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

Peer support in intensive care unit follow-up: A qualitative evaluation

BACKGROUND

Patients formerly admitted to an intensive care unit and their relatives seek information about life after critical illness to understand their symptoms and what to expect as survivors, and they express a desire to talk to others with similar experiences. Various operational models of post-intensive care peer support exist, and studies have reported potential beneficial mechanisms in patients involved in peer support programs. However, most models have not been formally evaluated.

AIM

To evaluate the content and setting of structured group meetings and explore participants' experiences of meeting peers.

STUDY DESIGN

A qualitative evaluation combining focused ethnographic observations and semi-structured interviews with 22 participants attending three intensive care unit café meetings in a university hospital. A thematic analysis was conducted using all data collected.

FINDINGS

Three main themes emerged; 'Accommodating the diversity of patients and relatives', 'A range of possibilities for identification' and 'A newfound community'. Findings indicate that the content, setting and timing of the café meetings were of minor concern for the participants. Patients and relatives should attend together because the consequences of surviving a critical illness affect both. Larger groups of participants appeared to increase the likelihood of encountering broad variances in participants' experiences from the critical illness trajectory. The findings indicate that before attending a meeting, the participants did not find previous experiences sufficient in managing their new life situations and they felt alone in their experiences.

CONCLUSION

Peer support invited participants into a secure community and eased their sense of being alone in their struggles. Meeting peers seemed to be more important than following a specific model of peer support.

RELEVANCE TO CLINICAL PRACTICE

When setting up peer support for former intensive care patients, the most important aspect is to create a secure space for patients and their relatives to meet.

Adherence with post-hospitalization follow-up after pediatric critical illness due to respiratory failure

BACKGROUND

Adherence with follow-up appointments after a pediatric intensive care unit (PICU) admission is likely a key component in managing post-PICU sequalae. However, prior work on PICU follow-up adherence is limited. The objective of this study is to identify hospitalization characteristics, discharge child health metrics, and follow-up characteristics associated with full adherence with recommended follow-up at a quaternary care center after a PICU admission due to respiratory failure.

METHODS

We conducted a retrospective cohort study of patients ≤ 18 years with respiratory failure admitted between 1/2013-12/2014 to a quaternary care PICU. Post-hospitalization full adherence with recommended follow-up in the two years post discharge (1/2013-3/2017) at the quaternary care center was quantified and compared by demographics, baseline child health metrics, hospitalization characteristics, discharge child health metrics, and follow-up characteristics in bivariate and multivariate analyses. Patients were dichotomized into being non-adherent with follow-up (patients who attended less than 100% of recommended appointments at the quaternary care center) and fully adherent (patients who attended 100% of recommended appointments at the quaternary care center).

RESULTS

Of 155 patients alive at hospital discharge, 140 (90.3%) were recommended to follow-up at the quaternary care center. Of the 140 patients with recommended follow-up at the quaternary care center, 32.1% were non-adherent with follow-up and 67.9% were fully adherent. In a multivariable logistic regression model, each additional recommended unique follow-up appointment was associated with lower odds of being fully adherent with follow-up (OR 0.74, 95% CI 0.60-0.91, p = 0.005), and each 10% increase in the proportion of appointments scheduled before discharge was associated with higher odds of being fully adherent with follow-up (OR 1.02, 95% CI 1.01-1.03, p = 0.004).

CONCLUSIONS

After admission for acute respiratory failure, only two-thirds of children were fully adherent with recommended follow-up at a quaternary care center. Our findings suggest that limiting the recommended follow-up to only key essential healthcare providers and working to schedule as many appointments as possible before discharge could improve follow-up adherence. However, a better understanding of the factors that lead to non-adherence with follow-up appointments is needed to inform broader system-level approaches could help improve PICU follow-up adherence.

Impression of Primary Care Follow-Up After a PICU Admission: A Pilot Survey of Primary Care Pediatricians

OBJECTIVES

The majority of PICU general follow-up occurs with primary care providers. Our objective was to investigate primary care pediatricians': 1) comfort with and barriers to caring for children after a PICU admission, 2) knowledge of and screening for post-intensive care syndrome in pediatrics (PICS-P), and 3) resource needs.

DESIGN

Pilot cross-sectional survey study.

SETTING

Metropolitan Detroit, Michigan from September 2022 to March 2023.

SUBJECTS

Primary care pediatricians.

MEASUREMENT AND MAIN RESULTS

The survey included 15 questions on provider demographics, comfort with and barriers to caring for children after a PICU admission, knowledge of and screening practices for PICS-P, and resource needs. The median values for continuous data and frequencies for categorical data were calculated. The survey response rate was 17% (26/152). The median age was 38.5 years (interquartile range 34-52 yr) and 19 of 26 (73%) were female. In case studies, 26 of 26 (100%) were "very comfortable" resuming care for a patient with a straightforward bronchiolitis PICU admission while 8 of 26 participants (31%) were "somewhat uncomfortable" and 1 of 26 (4%) was "not at all comfortable" with caring for a patient after a complex acute respiratory distress syndrome PICU admission. Seven of 26 participants (27%) were familiar with the term "post-intensive care syndrome in pediatrics." Over 50% screened for four of five PICS-P domains. Key barriers were care coordination with specialists, discomfort or difficulties with managing new home equipment, and inadequate or missing documentation.

CONCLUSIONS

In this pilot study, approximately one-third of primary care pediatricians had knowledge of PICS-P. Participants experienced numerous care barriers. Our findings suggest future research could engage improved study methods and designs, and focus on interventions to support primary care-provided PICU follow-up.

Impact of Persistent Inflammation, Immunosuppression, and Catabolism Syndrome during Intensive Care Admission on Each Post-Intensive Care Syndrome Component in a PICS Clinic

BACKGROUND

Persistent inflammation, immunosuppression, and catabolism syndrome (PIICS) is known as a prolonged immunodeficiency that occurs after severe infection. Few studies have demonstrated a direct relationship between PIICS and physical dysfunction in post-intensive care syndrome (PICS). We herein investigated how each component of PICS was affected by the diagnosis of PIICS during hospitalization and examined the relationship between PIICS and PICS using PICS assessments performed at the Hitachi General Hospital PICS Clinic.

METHODS

The 273 patients who visited the PICS clinic at one month after discharge from the ICU at Hitachi General Hospital were included in the study. We used the diagnostic criteria for PIICS described in previous studies. At least two of the following blood test values on day 14 of hospitalization had to be met for a diagnosis of PIICS: C-reactive protein (CRP) > 2.0 mg/dL, albumin (Alb) < 3.0 g/dL, and lymphocytes (Lym) < 800/μL. Blood test values closest to day 14 out of 11-17 days of hospitalization were used. The primary outcome was a Barthel Index (BI) < 90, while secondary outcomes were the results of various PICS assessments, including mental and cognitive impairments, performed at the PICS clinic. We supplemented missing data with multiple imputations by chained equations. We performed a nominal logistic regression analysis with age, sex, BMI, SOFA, and the presence of PIICS as variables for BI < 90.

RESULTS

Forty-three out of two hundred seventy-three PICS outpatients met the diagnostic criteria for PIICS during hospitalization. In comparisons with non-PIICS patients, significantly higher severity scores for APACHE II and SOFA and a longer hospital stay were observed in PIICS patients, suggesting a higher clinical severity. The primary outcome, BI, was lower in the PIICS group (97.5 (58.5, 100) vs. 100 (95, 100), p = 0.008), as were the secondary outcomes (FSS-ICU: 35 (31, 35) vs. 35 (35, 35), MRC score: 55 (50.25, 58) vs. 58 (53, 60), grip strength: 16.45 (9.2, 25.47) vs. 20.4 (15.3, 27.7)). No significant differences were noted in mental or cognitive function assessments, such as HADS, IES-R, and SMQ. A multivariable analysis supplemented with missing data revealed that PIICS (odds ratio: 1.23 (1.08-1.40 p = 0.001) and age (odds ratio: 1.007 (1.004-1.01), p < 0.001) correlated with BI < 90, independent of clinical severity such as sequential organ failure assessment (SOFA). Similar results were obtained in the sensitivity analysis excluding missing data.

CONCLUSIONS

The present study revealed a strong relationship between PIICS and post-discharge PICS physical dysfunction in patients requiring intensive care.

Organization, feasibility and patient appreciation of a follow-up consultation in surgical critically ill patients with favorable baseline quality of life and prolonged ICU-stay: a pilot study

OBJECTIVES

Intensive care unit (ICU) survivors are often left with impairments in physical, mental and cognitive functioning (Post-Intensive Care Syndrome (PICS)). We evaluated the organization, the feasibility for caregivers and patients and the patients' appreciation of a post-ICU consultation aiming to detect these PICS-symptoms.

METHODS

A single-center prospective observational pilot study was conducted during an 18 month-period in the surgical ICU of a tertiary care hospital. Consecutive adult patients with an ICU-stay of ≥8 days and a favorable baseline quality of life (utility index ≥0.6 on EQ-5D-3 L) were eligible for inclusion. A post-ICU follow-up consultation consisting of a structured interview was scheduled 3 months after hospital discharge. Characteristics of the consultation (CG) and no consultation group (NCG) were compared. P-values <0.05 were considered significant.

RESULTS

Of 133 eligible patients, 85 (64%) consented for the study and 42 (49%) attended the consultation. A total of 148 phone calls were made to schedule the consultations. Consultations took a median of 68 (61-74) minutes. Compared to CG-patients, NCG-patients were more often discharged to a care facility (P = 0.003) and had more problems with mobility (P = 0.014), self-care (P < 0.001) and usual activities (P = 0.005) after 3 months. At least one PICS-related problem was documented in all patients in the CG and NCG. Thirty-four CG-patients (81%) appreciated the initiative.

CONCLUSION

Organizing an ICU-follow-up consultation was difficult and feasibility was low, but most attending patients appreciated the initiative. Better developed structures for ICU-follow-up are needed in view of the high number of PICS-related problems documented.

Grip Strength Correlates with Mental Health and Quality of Life after Critical Care: A Retrospective Study in a Post-Intensive Care Syndrome Clinic

Post-intensive care syndrome (PICS) is characterized by several prolonged symptoms after critical care, including physical and cognitive dysfunctions as well as mental illness. In clinical practice, the long-term follow-up of PICS is initiated after patients have been discharged from the intensive care unit, and one of the approaches used is a PICS clinic. Although physical dysfunction and mental illness often present in combination, they have not yet been examined in detail in PICS patients. Grip strength is a useful physical examination for PICS, and is reported to be associated with mental status in the elderly. We herein investigated the relationship between grip strength and the mental status using data from our PICS clinic. We primarily aimed to analyze the correlation between grip strength and the Hospital Anxiety and Depression Scale (HADS) score. We also analyzed the association between grip strength and the EuroQol 5 Dimension (EQ5D) score as quality of life (QOL). Subjects comprised 133 patients who visited the PICS clinic at one month after hospital discharge between August 2019 and December 2020. Total HADS scores were 7 (4, 13) and 10 (6, 16) (p = 0.029) and EQ5D scores were 0.96 (0.84, 1) and 0.77 (0.62, 0.89) (p ≤ 0.0001) in the no walking disability group and walking disability group, respectively. Grip strength negatively correlated with HADS and EQ5D scores. Correlation coefficients were r = -0.25 (p = 0.011) and r = -0.47 (p < 0.0001) for HADS and EQ5D scores, respectively. Grip strength was a useful evaluation that also reflected the mental status and QOL.

Posthospitalization follow-up recommendations after pediatric critical illness due to respiratory failure

OBJECTIVES

To characterize the recommended posthospitalization follow-up by provider type and location after a pediatric critical illness due to respiratory failure.

WORKING HYPOTHESIS

After pediatric critical illness due to respiratory failure, patients will not have a standard follow-up pattern with regard to provider type or follow-up location.

STUDY DESIGN

A retrospective cohort study.

SUBJECT SELECTION

Children, 18 years or younger, admitted to a quaternary care pediatric intensive care unit with respiratory failure between January 1, 2013 and December 31, 2014.

METHODOLOGY

For eligible patients, recommendations for posthospitalization follow-up including provider type (primary care and specialty care) and location (community care center vs. tertiary care center) were characterized from medical chart review. Recommendations were examined for all patients and two patient subgroups (patients who received extracorporeal membrane oxygenation and patients with tracheostomy).

RESULTS

Of 155 patients alive at hospital discharge, the median age was 2.1 (interquartile range, 0.7-10.6) years. Eighty percent of patients were instructed to follow-up with a primary care provider but only 52.9% with a pulmonologist. We found 10 unique follow-up patterns between provider location (community care center, tertiary care center, or both) and global provider type (primary care versus specialty care). Primary care follow-up was recommended more often at community locations (74.2%), whereas specialty care was more often recommended at tertiary care centers (68.6%).

CONCLUSIONS

Our study findings demonstrate significant variability in the recommendations for follow-up by provider type and location after hospitalization for acute respiratory failure and highlight areas for improvement in follow-up care after pediatric critical illness.

Bridging the Gap Between the Intensive Care Unit and the Acute Medical Care Unit

BACKGROUND

Despite a growing cohort of intensive care unit (ICU) survivors, little is known about the early ICU aftercare period.

OBJECTIVE

To identify gaps in early ICU aftercare and factors associated with poor hospital outcomes.

METHODS

A multisite, retrospective study (January 1 to December 31, 2017) was conducted among randomly selected patients admitted to the medical ICU and subsequently transferred to acute medical care units. Records were reviewed for patient characteristics, ICU course, and early ICU aftercare practices and syndromes. Associations between practices and hospital outcomes were calculated with χ2 and Wilcoxon rank sum tests, followed by logistic regression.

RESULTS

One hundred fifty-one patients met inclusion criteria (mean [SD] age, 64.2 [19.1] years; 51.7% male; 44.4% White). The most frequent diagnoses were sepsis (35.8%) and respiratory failure (33.8%). During early ICU aftercare, 46.4% had dietary restrictions, 25.8% had bed rest orders, 25.0% had a bladder catheter, 26.5% had advance directive documentation, 33.8% had dysphagia, 34.3% had functional decline, and 23.2% had delirium. Higher Charlson Comorbidity Index (odds ratio, 1.6) and midodrine use on medical units (odds ratio, 7.5) were associated with in-hospital mortality; mechanical ventilation in the ICU was associated with rapid response on medical unit (odds ratio, 12.9); and bladder catheters were associated with ICU readmission (odds ratio, 5.2).

CONCLUSIONS

Delirium, debility, and dysphagia are frequently encountered in early ICU aftercare, yet bed rest, dietary restriction, and lack of advance directive documentation are common. Future studies are urgently needed to characterize and address early ICU aftercare.

ICU discharge screening for prediction of new-onset physical disability-A multinational cohort study

BACKGROUND

Methods to identify patients at risk for incomplete physical recovery after intensive care unit (ICU) stay are lacking. Our aim was to develop a method for prediction of new-onset physical disability at ICU discharge.

METHODS

Multinational prospective cohort study in 10 general ICUs in Sweden, Denmark, and the Netherlands. Adult patients with an ICU stay ≥12 hours were eligible for inclusion. Sixteen candidate predictors were analyzed with logistic regression for associations with the primary outcome; new-onset physical disability 3 months post-ICU, defined as a ≥10 score reduction in the Barthel Index (BI) compared to baseline.

RESULTS

Of the 572 included patients, follow-up data are available on 78% of patients alive at follow-up. The incidence of new-onset physical disability was 19%. Univariable and multivariable modeling rendered one sole predictor for the outcome: physical status at ICU discharge, assessed with the five first items of the Chelsea critical care physical assessment tool (CPAx) (odds ratio 0.87, 95% confidence interval (CI) 0.81-0.93), a higher score indicating a lower risk, with an area under the receiver operating characteristics curve of 0.68 (95% CI 0.61-0.76). Negative predictive value for a low-risk group (CPAx score >18) was 0.88, and positive predictive value for a high-risk group (CPAx score ≤18) was 0.32.

CONCLUSION

The ICU discharge assessment described in this study had a moderate AUC but may be useful to rule out patients unlikely to need physical interventions post-ICU. For high-risk patients, research to determine post-ICU risk factors for an incomplete rehabilitation is mandated.

A national survey of intensive care follow-up clinics in Australia

BACKGROUND

Intensive care follow-up clinics (ICFCs) have been implemented internationally with the aim to address the growing number of patients living with sequalae of critical illness and intensive care. However, data on Australian intensive care follow-up practice are rare.

OBJECTIVES

The primary objective was to determine the proportion of Australian intensive care units (ICUs) that offer a dedicated ICFC to ICU survivors, with the intention of improving long-term outcomes of critical illness. Secondary objectives were to identify models of ICU follow-up and barriers to the implementation of ICFCs.

METHODS

A custom-designed, pilot-tested 12-question online survey was sent to the nurse unit managers and medical directors of all 167 Australian ICUs listed in the database of the Australian and New Zealand Intensive Care Society. Outcome measures included proportion of ICUs offering ICFCs, details on types of follow-up services with staffing, funding source, and reasons for not providing ICU follow-up.

RESULTS

One hundred seven of the 167 ICUs contacted responded to the survey. Of these, two (2%) operated a dedicated ICFC. Both ICFCs were nursing-led, with one receiving dedicated funding and the other being unfunded. Three units (3%) conducted routine outpatient follow-up by telephone; one of these services was doctor-led, and two were nurse-led. Four units (4%) were performing outpatient follow-up as part of research studies only. Among the units not operating an ICFC, the main reason given for not doing so were financial constraints (58%), followed by lack of clinical need (19%) and perceived lack of evidence (11%).

CONCLUSION

In Australia, only two ICUs operated an ICFC. Only one outpatient follow-up service received dedicated funding, and financial constraints were the main reason given for units not offering outpatient follow-up services.

Experiencias de pacientes con discapacidades funcionales posteriores al tratamiento en la Unidad de Cuidados Intensivos

Introducción: Comprender las experiencias de los pacientes con discapacidades funcionales después del tratamiento en la Unidad de Cuidados Intensivos a su regreso a casa. Materiales y métodos: Se trata de un estudio de enfoque cualitativo que utilizó el estudio de caso como método de investigación. La muestra de ocho participantes fue compuesta intencionalmente y cerrada por saturación teórica. La recolección de datos se realizó a través de entrevistas domiciliarias semiestructuradas complementadas con notas y diarios de campo. Los datos fueron analizados mediante el análisis de contenido temático propuesto por Minayo. Resultados: La atención primaria, a través de la atención domiciliaria, fue la principal responsable del seguimiento posterior al alta de los participantes. Del material empírico, surgieron las categorías "sufrimiento emocional y sus repercusiones en la recuperación funcional" y "la pérdida del rol familiar y los conflictos con los cuidadores". Discusión y conclusiones: La recuperación funcional de pacientes con discapacidades funcionales después de pasar por cuidados intensivos puede ser compleja y requiere, además de rehabilitación física, monitoreo psicoemocional adecuado, aclaración de los recuerdos de hospitalización y apoyo profesional a la familia. Se sugiere que la atención primaria reciba capacitación sobre la complejidad de estos pacientes y la creación de estrategias que lo acerquen a la atención hospitalaria, lo que permite una atención compartida y continua. Como citar este artículo: Silva, Camila Zucato; Campos, Claudinei José Gomes; Jamarim, Michelle Ferraz Martins; Lima, Gerusa Marcondes Pimentel de Abreu. Vivências de pacientes diante de incapacidades funcionais pós-tratamento em Unidade de Terapia Intensiva. Revista Cuidarte. 2020; 11(2): e1018. http://dx.doi.org/10.15649/cuidarte.1018

Healthcare providers' knowledge and handling of impairments after intensive unit treatment: A questionnaire survey

BACKGROUND

Numerous patients experience long-term impairments after discharge from the intensive care unit (ICU), including physical, psychological and cognitive deficiencies. This study aims to investigate the knowledge and handling of post-intensive care impairments among Danish doctors and nurses in the medical and surgical wards.

METHODS

An electronic questionnaire survey was distributed to consultants and development nurses, head nurses and assistant head nurses at departments of abdominal surgery and internal medicine of hospitals with an ICU in the Region Zealand of Denmark.

RESULTS

We invited 350 employees to participate, 48% responded. Most participants, 82.8% nurses and 86.6% doctors, reported their knowledge of in-hospital needs of the ICU patients to be average or higher. Sixty per cent of doctors reported having average or higher knowledge of the patients' post-discharge needs. More than half the doctors (60.2%) reported that they "Rarely" or "Never" addressed possible ICU-related impairments in the discharge summary. During hospital admission, 22.9% replied "No screening performed" for physical impairment, while the rates for psychological and cognitive impairments were 70.7% and 57.3%, respectively. Most respondents believed that doctors (92.8%) and nurses (92.1%) in the ward and ICU doctors (89.4%) play an important role in detecting ICU-related impairments; 63.8% felt that general practitioners play a key role.

CONCLUSION

Doctors and nurses generally reported having average or higher knowledge of ICU patients' in-hospital needs, but few screened systematically for ICU-related impairments. Most respondents believed that detecting these problems is a shared responsibility between professionals in the primary and, especially, the secondary healthcare sector.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Trial registration

The study was registered at clinicaltrials.gov, NCT02679157.

Electronic supplementary material

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

Implementation and evaluation of a follow-up programme after intensive care treatment: A practice development project

OBJECTIVES

This study aimed to measure the effects of a newly developed follow-up programme on intensive care unit patient quality of care, as perceived by their relatives, and the appropriateness of the programme according to nurses.

METHODS AND SETTING

This before and after implementation study was conducted in a level III intensive care unit for adult patients and related follow-up wards and included 135 intensive care nurses and 105 general ward nurses. The implemented programme included a personalised poster, a revised discharge protocol and follow-up visits on the ward. Eligible relatives of patients who had remained in the intensive care for a minimum of 48 hours were included.

MAIN OUTCOME MEASURES AND RESULTS

Total quality of care and communication were assessed by relatives as high according to the Quality Monitor. Most intensive care nurses evaluated the usefulness of the discharge protocol as positive (71.8% partly/totally agreed) and in accordance with the patients' needs (82.1% partly/totally agreed).

CONCLUSION

Communication and general support as perceived by patients' relatives improved; however, no influence on the total quality of care of the revised discharge protocol was shown. Nurses considered the programme as useful. The intervention might enable nurses to better respond to the instrumental and affective needs of patients and their relatives.