540 patients were included (standard, n = 272; multidisciplinary, n = 268). The risk for a poor outcome was significantly greater in the multidisciplinary group than in the standard group [adjusted odds ratio 1.49 (95% confidence interval, (1.04-2.13)]. Seventy-two (13.3%) patients died at M12 (standard, n = 32; multidisciplinary, n = 40). The functional, psychological, and cognitive scores at M12 did not statistically differ between groups.

CONCLUSIONS

A hospital-based, face-to-face, intensivist-led multidisciplinary consultation at ICU discharge then at 3 and 6 months was associated with poor outcome 1 year after ICU.

Association of Psoas Muscle Mass at Intensive Care Unit Admission With Physical Function and Post-discharge Destination in Survivors of Critical Illness

OBJECTIVE

Survivors of critical illness may have physical impairments, known as post-intensive care syndrome (PICS). Early screening for the risk of PICS is recommended to prevent PICS. Skeletal muscle mass is a clinically important indicator associated with various outcomes. This study aimed to examine the association of psoas muscle mass at intensive care unit (ICU) admission with the destination and physical function at hospital discharge.

METHODS

In this single-center retrospective cohort study, we reviewed the medical records of adult patients who had required emergency ICU admission and who had been intubated and mechanically ventilated. Psoas major muscle was measured as an indicator of skeletal muscle mass from abdominal computed tomography images at ICU admission. Physical function was assessed using the functional status score for the ICU and ICU mobility scale at hospital discharge. Multinomial logistic and multivariable linear regression were used to analyze the associations of the psoas muscle mass with the discharge destination and physical function at discharge.

RESULTS

We enrolled 124 patients (79 men and 45 women) with a median (interquartile range) age of 72.0 (62.0-80.0) years; 39 (31.5%) were discharged to home, 50 (40.3%) were transferred to rehabilitation wards, and 35 (28.2%) were transferred to long-term care settings. The psoas muscle area and volume were 16.9 (11.3-20.6) cm2 and 228.3 (180.2-282.0) cm3 in home discharge patients, 17.5 (11.5-21.5) cm2 and 248.4 (162.0-311.4) cm3 in rehabilitation ward patients, and 15.9 (10.3-19.5) cm2 and 184.0 (137.0-251.1) cm3 in long-term care patients. The areas and volumes of the psoas muscle were not significantly different in the three groups. Furthermore, psoas muscle mass was not significantly associated with the discharge destination and physical function.

CONCLUSIONS

Discharge destination and physical function at hospital discharge were not significantly associated with psoas muscle mass at ICU admission.

Determinants of Subjective Mental and Functional Health of Critical Illness Survivors: Comparing Pre-ICU and Post-ICU Status

OBJECTIVES

To compare ICU survivors' subjective mental and functional health before ICU admission and after discharge and to assess determinants of subjective health decline or improvement.

DESIGN

Secondary analysis of the multicenter cluster-randomized Enhanced Recovery after Intensive Care trial ( ClinicalTrials.gov : NCT03671447).

SETTING

Ten ICU clusters in Germany.

PATIENTS

Eight hundred fifty-five patients with 1478 follow-up assessments.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At two patient follow-ups scheduled 3 and 6 months after ICU discharge, patients rated their subjective mental and functional/physical health on two separate visual analog scales from 0 (worst) to 10 (best) in the previous week and before ICU admission. We compared pre-ICU and post-ICU subjective health and used mixed-effects regression to assess determinants of a health decline or improvement. At the first follow-up, 20% ( n = 165/841) and 30% ( n = 256/849) of patients reported a decline in subjective mental and functional health of at least three points, respectively; 16% ( n = 133/841 and n = 137/849) outlined improvements of mental and functional health. For 65% ( n = 543/841) and 54% ( n = 456/849), mental and functional health did not change three points or more at the first follow-up. Multivariable mixed-effects logistic regressions revealed that the ICU length of stay was a predictor of mental (adjusted odds ratio [OR] per ICU day, 1.04; 95% CI, 1.00-1.09; p = 0.038) and functional health (adjusted OR per ICU day, 1.06; 95% CI, 1.01-1.12; p = 0.026) decline. The odds of a mental health decline decreased with age (adjusted OR per year, 0.98; 95% CI, 0.96-0.99; p = 0.003) and the odds of a functional health decline decreased with time after discharge (adjusted OR per month, 0.86; 95% CI, 0.79-0.94; p = 0.001).

CONCLUSIONS

The majority of ICU survivors did not experience substantial changes in their subjective health status, but patients with long ICU stays were prone to subjective mental and functional health decline. Hence, post-ICU care in post-ICU clinics could focus on these patients.

Effects of education, income and employment on ICU and post-ICU survival - A nationwide Swedish cohort study of individual-level data with 1-year follow up

PURPOSE

The aim of this study was to examine relationships between education, income, and employment (socioeconomic status, SES) and intensive care unit (ICU) survival and survival 1 year after discharge from ICU (Post-ICU survival).

METHODS

Individual data from ICU patients were linked to register data of education level, disposable income, employment status, civil status, foreign background, comorbidities, and vital status. Associations between SES, ICU survival and 1-year post-ICU survival was analysed using Cox's regression.

RESULTS

We included 58,279 adults (59% men, median length of stay in ICU 4.0 days, median SAPS3 score 61). Survival rates at discharge from ICU and one year after discharge were 88% and 63%, respectively. Risk of ICU death (Hazard ratios, HR) was significantly higher in unemployed and retired compared to patients who worked prior to admission (1.20; 95% CI: 1.10-1.30 and 1.15; (1.07-1.24), respectively. There was no consistent association between education, income and ICU death. Risk of post-ICU death decreased with greater income and was roughly 16% lower in the highest compared to lowest income quintile (HR 0.84; 0.79-0.88). Higher education levels appeared to be associated with reduced risk of death during the first year after ICU discharge.

CONCLUSIONS

Significant relationships between low SES in the critically ill and increased risk of death indicate that it is important to identify and support patients with low SES to improve survival after intensive care. Studies of survival after critical illness need to account for participants SES.

Depression Negatively Impacts Dyadic Quality of Life Following Neuro-ICU Admission: A Prospective Study of Cognitively Intact Patients and Caregivers

BACKGROUND

Admission to a neurological intensive care unit (Neuro-ICU) can increase risk for depressive and anxiety symptoms for both patients and caregivers. To better understand the long-term mental health impact of a Neuro-ICU admission, we examined the dyadic interdependence between depression and anxiety at Neuro-ICU admission with 3-month quality of life (QoL) for patients and caregivers in a longitudinal, observational cohort study.

METHOD

We assessed depressive and anxiety symptoms (Hospital Anxiety and Depression Scale; HADS) reported by neurologically intact patients (n = 72) and their caregivers (n = 72) within 2 weeks of Neuro-ICU admission (baseline) and 3-months post-discharge (follow-up). We examined the longitudinal association between dyadic depression and anxiety at Neuro-ICU admission and 3-month QoL (World Health Organization; QOL-BREF) across four domains (Physical, Psychological, Social relationships, and Environmental QoL) in separate actor-partner interdependence models (APIM) for patients and caregivers.

RESULTS

In the overall models, patients' own baseline depression levels were negatively associated with their own 3-month QoL in all domains (β =  - 0.53 to - 0.64, p < 0.001), and for caregivers, only in the psychological (β =  - 0.73, p < .001) and social relationships (β =  - 0.56, p < .001) domains. No actor effects were found for one's own baseline anxiety impacting one's own 3-month QoL. Partner effects for one's own depression were significant for caregivers on patients' 3-month psychological (β =  - 0.26, p < .02) and environmental (β =  - 0.29, p < .03) QoL, as well as for patients on caregiver's 3-month psychological QoL (β = 0.25, p < .02). No partner effects were significant in association with baseline anxiety and 3-month QoL in both patients and caregivers.

CONCLUSION

Neuro-ICU patients' and caregivers' baseline depression has significant negative impacts on their own long-term QoL. Caregivers demonstrate significant negative impacts on patient long-term QoL in domains related to emotional distress and caregiver burden. Early identification of mental health symptoms, especially depression, during Neuro-ICU admission may provide an intervention opportunity to improve QoL post-discharge for both dyad members.

Lower quality of life in obese ICU survivors: a multicenter cohort study

PURPOSE

To compare health-related quality of life (HRQoL) and functional status between obese, underweight, normal-weight, and overweight patients after three months post-intensive care unit (ICU) discharge.

METHODS

Multicenter cohort study (10 Brazilian ICUs). 1600 ICU survivors (≥ 72 h in the ICU) were included.The main outcomes were HRQoL and functional status assessed three months after the ICU discharge. The secondary outcomes were mortality, hospital readmission, and ICU readmission during the same period.

RESULTS

Obese patients (median 50.1; IQR 39.6-59.6) had lower HRQoL in the mental component than normal-weight patients (median 53; IQR 45.6-60.1) (p = 0.033). No differences were found between BMI categories regarding the physical component of HRQoL and the Barthel Index (p = 0.355 and 0.295, respectively). Regarding readmissions, 65.1 and 25.1% of patients were readmitted to the hospital and ICU, but there was no difference between the groups (p = 0.870 and 0.220, respectively). Obese patients died less frequently (11.8%) than underweight (30.9%) and normal-weight (19.3%) patients (p < 0.001).

CONCLUSION

After three months of post-ICU discharge, obese patients had lower HRQoL in the mental component than normal-weight patients. However, obese patients died less than underweight and normal-weight patients.

The Experience of Physical Recovery and Physical Rehabilitation Following Hospital Discharge for Intensive Care Survivors-A Qualitative Systematic Review

BACKGROUND

Over 120,000 people in the UK survive critical illness each year, with over 60% of these experiencing mobility issues and reduced health-related quality of life after discharge home. This qualitative systematic review aimed to explore critical care survivors' perceptions, opinions, and experiences of physical recovery and physical rehabilitation following hospital discharge.

METHODS

This review followed the Joanna Briggs Institute (JBI) methodology with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was conducted between January 2020 and June 2022. The search was conducted using the following databases: Embase, CINAHL, Medline Ovid, Cochrane, and the Joanna Briggs Institute, and sources of grey literature were searched for eligible studies. Qualitative studies focused on physical rehabilitation or recovery, involving adult survivors of critical illness who had been discharged from hospital.

RESULTS

A total of 7 of 548 identified studies published in 2007-2019 were eligible for inclusion. The findings indicate that qualitative evidence around the experiences of physical recovery and rehabilitation interventions following discharge home after critical illness is limited. Three synthesised findings were identified: 'Positivity, motivation and hope'; 'Recovery is hard and patients need support'; and 'Patients experience challenges in momentum of physical recovery'.

CONCLUSIONS

Survivors struggle to access healthcare professionals and services following discharge home, which influences the momentum of physical recovery. Supervised exercise programmes had a positive impact on the perception of recovery and motivation. However, 'simple' structured exercise provision will not address the range of challenges experienced by ICU survivors. Whilst some factors influencing physical recovery are similar to other groups, there are unique issues experienced by those returning home after critical illness. Further research is needed to identify the support or interventions survivors feel would meet their needs and assist their physical recovery. This study was prospectively registered with Prospero on 3/2/2020 with registration number CRD42020165290.

Long-term functional disabilities in intensive care unit survivors: A prospective cohort study

BACKGROUND

Functional disabilities are common in intensive care unit (ICU) survivors and may affect their ability to live independently. Few previous studies have investigated long-term functional outcomes with health status before ICU admission (pre-ICU health), and they are limited to specific patient groups.

OBJECTIVES

The objective of this study was to investigate the prevalence of functional disabilities and examine pre-ICU health variables as possible predictive factors of functional disabilities 12 months after ICU admission in a mixed population of ICU survivors.

METHODS

This prospective cohort study was conducted in six ICUs in Norway. Data on pre-ICU health were collected as soon as possible after ICU admission using patients, proxies, and patient electronic health records and at 12 months after ICU admission. Self-reported functional status was assessed using the Katz Index of independence in personal activities of daily living (P-ADL) and the Lawton instrumental activities of daily living scale (I-ADL).

RESULTS

A total of 220 of 343 (64%) ICU survivors with data on pre-ICU health completed the questionnaires at 12 months and reported the following functional disabilities at 12 months: 31 patients (14.4%) reported P-ADL dependencies (new in 16 and persisting in 15), and 80 patients (36.4%) reported I-ADL dependencies (new in 41 and persisting in 39). In a multivariate analysis, worse baseline P-ADL and I-ADL scores were associated with dependencies in P-ADLs (odds ratio [OR]: 1.87; 95% confidence interval [CI]: 1.14-3.06) and I-ADLs (OR: 1.52; 95% CI: 1.03-2.23), respectively, at 12 months. Patients who were employed were less likely to report I-ADL dependencies at 12 months (OR: 0.34; 95% CI: 0.12-0.95).

CONCLUSION

In a subsample of ICU survivors, patients reported functional disabilities 12 months after ICU admission, which was significantly associated with their pre-ICU functional status. Early screening of pre-ICU functional status may help identify patients at risk of long-term functional disabilities. ICU survivors with pre-ICU functional disabilities may find it difficult to improve their functional status.

Do critical illness survivors with multimorbidity need a different model of care?

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

Longitudinal study evaluating post-ICU syndrome differences between acute care surgery and trauma SICU survivors

BACKGROUND

Post-intensive care unit (ICU) syndrome (PICS) occurs at an exorbitant rate in surgical ICU (SICU) survivors. It remains unknown if critical illness due to trauma versus acute care surgery (ACS) may represent different pathophysiologic entities. In this longitudinal study, we determined if admission criteria in a cohort of trauma and ACS patients were associated with differences in the occurrence of PICS.

METHODS

Patients were 18 years or older, admitted to a Level I trauma center to the trauma or ACS services, remained in the SICU for ≥72 hours, and were seen in an ICU Recovery Center at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. Post-ICU syndrome sequelae were diagnosed by dedicated specialist staffing using clinical criteria and screening questionnaires. The PICS symptoms were distilled into physical, cognitive, and psychiatric categories. Preadmission histories, hospital courses, and recovery data were collected via retrospective chart review.

RESULTS

One hundred twenty-six patients were included: 74 (57.3%) trauma patients and 55 (42.6%) ACS patients. Prehospital psychosocial histories were similar between groups. Acute care surgery patients had a significantly longer hospital course, higher APACHE II and III scores, were intubated for longer, and had higher rates of sepsis, acute renal failure, open abdomen, and hospital readmissions. At the 2-week follow-up visit, ACS patients had higher rates of PICS sequelae (ACS, 97.8% vs. trauma 85.3%; p = 0.03), particularly in the physical (ACS, 95.6% vs. trauma 82.0%, p = 0.04), and psychiatric domains (ACS, 55.6% vs. trauma 35.0%, p = 0.04). At the 12-week and 24-week visits, rates of PICS symptoms were comparable between groups.

CONCLUSION

The occurrence of PICS is extraordinarily high in both trauma and ACS SICU survivors. Despite entering the SICU with similar psychosocial histories, the two cohorts have different pathophysiologic experiences, which are associated with a higher rate of impairment in the ACS patients during early follow-up.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

The relationship between ICU survivorship, comorbidity and educational level in quality of life after intensive care

BACKGROUND

ICU survivors have lower quality of life (QoL) compared to a non-ICU-treated population. The reason for this is not fully understood, but differences in baseline characteristics may be an important factor. This study evaluates the roles of comorbidity and educational level as possible explanatory factors for differences in QoL in ICU survivors compared to a non-ICU-treated population.

METHODS

Using a provisional questionnaire with 218 questions in 13 domains on QoL after intensive care, we compared the responses from 395 adult ICU survivors and 195 non-ICU-treated controls. An initial bivariable linear correlation analysis compared the responses from the two groups. Two secondary multivariable regression analyses tested for effect modification by comorbidity and educational level, respectively, on the effect on QoL from belonging to the ICU survivor group compared to the control group.

RESULTS

There was a significant difference in QoL between the two groups in 170 of 218 (78%) questions. In the multivariable analyses, associations between group belonging and QoL remained in 139 questions. In 59 of these, both belonging to the ICU survivor group and comorbidity was associated to QoL, in parallel to each other. Comorbidity moderated the association between group belonging and QoL in six questions, with the highest proportion of questions within the domains of cognition and urinary functions, and the lowest proportion within appetite and alcohol, physical health, and fatigue. In 26 questions, both belonging to the ICU survivor group and educational level were associated to QoL, in parallel to each other. Educational level moderated the association between group belonging and QoL in 34 questions, with the highest proportion of questions within the domains of urinary functions, ADL and physical health, and the lowest proportion within the domains of cognition, appetite and alcohol, pain, sensory functions, and fatigue.

CONCLUSIONS

Lower QoL seen in ICU survivors compared to non-ICU-treated controls, as measured by our provisional questionnaire, cannot be explained only by a higher burden of comorbidity, and rarely by only educational level. In issues where comorbidity or educational level was associated to QoL, it often was so in parallel to an association from belonging to the ICU survivor group. Comparing QoL in ICU survivors to that of a non-ICU-treated population may be adequate despite differences in baseline characteristics.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): feasibility of a pragmatic randomised controlled trial

BACKGROUND

ICU survivors often suffer from prolonged physical and mental impairments resulting in the so called "Post-Intensive Care Syndrome" (PICS). The aftercare of former ICU patients affected by PICS in particular has not been addressed sufficiently in Germany so far. The aim of this study was to evaluate the feasibility of a pragmatic randomised trial (RCT) comparing an intensive care unit (ICU) follow-up clinic intervention to usual care.

METHODS

This pilot study in a German university hospital evaluated the feasibility of a pragmatic RCT. Patients were assigned in a 1:1 ratio to an ICU follow-up clinic intervention or to usual care. The concept of this follow-up clinic was previously developed in a participatory process with patients, next of kin, health care professionals and researchers. We performed a process evaluation and determined acceptability, fidelity, completeness of measurement instruments and practicality as feasibility outcomes. The RCT's primary outcome (health-related quality of life) was assessed six months after ICU discharge by means of the physical component scale of the Short-Form-12 self-report questionnaire.

RESULTS

The pilot study was conducted from June 2020 to May 2021 with 21 and 20 participants in the intervention and control group. Principal findings related to feasibility were 85% consent rate (N = 48), 62% fidelity rate, 34% attrition rate (N = 41) and 77% completeness of outcome measurements. The primary effectiveness outcome (health-related quality of life) could be measured in 93% of participants who completed the study (N = 27). The majority of participants (85%) needed assistance with follow-up questionnaires (practicality). Median length of ICU stay was 13 days and 85% (N = 41) received mechanical ventilation, median Sequential Organ Failure Assessment Score was nine. Six-month follow-up assessment was planned for all study participants and performed for 66% (N = 41) of the participants after 197 days (median).

CONCLUSION

The participatory developed intervention of an ICU follow-up clinic and the pragmatic pilot RCT both seem to be feasible. We recommend to start a pragmatic RCT on the effectiveness of the ICU follow-up clinic.

TRIAL REGISTRATION

ClinicalTrials.gov US NLM, NCT04186468, Submission: 02/12/2019, Registration: 04/12/2019, https://clinicaltrials.gov/ct2/show/NCT04186468.

Responsiveness of Critically Ill Adults With Multimorbidity to Rehabilitation Interventions: A Patient-Level Meta-Analysis Using Individual Pooled Data From Four Randomized Trials

OBJECTIVE

To explore if patient characteristics (pre-existing comorbidity, age, sex, and illness severity) modify the effect of physical rehabilitation (intervention vs control) for the coprimary outcomes health-related quality of life (HRQoL) and objective physical performance using pooled individual patient data from randomized controlled trials (RCTs).

DATA SOURCES

Data of individual patients from four critical care physical rehabilitation RCTs.

STUDY SELECTION

Eligible trials were identified from a published systematic review.

DATA EXTRACTION

Data sharing agreements were executed permitting transfer of anonymized data of individual patients from four trials to form one large, combined dataset. The pooled trial data were analyzed with linear mixed models fitted with fixed effects for treatment group, time, and trial.

DATA SYNTHESIS

Four trials contributed data resulting in a combined total of 810 patients (intervention n = 403, control n = 407). After receiving trial rehabilitation interventions, patients with two or more comorbidities had HRQoL scores that were significantly higher and exceeded the minimal important difference at 3 and 6 months compared with the similarly comorbid control group (based on the Physical Component Summary score (Wald test p = 0.041). Patients with one or no comorbidities who received intervention had no HRQoL outcome differences at 3 and 6 months when compared with similarly comorbid control patients. No patient characteristic modified the physical performance outcome in patients who received physical rehabilitation.

CONCLUSIONS

The identification of a target group with two or more comorbidities who derived benefits from the trial interventions is an important finding and provides direction for future investigations into the effect of rehabilitation. The multimorbid post-ICU population may be a select population for future prospective investigations into the effect of physical rehabilitation.

Application of the whole-course care model (IWF/C Care) for postintensive care syndrome based on an early warning system in critically ill patients: a randomised controlled trial study protocol

INTRODUCTION

Critically ill patients are at risk of developing postintensive care syndrome (PICS), which is manifested by physical, psychological and cognitive impairment. Currently, there are no programmes that combine early warning systems with interventions for PICS. We hypothesise that a comprehensive care model for PICS based on an early warning system would reduce medical costs and the incidence of PICS.

METHODS AND ANALYSIS

The Intensive Care Unit (ICU) -Ward-Family/Community whole-course care (IWF/C Care) trial will be a unicentric, randomised, controlled trial. A total of 138 ICU patients from two ICUs at a university hospital in Guizhou province, China, will be enrolled in February 2023. The inclusion criteria are an age of 18 years or older, an ICU stay of more than 48 hours, provide informed consent and the ability to communicate normally. Patients will be followed for 12 months and randomised in a 1:1:1 ratio to three groups.

INTERVENTIONS

Patients in intervention group 1 will be assessed by the PICS early warning system within 24 hours of ICU discharge, and precise interventions will be carried out according to the results; that is, high-risk patients will receive care based on the IWF/C Care model and low-risk patients will receive routine care. All patients in intervention group 2 will receive care based on the IWF/C Care model. The control group will receive routine care. The primary endpoints are the incidence of PICS and quality of life. The secondary endpoints include the incidence of adverse events: the unplanned readmission rate, cost-effectiveness, and the experiences and feelings of patients receiving care based on the IWF/C Care model. The incidence of PICS will be measured at ICU discharge, general ward discharge, the home/community stage and 1 month and 3, 6, 9, and 12 months after discharge.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Biomedical Research Ethics Committee of the Affiliated Hospital of Zunyi Medical University (approval number: KLL-2022-780). The results of this study will be distributed through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300068135.

Association Between Socioeconomic Status and Outcomes in Critical Care: A Systematic Review and Meta-Analysis

OBJECTIVES

Socioeconomic status is well established as a key determinant of inequalities in health outcomes. Existing literature examining the impact of socioeconomic status on outcomes in critical care has produced inconsistent findings. Our objective was to synthesize the available evidence on the association between socioeconomic status and outcomes in critical care.

DATA SOURCES

A systematic search of CINAHL, Ovid MEDLINE, and EMBASE was undertaken on September 13, 2022.

STUDY SELECTION

Observational cohort studies of adults assessing the association between socioeconomic status and critical care outcomes including mortality, length of stay, and functional outcomes were included. Two independent reviewers assessed titles, abstracts, and full texts against eligibility and quality criteria.

DATA EXTRACTION

Details of study methodology, population, exposure measures, and outcomes were extracted.

DATA SYNTHESIS

Thirty-eight studies met eligibility criteria for systematic review. Twenty-three studies reporting mortality to less than or equal to 30 days following critical care admission, and eight reporting length of stay, were included in meta-analysis. Random-effects pooled analysis showed that lower socioeconomic status was associated with higher mortality at less than or equal to 30 days following critical care admission, with pooled odds ratio of 1.13 (95% CIs, 1.05-1.22). Meta-analysis of ICU length of stay demonstrated no significant difference between socioeconomic groups. Socioeconomic status may also be associated with functional status and discharge destination following ICU admission.

CONCLUSIONS

Lower socioeconomic status was associated with higher mortality following admission to critical care.

Differences in long-term outcomes between ICU patients with persistent delirium, non-persistent delirium and no delirium: A longitudinal cohort study

PURPOSE

Determine differences in physical, mental and cognitive outcomes 1-year post-ICU between patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND).

MATERIALS AND METHODS

A longitudinal cohort study was performed in adult ICU patients of two hospitals admitted between July 2016-February 2020. Questionnaires on physical, mental and cognitive health, frailty and QoL were completed regarding patients' pre-ICU health status and 1-year post-ICU. Delirium data were from patients' total hospital stay. Patients were divided in PD (≥14 days delirium), NPD (<14 days delirium) or ND patients.

RESULTS

2400 patients completed both questionnaires, of whom 529 (22.0%) patients developed delirium; 35 (6.6%) patients had PD and 494 (93.4%) had NPD. Patients with delirium (PD or NPD) had worse outcomes in all domains compared to ND patients. Compared to NPD, more PD patients were frail (34.3% vs. 14.6%, p = 0.006) and fatigued (85.7% vs. 61.1%, p = 0.012). After adjustment, PD was significantly associated with long-term cognitive impairment only (aOR 3.90; 95%CI 1.31-11.63).

CONCLUSIONS

Patients with PD had a higher likelihood to develop cognitive impairment 1-year post-ICU compared to NPD or ND. Patients with PD and NPD were more likely to experience impairment on all health domains (i.e. physical, mental and cognitive), compared to ND patients.

Comorbidities, multimorbidity and COVID-19

The influence of comorbidities on COVID-19 outcomes has been recognized since the earliest days of the pandemic. But establishing causality and determining underlying mechanisms and clinical implications has been challenging-owing to the multitude of confounding factors and patient variability. Several distinct pathological mechanisms, not active in every patient, determine health outcomes in the three different phases of COVID-19-from the initial viral replication phase to inflammatory lung injury and post-acute sequelae. Specific comorbidities (and overall multimorbidity) can either exacerbate these pathological mechanisms or reduce the patient's tolerance to organ injury. In this Review, we consider the impact of specific comorbidities, and overall multimorbidity, on the three mechanistically distinct phases of COVID-19, and we discuss the utility of host genetics as a route to causal inference by eliminating many sources of confounding. Continued research into the mechanisms of disease-state interactions will be crucial to inform stratification of therapeutic approaches and improve outcomes for patients.

Predictive validity of the Chelsea Critical Care Physical Assessment tool (CPAx) in critically ill, mechanically ventilated adults: a prospective clinimetric study

PURPOSE

To investigate the predictive validity of the Chelsea Critical Care Physical Assessment tool (CPAx) at intensive care unit (ICU) discharge in critically ill adults for their 90-day outcomes.

MATERIALS AND METHODS

This prospective clinimetric study investigated four theory-driven, a-priori hypotheses in critically ill adults recruited within 72-144 h of mechanical ventilation. The primary hypothesis was a moderate accuracy (AUROC = 0.750) in predicting residence at home within 90 days. Secondary hypotheses included discrimination between hospital discharge destinations, correlation with subsequent health-related quality of life and length of ICU stay.

RESULTS

We observed a good accuracy (AUROC = 0.778) of the CPAx at ICU discharge in predicting a return to home within 90 days. The CPAx score significantly increased between the discharge groups "undesirable" ≤ "rehabilitation" ≤ "home" (p < 0.001), but was not associated with 90-day health-related quality of life (physical: r = 0.261, mental: r = 0.193). Measured at baseline, CPAx scores correlated as expected with length of ICU stay (r = -0.443).

CONCLUSIONS

The CPAx at ICU discharge had a good predictive validity in projecting residence at home within 90 days and general discharge destinations. The CPAx might therefore have clinical value in prediction, though it does not seem useful to predict subsequent health-related quality of life. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) identification number: DRKS00012983, registered on September 20, 2017IMPLICATIONS FOR REHABILITATIONThe CPAx is a valid and reliable measurement instrument to evaluate critically ill adults' physical function and activity, in addition the CPAx might be useful to predict rehabilitation needs.The CPAx had a moderate to good predictive validity with three out of four a-priori hypotheses accepted.A CPAx score of ≥18 at critical care discharge has a sensitivity of 80% and a specificity of 70% in predicting a return to home within 90 days.The CPAx might consequently be valuable to identify critically ill adults' rehabilitation needs, to advise on their potential trajectory of recovery or to screen patients for follow-up after hospital discharge.

Healthcare delivery and recovery after critical illness

PURPOSE OF REVIEW

To summarize improvements and innovations in healthcare delivery which could be implemented to improve the recovery experience after critical illness for adult survivors and their families.

RECENT FINDINGS

For survivors of critical illness, the transitions in care during their recovery journey are points of heightened vulnerability associated with adverse events. Survivors of critical illness often have errors in the management of their medications during the recovery period. A multicomponent intervention delivered for 30 days that focused on four key principles of improved recovery care after sepsis care was associated with a durable effect on 12-month rehospitalization and mortality compared with usual care. A recent multicentre study which piloted integrating health and social care for critical care survivors demonstrated improvements in health-related quality of life and self-efficacy at 12 months. Multiple qualitative studies provide insights into how peer support programmes could potentially benefit survivors of critical illness by providing them mechanism to share their experiences, to give back to other patients, and to set more realistic expectations for recovery.

SUMMARY

Future research could focus on exploring safety outcomes as primary endpoints and finding ways to develop and test implementation strategies to improve the recovery after critical illness.

Social determinants of recovery

PURPOSE OF REVIEW

The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy.

RECENT FINDINGS

Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery.

SUMMARY

Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Long-term health-related quality of life, healthcare utilisation and back-to-work activities in intensive care unit survivors: Prospective confirmatory study from the Frisian aftercare cohort

Purpose

More substantial information on recovery after Intensive Care Unit (ICU) admission is urgently needed. In a previous retrospective study, the proportion of non-recovery patients was 44%. The aim of this prospective follow-up study was to evaluate changes in Health-Related Quality of Life (HRQoL) in the first year after ICU-admission.

Methods

Long-stay adult ICU-patients (≥ 48 hours) were included. HRQoL was evaluated with the Dutch translation of the RAND-36 item Health Survey (RAND-36) at baseline via proxy measurement, and at three, six, and twelve months after ICU admission. Subsequently, the relation between physical functioning, healthcare utilisation, and work activities was explored.

Results

A total of 81 patients were included in this study. Fifty-five percent of patients did not meet criteria for full recovery and were allocated to the Non Recovery (NR)-group (Physical Functioning domain-score: 35 [15–55]). Baseline physical HRQoL differed significantly between the Recovery (R) and NR-group. Patients in the NR-group received home care more often and had higher healthcare utilisation (44 versus 17% in the first three months post-ICU, p = 0.013). Only fourteen percent of NR-patients were able to participate in work activities. Moreover, NR-patients persistently showed impaired overall HRQoL throughout the year after critical illness.

Conclusions

Limited recovery in ICU survivors is reflected in overall impaired HRQoL, as well as in far-reaching consequences for patients’ healthcare needs and their ability to reintegrate into society. In our study, baseline HRQoL appeared to be an important predictor of long-term outcomes, but not Clinical Frailty Scale (CFS) score. And, (proxy-derived) HRQoL may help to identify patients at risk of long-term non-recovery.

Prevalence, characteristics, and longer-term outcomes of patients with persistent critical illness attributable to COVID-19 in Scotland: a national cohort study

BACKGROUND

Patients with COVID-19 can require critical care for prolonged periods. Patients with persistent critical Illness can have complex recovery trajectories, but this has not been studied for patients with COVID-19. We examined the prevalence, risk factors, and long-term outcomes of critically ill patients with COVID-19 and persistent critical illness.

METHODS

This was a national cohort study of all adults admitted to Scottish critical care units with COVID-19 from March 1, 2020 to September 4, 20. Persistent critical illness was defined as a critical care length of stay (LOS) of ≥10 days. Outcomes included 1-yr mortality and hospital readmission after critical care discharge. Fine and Gray competing risk analysis was used to identify factors associated with persistent critical Illness with death as a competing risk.

RESULTS

A total of 2236 patients with COVID-19 were admitted to critical care; 1045 patients were identified as developing persistent critical Illness, comprising 46.7% of the cohort but using 80.6% of bed-days. Patients with persistent critical illness used more organ support, had longer post-critical care LOS, and longer total hospital LOS. Persistent critical illness was not significantly associated with long-term mortality or hospital readmission. Risk factors associated with increased hazard of persistent critical illness included age, illness severity, organ support on admission, and fewer comorbidities.

CONCLUSIONS

Almost half of all patients with COVID-19 admitted to critical care developed persistent critical illness, with high resource use in critical care and beyond. However, persistent critical illness was not associated with significantly worse long-term outcomes compared with patients who were critically ill for shorter periods.

A multicentre evaluation exploring the impact of an integrated health and social care intervention for the caregivers of ICU survivors

Background

Caregivers and family members of Intensive Care Unit (ICU) survivors can face emotional problems following patient discharge from hospital. We aimed to evaluate the impact of a multi-centre integrated health and social care intervention, on caregiver and family member outcomes.

Methods

This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme across 9 sites in Scotland. InS:PIRE is an integrated health and social care intervention. We compared caregivers who attended this programme with a contemporary control group of ICU caregivers (usual care cohort), who did not attend.

Results

The primary outcome was anxiety measured via the Hospital Anxiety and Depression Scale at 12 months post-hospital discharge. Secondary outcome measures included depression, carer strain and clinical insomnia. A total of 170 caregivers had data available at 12 months for inclusion in this study; 81 caregivers attended the InS:PIRE intervention and completed outcome measures at 12 months post-hospital discharge. In the usual care cohort of caregivers, 89 completed measures. The two cohorts had similar baseline demographics. After adjustment, those caregivers who attended InS:PIRE demonstrated a significant improvement in symptoms of anxiety (OR: 0.42, 95% CI: 0.20–0.89, p = 0.02), carer strain (OR: 0.39; 95% CI: 0.16–0.98 p = 0.04) and clinical insomnia (OR: 0.40; 95% CI: 0.17–0.77 p < 0.001). There was no significant difference in symptoms of depression at 12 months.

Conclusions

This multicentre evaluation has shown that caregivers who attended an integrated health and social care intervention reported improved emotional health and less symptoms of insomnia, 12 months after the delivery of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04014-z.

Health-related quality of life measured with the EQ-5D-5L in critical care survivors: A cross-sectional study

OBJECTIVES

The aim of this study was to investigate health-related quality of life (HRQOL) and related factors in intensive care unit survivors one-12 months after discharge.

RESEARCH METHODOLOGY/DESIGN

This cross-sectional survey included survivors who had been admitted to an intensive care unit for ≥48 hours.

MAIN OUTCOME MEASURES

HRQOL was measured using the EQ-5D-5L profile, which evaluates five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) on five levels (no, slight, moderate, severe, and extreme problems), EQ-VAS (score range 0-100, 100 indicating best health) and EQ values (score range -0.066-1, 1 indicating best health). The factors influencing HRQOL were analyzed by Tobit regression.

SETTING

Survivors treated in an intensive care unit at six institutions in Korea.

RESULTS

Only 7.9% of the 534 participants had self-reported profiles of no health problems in all five dimensions. The proportion of participants with slight problems was highest in pain/discomfort with 85.0%. The proportion with severe problems was highest in usual activities with 21.7%, followed by mobility with 21.0%. The median and interquartile range of the EQ-VAS and EQ values were 60.00 (45.00 to 75.00) and 0.72 (0.52 to 0.80), respectively. Negative impact factors on HRQOL included older age, women, residing in a long term care facility, unemployment, emergency intensive care admission, and intensive care stay ≥ 7 days.

CONCLUSION

HRQOL among Korean intensive care survivors is low. The level of problems in physical dimensions is more severe than that in mental health dimensions. Early rehabilitation in the intensive care unit should be provided to facilitate long-term recovery.

Does a screening checklist for complex health and social care needs have potential clinical usefulness for predicting unplanned hospital readmissions in intensive care survivors: development and prospective cohort study

OBJECTIVES

Intensive care (ICU) survivors are at high risk of long-term physical and psychosocial problems. Unplanned hospital readmission rates are high, but the best way to triage patients for interventions is uncertain. We aimed to develop and evaluate a screening checklist to help predict subsequent readmissions or deaths.

DESIGN

A checklist for complex health and social care needs (CHSCNs) was developed based on previous research, comprising six items: multimorbidity; polypharmacy; frequent previous hospitalisations; mental health issues; fragile social circumstances and impaired activities of daily living. Patients were considered to have CHSCNs if two or more were present. We prospectively screened all ICU discharges for CHSCNs for 12 months.

SETTING

ICU, Royal Infirmary, Edinburgh, UK.

PARTICIPANTS

ICU survivors over a 12-month period (1 June 2018 and 31 May 2019).

INTERVENTIONS

None.

OUTCOME MEASURE

Readmission or death in the community within 3 months postindex hospital discharge.

RESULTS

Of 1174 ICU survivors, 937 were discharged alive from the hospital. Of these 253 (27%) were classified as having CHSCNs. In total 28% (266/937) patients were readmitted (N=238) or died (N=28) within 3 months. Among CHSCNs patients 45% (n=115) patients were readmitted (N=105) or died (N=10). Patients without CHSCNs had a 22% readmission (N=133) or death (N=18) rate. The checklist had: sensitivity 43% (95% CI 37% to 49%), specificity 79% (95% CI 76% to 82%), positive predictive value 45% (95% CI 41% to 51%), and negative predictive value 78% (95% CI 76% to 80%). Relative risk of readmission/death for patients with CHSCNs was 2.06 (95% CI 1.69 to 2.50), indicating a pretest to post-test probability change of 28%-45%. The checklist demonstrated high inter-rater reliability (percentage agreement ≥87% for all domains; overall kappa, 0.84).

CONCLUSIONS

Early evaluation of a screening checklist for CHSCNs at ICU discharge suggests potential clinical usefulness, but this requires further evaluation as part of a care pathway.

Development of an electronic Poor Outcome Screening (ePOS) Score to identify critically ill patients with potential palliative care needs

PURPOSE

To develop and validate an electronic poor outcome screening (ePOS) score to identify critically ill patients with potentially unmet palliative care (PC) needs at 48 hours after ICU admission.

MATERIALS AND METHODS

Retrospective single-centre cohort study of 1'772 critically ill adult patients admitted to a tertiary academic ICU in Switzerland between 2017 and 2018. We used data available from electronic health records (EHR) in the first 48 hours and least absolute shrinkage and selection operator (LASSO) logistic regression to develop a prediction model and generate a score to predict the risk of all cause 6-month mortality.

RESULTS

Within 6 months of the ICU admission, 598 patients (33.7%) had died. At a cut-off of 20 points, the ePOS score (range 0-46 points) had a sensitivity of 0.81 (95% CI 0.78 to 0.84) and a specificity of 0.51 (0.48 to 0.54) for predicting 6-month mortality and showed good discriminatory performance (AUROC 0.72, 0.67 to 0.77).

CONCLUSIONS

The ePOS score can easily be implemented in EHR and can be used for automated screening and stratification of ICU patients, pinpointing those in whom a comprehensive PC assessment should be performed. However, it should not replace clinical judgement.

Six-month and 12-month patient outcomes based on inflammatory subphenotypes in sepsis-associated ARDS: secondary analysis of SAILS-ALTOS trial

BACKGROUND

Prior acute respiratory distress syndrome (ARDS) trials have identified hypoinflammatory and hyperinflammatory subphenotypes, with distinct differences in short-term outcomes. It is unknown if such differences extend beyond 90 days or are associated with physical, mental health or cognitive outcomes.

METHODS

568 patients in the multicentre Statins for Acutely Injured Lungs from Sepsis trial of rosuvastatin versus placebo were included and assigned a subphenotype. Among 6-month and 12-month survivors (N=232 and 219, respectively, representing 243 unique survivors), subphenotype status was evaluated for association with a range of patient-reported outcomes (eg, mental health symptoms, quality of life). Patient subsets also were evaluated with performance-based tests of physical function (eg, 6 min walk test) and cognition.

FINDINGS

The hyperinflammatory versus hypoinflammatory subphenotype had lower overall 12-month cumulative survival (58% vs 72%, p<0.01); however, there was no significant difference in survival beyond 90 days (86% vs 89%, p=0.70). Most survivors had impairment across the range of outcomes, with little difference between subphenotypes at 6-month and 12-month assessments. For instance, at 6 months, in comparing the hypoinflammatory versus hyperinflammatory subphenotypes, respectively, the median (IQR) patient-reported SF-36 mental health domain score was 47 (33-56) vs 44 (35-56) (p=0.99), and the per cent predicted 6 min walk distance was 66% (48%, 80%) vs 66% (49%, 79%) (p=0.76).

INTERPRETATION

Comparing the hyperinflammatory versus hypoinflammatory ARDS subphenotype, there was no significant difference in survival beyond 90 days and no consistent findings of important differences in 6-month or 12-month physical, cognitive and mental health outcomes. These findings, when considered with prior results, suggest that inflammatory subphenotypes largely reflect the acute phase of illness and its short-term impact.

Lean mass as a risk factor for intensive care unit admission: an observational study

Purpose

Intensive care unit (ICU) survivors have reduced physical function likely due to skeletal muscle wasting and weakness acquired during critical illness. However, the contribution of pre-morbid muscle mass has not been elucidated. We aimed to examine the association between pre-ICU muscle mass and ICU admission risk. Secondary outcomes include the relationship between muscle mass and ICU outcomes.

Methods

ICU admissions between June 1, 1998, and February 1, 2019, were identified among participants of Geelong Osteoporosis Study (GOS), a population-based cohort study. Cox proportional hazard regression models estimated hazard ratios (HR) for ICU admission across T-score strata and continuous values of DXA-derived lean mass measures of skeletal mass index (SMI, lean mass/body mass %) and appendicular lean mass corrected for height (ALM/h², kg/m²). Multivariable regression was used to determine the relationship between lean mass and ICU outcomes.

Results

One hundred and eighty-six of 3126 participants enrolled in GOS were admitted to the ICU during the follow-up period. In adjusted models, lean mass was not predictive of ICU admission (SMI: HR 0.99 95%CI 0.97–1.01, p = 0.32; ALM/h²: HR 1.11 95%CI 0.94–1.31, p = 0.23), while greater appendicular lean mass was related to reduced 28-day mortality (ALM/h² adjOR: 0.25, 95%CI 0.10–0.63, p = 0.003, SMI adjOR: 0.91, 95%CI 0.82–1.02, p = 0.09).

Conclusion

Lean mass was not associated with ICU admission in this population-based cohort study; however, greater appendicular lean mass was associated with reduced mortality. This suggests pre-ICU muscle status may not predict development of critical illness but is associated with better survival after critical illness occurs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03788-y.

Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies

INTRODUCTION

Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery.

AREAS COVERED

First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families.

EXPERT OPINION

PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.

Talking to multi-morbid patients about critical illness: an evolving conversation

Conversations around critical illness outcomes and benefits from intensive care unit (ICU) treatment have begun to shift away from binary discussions on living versus dying. Increasingly, the reality of survival with functional impairment versus survival with a late death is being recognised as relevant to patients. Most ICU admissions are associated with new functional and cognitive disabilities that are significant and long lasting. When discussing outcomes, clinicians rightly focus on patients' wishes and the quality of life (QoL) that they would find acceptable. However, patients' views may encompass differing views on acceptable QoL post-critical illness, not necessarily reflected in standard conversations. Maintaining independence is a greater priority to patients than simple survival. QoL post-critical illness determines judgments on the benefits of ICU support but translating this into clinical practice risks potential conflation of health outcomes and QoL. This article discusses the concept of response shift and the implication for trade-offs between number/length of invasive treatments and change in physical function or death. Conversations need to delineate how health outcomes (e.g. tracheostomy, muscle wasting, etc.) may affect individual outcomes most relevant to the patient and hence impact overall QoL. The research strategy taken to explore decision-making for critically ill patients might benefit from gathering qualitative data, as a complement to quantitative data. Patients, families and doctors are motivated by far wider considerations, and a consultation process should relate to more than the simple likelihood of mortality in a shared decision-making context.

High occurrence of postintensive care syndrome identified in surgical ICU survivors after implementation of a multidisciplinary clinic

BACKGROUND

Postintensive care syndrome (PICS) has been identified in a large proportion of medical intensive care unit survivors; however, the occurrence surgical intensive care unit (SICU) survivors is unknown. We implemented a multidisciplinary critical care outpatient clinic (CCOC) to identify the occurrence of PICS in SICU survivors.

METHODS

Seventy acute care surgery and trauma patients, 18 years or older, who remained in the SICU for 72 hours or longer at a Level I trauma center were seen in CCOC at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. The CCOC staffing included a nurse coordinator, social worker, critical care pharmacist, physical therapist, and acute care surgeon who identified PICS sequelae in their respective specialties by clinical criteria and screening questionnaires.

RESULTS

Of 82 eligible patients, 70 (85.4%) were seen at least once for 116 total visits. Forty-three (61.4%) patients suffered traumatic injuries and 27 (38.6%) underwent emergent general surgery. Sixty-seven (95.7%) demonstrated at least one PICS criterion. Over all visits, 26 (37.1%) patients presented with one PICS criterion, 24 (34.3%) patients with two, and 17 (24.3%) with three. Cognitive impairment was observed in 29 (41.4%) patients, psychiatric in 30 (42.9%), and physical symptoms in 65 (92.9%). Activity Measure for Post-Acute Care scores improved from severe impairment at admission to full function by 12 weeks postdischarge, yet 6 Minute Walk Test scores remained below age-matched references through all visits. Patients expressed mild to moderate depression based on Patient Health Questionnaire-9 scores. A medication reconciliation was completed at 96.5% (112/116) of the visits with 116 total medication recommendations. By 24 weeks following discharge, only 26.4% (14/53) of previously employed patients had resumed work.

CONCLUSION

Through the successful implementation of a multidisciplinary CCOC, this study identifies an exorbitant rate of PICS among SICU survivors.

LEVEL OF EVIDENCE

Therapeutic/epidemiological, level III.

Resilience in survivors of critical illness: A scoping review of the published literature in relation to definitions, prevalence, and relationship to clinical outcomes

Survivors of critical illness face substantial challenges in their recovery, including physical and cognitive dysfunction. Resilience is the ability to adapt and maintain one’s mental health after facing such challenges. Higher resilience levels have been found to be beneficial throughout the illness trajectory in cancer patients, but resilience has not been widely researched in critical care patients. We undertook a scoping review to identify published studies on resilience following critical illness and describe: how resilience has been measured; the prevalence of low resilience in critical care patients; and what associations (if any) exist between resilience and clinical outcomes. We searched: PubMed, Medline, PsychINFO, CINAHL, Web of Science, Cochrane Library, to identify relevant studies. We found 882 unique titles: 17 were selected for full text review, 10 were considered relevant. These included ICU inpatients and survivors, and trauma and sepsis survivors. A broad critical appraisal of each study was undertaken. The overall quality of published studies was low: there was wide variation in resilience-assessment tools across the studies, including the timing of measurement; only one used a validated tool. Estimates of low resilience ranged from 28%-67%, but with varying populations, high risk of inclusion bias, and small samples. Higher resilience levels were significantly associated with lower depression, anxiety, post-traumatic stress, pain, anger, executive dysfunction, and difficulty with self-care in critical care patients and survivors. Future studies should use validated resilience assessment, determine the optimum timing, and explore prevalence, associations with outcomes, and resilience-promoting interventions in non-selected or clearly defined populations.

The impact of distance on post-ICU disability

BACKGROUND

Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.

OBJECTIVES

The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.

METHODS

This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received >24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU: <50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p < 0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.

RESULTS

A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living <50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.

Quality of Life, Depression, and Anxiety in Survivors of Critical Illness from a Greek ICU. A Prospective Observational Study

The physical and psychological consequences of critical illness may affect intensive care unit survivors for up to five years, and hence, health-related quality of life has emerged as an important measure of outcome in this population. We aimed at investigating the quality of life, the presence of anxiety and depression symptoms, and the correlations of clinical and psychological parameters with the quality of life scores in survivors of critical illness one year after discharge from intensive care. Widely used scales that have been validated for the Greek population were used. One thousand two hundred and seventy (1270) patients were assessed for eligibility. Inclusion criteria were age between 18 and 68 years and the presence of critical illness requiring endotracheal intubation and mechanical ventilation for more than three days. One hundred and four (104) patients were included in the final analysis; forty-nine age and sex-matched healthy volunteers were included for comparison. One year following intensive care unit discharge, survivors of critical illness had impaired quality of life scores, as measured with the WHOQOL-Bref, compared to healthy subjects (p < 0.001 for the physical and psychological domains, and p = 0.006 for the domain of social relationships). In addition, we found that quality of life scores were significantly lower in patients with comorbidities (p < 0.01), and correlated with the duration of ICU stay (r = −0.19, p = 0.04) and with the presence of symptoms suggestive of depression (r = −0.66, p < 0.0001) and post-traumatic stress disorder (r = −0.61, p < 0.0001). Approximately one-third of our patients scored high in the CES-D scale for depression, while the majority of them scored high in the STAI scale for anxiety symptoms.

A Novel Approach to ICU Survivor Care: A Population Health Quality Improvement Project

OBJECTIVES

Deliver a novel interdisciplinary care process for ICU survivor care and their primary family caregivers, and assess mortality, readmission rates, and economic impact compared with usual care.

DESIGN

Population health quality improvement comparative study with retrospective data analysis.

SETTING

A single tertiary care rural hospital with medical/surgical, neuroscience, trauma, and cardiac ICUs.

PATIENTS

ICU survivors.

INTERVENTIONS

Reorganization of existing post discharge health care delivery resources to form an ICU survivor clinic care process and compare this new process to post discharge usual care process.

MEASUREMENTS AND MAIN RESULTS

Demographic data, Acute Physiology and Chronic Health Evaluation IV scores, and Charlson Comorbidity Index scores were extracted from the electronic health record. Additional data was extracted from the care manager database. Economic data were extracted from the Geisinger Health Plan database and analyzed by a health economist. During 13-month period analyzed, patients in the ICU survivor care had reduced mortality compared with usual care, as determined by the Kaplan-Meier method (ICU survivor care 0.89 vs usual care 0.71; log-rank p = 0.0108) and risk-adjusted stabilized inverse probability of treatment weighting (hazard ratio, 0.157; 95% CI, 0.058-0.427). Readmission for ICU survivor care versus usual care: at 30 days (10.4% vs 26.3%; stabilized inverse probability of treatment weighting hazard ratio, 0.539; 95% CI, 0.224-1.297) and at 60 days (16.7% vs 34.7%; stabilized inverse probability of treatment weighting hazard ratio, 0.525; 95% CI, 0.240-1.145). Financial data analysis indicates estimated annual cost savings to Geisinger Health Plan ranges from $247,052 to $424,846 during the time period analyzed.

CONCLUSIONS

Our ICU survivor care process results in decreased mortality and a net annual cost savings to the insurer compared with usual care processes. There was no statistically significant difference in readmission rates.

Physical, Mental, and Cognitive Health Status of ICU Survivors Before ICU Admission: A Cohort Study

OBJECTIVES

Although patient's health status before ICU admission is the most important predictor for long-term outcomes, it is often not taken into account, potentially overestimating the attributable effects of critical illness. Studies that did assess the pre-ICU health status often included specific patient groups or assessed one specific health domain. Our aim was to explore patient's physical, mental, and cognitive functioning, as well as their quality of life before ICU admission.

DESIGN

Baseline data were used from the longitudinal prospective MONITOR-IC cohort study.

SETTING

ICUs of four Dutch hospitals.

PATIENTS

Adult ICU survivors (n = 2,467) admitted between July 2016 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients, or their proxy, rated their level of frailty (Clinical Frailty Scale), fatigue (Checklist Individual Strength-8), anxiety and depression (Hospital Anxiety and Depression Scale), cognitive functioning (Cognitive Failure Questionnaire-14), and quality of life (Short Form-36) before ICU admission. Unplanned patients rated their pre-ICU health status retrospectively after ICU admission. Before ICU admission, 13% of all patients was frail, 65% suffered from fatigue, 28% and 26% from symptoms of anxiety and depression, respectively, and 6% from cognitive problems. Unplanned patients were significantly more frail and depressed. Patients with a poor pre-ICU health status were more often likely to be female, older, lower educated, divorced or widowed, living in a healthcare facility, and suffering from a chronic condition.

CONCLUSIONS

In an era with increasing attention for health problems after ICU admission, the results of this study indicate that a part of the ICU survivors already experience serious impairments in their physical, mental, and cognitive functioning before ICU admission. Substantial differences were seen between patient subgroups. These findings underline the importance of accounting for pre-ICU health status when studying long-term outcomes.

Reduced quality of life in ICU survivors - the story behind the numbers: A mixed methods study

PURPOSE

To gain insight into the daily functioning of ICU survivors who reported a reduced quality of life (QoL) one year after ICU admission.

MATERIALS AND METHODS

A two-phase mixed method study design. QoL was assessed using the SF-36 questionnaire before admission and after one year (Phase 1). Participants reporting a reduced QoL were invited for an in-depth interview (Phase 2). Interview data were coded thematically using the PROMIS framework.

RESULTS

Of the 797 participants, 173 (22%) reported a reduced QoL, of which 19 purposively selected patients were interviewed. In line with their questionnaire scores, most participants described their QoL as reduced. They suffered from physical, mental and/or cognitive problems, impacting their daily life, restricting hobbies, work, and social activities. A new balance in life, including relationships, had to be found. Some interviewees experienced no changes in their QoL; they were grateful for being alive, set new life priorities, and were able to accept their life with its limitations.

CONCLUSIONS

Reduction in QoL is due to physical, mental, and cognitive health problems, restricting participants what they want to do. However, QoL was not only affected by the critical illness, but also by factors including independency, comorbidity, and life events. Registration: NCT03246334 (clinical trials.gov).

Theorising survivorship after intensive care: A systematic review of patient and family experiences

AIMS AND OBJECTIVE

This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined.

BACKGROUND

Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research.

DESIGN

Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed.

RESULTS

The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship.

CONCLUSION

We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.

Non-sedation-Does it improve health-related quality of life after critical illness? A 3-month follow-up sub-study of the NONSEDA trial

BACKGROUND

Critical illness is associated with severely impaired health-related quality of life (HRQoL) for years following discharge. The NONSEDA trial was a multicenter randomized trial on non-sedation versus sedation with a daily wake-up trial in critically ill, mechanically ventilated patients in Scandinavia. The aim of this sub-study was to assess the effect of non-sedation on HRQoL and degree of independence in activities in daily living (ADL) 3 months post-ICU.

METHODS

All survivors were asked to complete the Medical Outcomes Study Short-Form 36 questionnaire (SF-36) and the Barthel Index 3 months post-ICU. To limit missing data, reminders were sent. If unsuccessful, telephone interviews could be used. Outcomes were the level of HRQoL and ADL-function in each group. All outcomes were assessed blinded.

RESULTS

Of the 700 patients included 412 survived to follow-up. A total of 344 survivors participated (82%). Baseline data were equal between the two groups. Mean SF-36 scores for the non-sedated vs sedated patients were as follows: Physical Function 45 vs 40, P = .69, Bodily Pain: 61 vs 52, P = .81, General Health: 50 vs 50, P = .84, Vitality: 42 vs 44, P = .85, Social Function: 75 vs 63, P = .85, Role Emotional: 58 vs 50, P = .82, Mental Health: 70 vs 70, P = .89, Role Physical: 25 vs 28, P = .32, Physical Component Score: 38 vs 37, P = .81, Mental Component Score: 48 vs 46, P = .94, Barthel Index: 20 vs 20, P = .74.

CONCLUSION

Randomization to non-sedation neither improved nor impaired health-related quality of life or degree of independence in activities in daily living 3 months post-ICU discharge.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): study protocol for a pilot randomised controlled trial

Background

Intensive care unit (ICU) survivors often suffer from cognitive, physical and mental impairments, known as post-intensive care syndrome (PICS). ICU follow-up clinics may improve aftercare of these patients. There is a lack of evidence whether or which concept of an ICU follow-up clinic is effective. Within the PINA study, a concept for an ICU follow-up clinic was developed and will be tested in a pilot randomised controlled trial (RCT), primarily to evaluate the feasibility and additionally the potential efficacy.

Methods/design

Design: Pilot RCT with intervention and control (usual care) arms plus mixed-methods process evaluation. Participants: 100 ICU patients (50 per arm) of three ICUs in a university hospital (Regensburg, Germany), ≥ 18 years with an ICU stay of > 5 days, a sequential organ failure assessment (SOFA) score > 5 during the ICU stay and a life expectancy of more than 6 months.

Intervention: The intervention will contain three components: information, consultation and networking. Information will be available in form of an intensive care guide for patients and next of kin at the ICU and phone support during follow-up. For consultation, patients will visit the ICU follow-up clinic at least once during the first 6 months after discharge from ICU. During these visits, patients will be screened for symptoms of PICS and, if required, referred to specialists for further treatment. The networking part (e.g. special referral letter from the ICU follow-up clinic) aims to provide a network of outpatient care providers for former ICU patients. Feasibility Outcomes: Qualitative and quantitative evaluation will be used to explore reasons for non-participation and the intervention´s acceptability to patients and caregivers. Efficacy Outcomes: Health-related quality of life (HRQOL) will be assessed as primary outcome by the physical component score (PCS) of the Short-Form 12 Questionnaire (SF-12). Secondary outcomes encompass further patient-reported outcomes. All outcomes are assessed at 6 months after discharge from ICU.

Discussion

The PINA study will determine feasibility and potential efficacy of a complex intervention in a pilot RCT to enhance follow-up care of ICU survivors. The pilot study is an important step for further studies in the field of ICU aftercare and especially for the implementation of a pragmatic multi-centre RCT.

Trial registration

ClinicalTrials.gov, NCT04186468. Submitted 2 December 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00796-1.

Tools for assessment of acute psychological distress in critical illness: A scoping review

OBJECTIVES

Patients' experience of psychological distress in the intensive care unit (ICU) is associated with adverse effects, reduced satisfaction, and delayed physical and psychological recovery. There are no specific guidelines for the assessment and management of acute psychological distress during hospitalisation in the ICU. We reviewed existing tools for the assessment of acute psychological distress in ICU patients, examined evidence on their metric properties, and identified potential gaps and methodological considerations.

METHOD

A scoping review based on literature searches (Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, PsycINFO, Scopus, Health and Psychosocial Instruments, Dissertations and Theses Global, and Google Scholar) and predefined eligibility criteria was conducted as per current scoping review guidelines.

FINDINGS

Overall, 14 assessment tools were identified having been developed in diverse ICU settings. The identified tools assess mainly anxiety and depressive symptoms and ICU stressors, and investigators have reported various validity and reliability metrics. It was unclear whether available tools can be used in specific groups, such as noncommunicative patients and patients with delirium, brain trauma, stroke, sedation, and cognitive impairments.

CONCLUSION

Available tools have methodological limitations worth considering in future investigations. Given the high prevalence of psychiatric morbidity in ICU survivors, rigorously exploring the metric integrity of available tools used for anxiety, depressive, and psychological distress symptom assessment in the vulnerable ICU population is a practice and research priority.

RELEVANCE TO CLINICAL PRACTICE

These results have implications for the selection and implementation of psychological distress assessment methods as a means for promoting meaningful patient-centred clinical outcomes and humanising ICU care experiences.

Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised many questions about the management of patients with chronic obstructive pulmonary disease (COPD) and whether modifications of their therapy are required. It has raised questions about recognizing and differentiating coronavirus disease (COVID-19) from COPD given the similarity of the symptoms. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee used established methods for literature review to present an overview of the management of patients with COPD during the COVID-19 pandemic. It is unclear whether patients with COPD are at increased risk of becoming infected with SARS-CoV-2. During periods of high community prevalence of COVID-19, spirometry should only be used when it is essential for COPD diagnosis and/or to assess lung function status for interventional procedures or surgery. Patients with COPD should follow basic infection control measures, including social distancing, hand washing, and wearing a mask or face covering. Patients should remain up to date with appropriate vaccinations, particularly annual influenza vaccination. Although data are limited, inhaled corticosteroids, long-acting bronchodilators, roflumilast, or chronic macrolides should continue to be used as indicated for stable COPD management. Systemic steroids and antibiotics should be used in COPD exacerbations according to the usual indications. Differentiating symptoms of COVID-19 infection from chronic underlying symptoms or those of an acute COPD exacerbation may be challenging. If there is suspicion for COVID-19, testing for SARS-CoV-2 should be considered. Patients who developed moderate-to-severe COVID-19, including hospitalization and pneumonia, should be treated with evolving pharmacotherapeutic approaches as appropriate, including remdesivir, dexamethasone, and anticoagulation. Managing acute respiratory failure should include appropriate oxygen supplementation, prone positioning, noninvasive ventilation, and protective lung strategy in patients with COPD and severe acute respiratory distress syndrome. Patients who developed asymptomatic or mild COVID-19 should be followed with the usual COPD protocols. Patients who developed moderate or worse COVID-19 should be monitored more frequently and accurately than the usual patients with COPD, with particular attention to the need for oxygen therapy.

Effect of non-sedation on physical function in survivors of critical illness - A substudy of the NONSEDA randomized trial

PURPOSE

Critical illness impairs physical function. The NONSEDA trial was a multicenter randomized trial, assessing non-sedation versus sedation during mechanical ventilation. The aim of this sub-study was to assess the effect of non-sedation on physical function.

METHODS

All patients from one NONSEDA trial site were included. At ICU discharge and three months thereafter, survivors were assessed for physical function.

RESULTS

205 patients were included, 118 survived to follow-up, 116 participated (98%).

PRIMARY OUTCOME

Three months after ICU-discharge, health-related quality of life (SF-36, physical component score) was similar (non-sedated 38.3 vs sedated 36.6, mean difference 1.7, 95% CI -1.7 to 5.1), as was function in activities of daily living (Barthel Index, non-sedated 19.5 vs sedated 18, median difference 1.5, 95% CI -0.2 to 3.2).

SECONDARY OUTCOMES

Non-sedated patients had a better Barthel Index at ICU-discharge (median 9 vs 4, median difference 5, 95% CI 2.5 to 7.5). At three months post-ICU discharge, the two groups did not differ regarding handgrip strength, walking distance, muscle size or biomechanical data.

CONCLUSION

Non-sedation did not lead to improved quality of life regarding physical function or better function in activities of everyday living. Non-sedated patients had a better physical recovery at ICU discharge.

TRIAL REGISTRATION

Clinicaltrials.govNCT02034942, registered January 14., 2014.

The effect of postintensive care syndrome on the quality of life of intensive care unit survivors: A secondary analysis

BACKGROUND

Despite increasing interest in postintensive care syndrome and the quality of life of intensive care unit survivors, the empirical literature on the relationship between these two variables is limited.

OBJECTIVES

This study aimed to examine whether postintensive care syndrome predicts the quality of life of intensive care unit survivors.

METHODS

We analysed secondary data, which were collected as part of a larger cross-sectional study. The participants were recruited from six health institutions in Korea. The data of 496 survivors who had been admitted to an intensive care unit for at least 48 h during the past year were analysed. They responded to measures of postintensive care syndrome and quality of life.

RESULTS

The participants' mean physical and mental component summary scores (quality of life) were 40.08 ± 8.99 and 40.24 ± 11.19, respectively. Physical impairment (β = -0.48, p < 0.001), unemployment (β = -0.19, p < 0.001), low income (β = -0.11, p = 0.004), older age (β = -0.08, p = 0.039), and cognitive impairment (β = -0.11, p = 0.045) predicted lower physical component summary scores. Mental (β = -0.49, p < 0.001) and cognitive impairment (β = -0.14, p = 0.005) and low income (β = -0.09, p = 0.014) predicted mental component summary scores.

CONCLUSIONS

The participants reported poor physical and mental health-related quality of life. Postintensive care syndrome, unemployment, low income, and older age were the main predictors of poor quality of life. In addition, postintensive care syndrome was a stronger risk factor for poor quality of life than demographic characteristics and intensive care unit treatment factors.

Acute skeletal muscle wasting and dysfunction predict physical disability at hospital discharge in patients with critical illness

BACKGROUND

Patients surviving critical illness develop muscle weakness and impairments in physical function; however, the relationship between early skeletal muscle alterations and physical function at hospital discharge remains unclear. The primary purpose of this study was to determine whether changes in muscle size, strength and power assessed in the intensive care unit (ICU) predict physical function at hospital discharge.

METHODS

Study design is a single-center, prospective, observational study in patients admitted to the medicine or cardiothoracic ICU with diagnosis of sepsis or acute respiratory failure. Rectus femoris (RF) and tibialis anterior (TA) muscle ultrasound images were obtained day one of ICU admission, repeated serially and assessed for muscle cross-sectional area (CSA), layer thickness (mT) and echointensity (EI). Muscle strength, as measured by Medical Research Council-sum score, and muscle power (lower-extremity leg press) were assessed prior to ICU discharge. Physical function was assessed with performance on 5-times sit-to-stand (5STS) at hospital discharge.

RESULTS

Forty-one patients with median age of 61 years (IQR 55-68), 56% male and sequential organ failure assessment score of 8.1 ± 4.8 were enrolled. RF muscle CSA decreased significantly a median percent change of 18.5% from day 1 to 7 (F = 26.6, p = 0.0253). RF EI increased at a mean percent change of 10.5 ± 21% in the first 7 days (F = 3.28, p = 0.081). At hospital discharge 25.7% of patients (9/35) met criteria for ICU-acquired weakness. Change in RF EI in first 7 days of ICU admission and muscle power measured prior to ICU were strong predictors of ICU-AW at hospital discharge (AUC = 0.912). Muscle power at ICU discharge, age and ICU length of stay were predictive of performance on 5STS at hospital discharge.

CONCLUSION

ICU-assessed muscle alterations, specifically RF EI and muscle power, are predictors of diagnosis of ICU-AW and physical function assessed by 5x-STS at hospital discharge in patients surviving critical illness.