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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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Agbakou M, Combet M, Martin M, Blonz G, Desmedt L, Seguin A, Lemarié J, Zambon O, Reignier J, Lascarrou JB, Ehrmann S, Canet E. Post-intensive care syndrome screening: a French multicentre survey. Ann Intensive Care 2024; 14:109. [PMID: 38980434 PMCID: PMC11233491 DOI: 10.1186/s13613-024-01341-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 06/21/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Post-intensive care syndrome (PICS), defined as physical, cognitive, and mental-health symptoms persisting long after intensive-care-unit (ICU) discharge, is increasingly recognised as a healthcare priority. Data on screening for PICS are sparse. Our objective here was to describe post-ICU screening in France, with special attention to visit availability and evaluations done during visits. METHODS We conducted an online multicentre survey by emailing an anonymous 43-item questionnaire to French ICUs. For each ICU, a single survey was sent to either the head or the intensivist in charge of follow-up visits. RESULTS Of 252 ICUs invited to participate, 161 (63.9%) returned the completed survey. Among them, 46 (28.6%) offered follow-up visits. Usually, a single visit led by an intensivist was scheduled 3 to 6 months after ICU discharge. Approximately 50 patients/year/ICU, that is, about 5% of admitted patients, attended post-ICU visits. The main criteria used to select patients for follow-up were ICU stay and/or invasive mechanical ventilation duration longer than 48 h, cardiac arrest, septic shock, and acute respiratory distress syndrome. Among ICUs offering visits, 80% used validated instruments to screen for PICS. Of the 115 ICUs not offering follow-up, 50 (43.5%) indicated an intention to start follow-up within the next year. The main barriers to offering follow-up were lack of available staff and equipment or not viewing PICS screening as a priority. Half the ICUs offering visits worked with an established network of post-ICU care professionals, and another 17% were setting up such a network. Obstacles to network creation were lack of interest among healthcare professionals and lack of specific training in PICS. CONCLUSION Only a small minority of ICU survivors received follow-up designed to detect PICS. Less than a third of ICUs offered follow-up visits but nearly another third planned to set up such visits within the next year. Recommendations issued by French health authorities in 2023 can be expected to improve the availability and standardisation of post-ICU follow-up.
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Affiliation(s)
- Maïté Agbakou
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France.
| | - Margot Combet
- Intensive Care Unit, Kremlin-Bicêtre University Hospital, Assistance Publique- Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Maëlle Martin
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Gauthier Blonz
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Luc Desmedt
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Amélie Seguin
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Jérémie Lemarié
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Olivier Zambon
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Jean Reignier
- Intensive Care Unit, Nantes University Hospital, Movement - Interactions - Performance Research Unit (MIP, (MIP, UR 4334), Nantes, France
| | - Jean-Baptiste Lascarrou
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
| | - Stephan Ehrmann
- Intensive Care Unit, Tours University Hospital, Tours, France
- INSERM CIC 1415, Tours University, Tours University Hospital, Tours, France
- Research Center for Respiratory Diseases, INSERM U110, Tours University, Tours, France
- Clinical Research in Intensive Care and Sepsis-Trial Group for Global Evaluation and Research in Sepsis (CRICS_TRIGGERSep), Tours, France
| | - Emmanuel Canet
- Intensive Care Unit, Nantes University Hospital, Nantes University, 30 Bd. Jean Monnet, Nantes, Cedex 1 44093, France
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Savino T, Vergara FH, Ramos MD, Warzecha D. Bringing Delirium to Light: Impact of CAM-ICU Tool to Improve Care Coordination. Prof Case Manag 2024; 29:149-157. [PMID: 38421724 DOI: 10.1097/ncm.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Delirium is a serious complication in patients in the critical care unit (CCU) that may lead to prolonged hospitalization if left undetected. The CCU at our hospital does not have a framework for determining delirium that could affect patient outcomes and discharge planning. PRIMARY PRACTICE SETTING CCU in a community hospital. METHOD A posttest-only design was used for this study. We established a framework for the early assessment of delirium, educated and trained nurses to detect delirium, collaborated with the informatics department, intensivist, nursing, respiratory therapy and worked with case management to deploy the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We used a one-tailed independent t test to determine the impact of CAM-ICU on length of stay (LOS). Cross-tabulation and chi-square tests were used to examine the impact of CAM-ICU tool on home care utilization between the intervention and comparison groups. RESULTS There was a 3.12% reduction in LOS after implementing the CAM-ICU tool. Also, a reduction in home care service utilization demonstrated statistical significance ( p = .001) between the intervention group (62.5%; n = 177) and the comparison group (37.5%; n = 106). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Case managers are essential in improving care transitions. Case managers need to become competent in understanding the implications of the CAM-ICU tool because of their relevant role in the multidisciplinary rounds as advocates to improve care transitions across the continuum of care. Case managers need to have an understanding on how to escalate when changes in the Richmond Agitation-Sedation Scale scores occur during the multidisciplinary rounds because it can affect care coordination throughout the hospital. CONCLUSIONS Implementing the CAM-ICU decreased LOS, and reduced health care utilization. The early identification of patients with delirium can affect the outcomes of critically ill patients and entails multidisciplinary collaboration.
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Affiliation(s)
- Theresa Savino
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
| | - Franz H Vergara
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
| | - Mary Dioise Ramos
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
| | - Deborah Warzecha
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
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Zhang F, Chen Z, Xue DD, Zhang R, Cheng Y. Barriers and facilitators to offering post-intensive care follow-up services from the perspective of critical care professionals: A qualitative study. Nurs Crit Care 2024; 29:682-694. [PMID: 38146140 DOI: 10.1111/nicc.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Various programmes and models for post-intensive care unit (ICU) follow-up services have been developed worldwide. In China, post-ICU follow-up remains in the exploratory stage and little is known regarding the appropriate form and challenges of implementation, which need to be further explored. AIM This study aimed to explore and describe the barriers to and facilitators of post-ICU follow-up services from the perspective of critical care professionals. DESIGN This was a descriptive qualitative study. Semi-structured interviews were conducted with 21 health care workers whose units had offered ICU survivors different forms of follow-up services; the data were analysed by qualitative content analysis during August 2022 and December 2022. SETTING The study was conducted at 14 ICUs in 11 tertiary hospitals in Shanghai, China. FINDINGS Seventeen subthemes were extracted as barriers and facilitators in the follow-up of ICU survivors. In the initiating process, the barriers included the restriction of decision-making rights and scope of practice, indifferent attitude towards survivors and repeated work. The facilitators included admitted significance, the needs of ICU survivors, the conscientiousness of professionals and the pioneers and leadership support. In the implementation process, lack of confidence, lack of cooperation in medical consortium, distrusted relationships, restrictions of medical insurance, ageing problems and insufficient human resources acted as barriers, whereas lessons learned, positive feedback and digital support served as facilitators. Furthermore, recommendations and tips were identified for offering follow-up services. CONCLUSION Medical personnel can better utilize available resources and develop strategies to overcome constraints by gaining insights into the abovementioned barriers and facilitators. The findings of this study can provide a useful reference for structured and systematic follow-ups to ameliorate post-intensive care syndrome in low- and middle-income countries. RELEVANCE TO CLINICAL PRACTICE Publicity and educational measures play a crucial role in enhancing the awareness of survivors and the consensus of health care professionals from medical consortium regarding impairments after critical care. Leadership and policy support can address numerous obstacles to guiding follow-up services.
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Affiliation(s)
- Feng Zhang
- Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
- School of Nursing, Fudan University, Shanghai, People's Republic of China
| | - Zhen Chen
- Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
| | - Dan-Dan Xue
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Rui Zhang
- Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
- School of Nursing, Fudan University, Shanghai, People's Republic of China
| | - Yun Cheng
- Nursing Department, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
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Enriquez de Salamanca Gambara R, Sanz-García A, del Pozo Vegas C, López-Izquierdo R, Sánchez Soberón I, Delgado Benito JF, Martínez Diaz R, Pérez-Oleaga CM, López NMM, Domínguez Azpíroz I, Martín-Rodríguez F. A Comparison of the Clinical Characteristics of Short-, Mid-, and Long-Term Mortality in Patients Attended by the Emergency Medical Services: An Observational Study. Diagnostics (Basel) 2024; 14:1292. [PMID: 38928707 PMCID: PMC11203341 DOI: 10.3390/diagnostics14121292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
AIM The development of predictive models for patients treated by emergency medical services (EMS) is on the rise in the emergency field. However, how these models evolve over time has not been studied. The objective of the present work is to compare the characteristics of patients who present mortality in the short, medium and long term, and to derive and validate a predictive model for each mortality time. METHODS A prospective multicenter study was conducted, which included adult patients with unselected acute illness who were treated by EMS. The primary outcome was noncumulative mortality from all causes by time windows including 30-day mortality, 31- to 180-day mortality, and 181- to 365-day mortality. Prehospital predictors included demographic variables, standard vital signs, prehospital laboratory tests, and comorbidities. RESULTS A total of 4830 patients were enrolled. The noncumulative mortalities at 30, 180, and 365 days were 10.8%, 6.6%, and 3.5%, respectively. The best predictive value was shown for 30-day mortality (AUC = 0.930; 95% CI: 0.919-0.940), followed by 180-day (AUC = 0.852; 95% CI: 0.832-0.871) and 365-day (AUC = 0.806; 95% CI: 0.778-0.833) mortality. DISCUSSION Rapid characterization of patients at risk of short-, medium-, or long-term mortality could help EMS to improve the treatment of patients suffering from acute illnesses.
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Affiliation(s)
| | - Ancor Sanz-García
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain
| | - Carlos del Pozo Vegas
- Faculty of Medicine, Universidad de Valladolid, 47011 Valladolid, Spain; (C.d.P.V.); (F.M.-R.)
- Emergency Department, Hospital Clínico Universitario, 47003 Valladolid, Spain
| | - Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain; (R.E.d.S.G.); (R.L.-I.)
- Faculty of Medicine, Universidad de Valladolid, 47011 Valladolid, Spain; (C.d.P.V.); (F.M.-R.)
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Irene Sánchez Soberón
- Advanced Life Support, Emergency Medical Services (SACYL), 47007 Valladolid, Spain; (I.S.S.); (J.F.D.B.)
| | - Juan F. Delgado Benito
- Advanced Life Support, Emergency Medical Services (SACYL), 47007 Valladolid, Spain; (I.S.S.); (J.F.D.B.)
| | - Raquel Martínez Diaz
- Department of Project Management, Universidad Europea del Atlántico, 39011 Santander, Spain; (R.M.D.); (C.M.P.-O.); (N.M.M.L.); (I.D.A.)
- Department of Project Management, Universidad Internacional Iberoamericana, Campeche 24560, Mexico
- Department of Project Management, Universidad de La Romana, La Romana 22000, Dominican Republic
| | - Cristina Mazas Pérez-Oleaga
- Department of Project Management, Universidad Europea del Atlántico, 39011 Santander, Spain; (R.M.D.); (C.M.P.-O.); (N.M.M.L.); (I.D.A.)
- Department of Project Management, Universidad Internacional Iberoamericana, Arecibo 00613, Puerto Rico
- Department of Project Management, Universidade Internacional do Cuanza, Cuito EN250, Angola
| | - Nohora Milena Martínez López
- Department of Project Management, Universidad Europea del Atlántico, 39011 Santander, Spain; (R.M.D.); (C.M.P.-O.); (N.M.M.L.); (I.D.A.)
- Department of Project Management, Universidad Internacional Iberoamericana, Campeche 24560, Mexico
- Fundación Universitaria Internacional de Colombia, Bogotá 111321, Colombia
| | - Irma Domínguez Azpíroz
- Department of Project Management, Universidad Europea del Atlántico, 39011 Santander, Spain; (R.M.D.); (C.M.P.-O.); (N.M.M.L.); (I.D.A.)
- Department of Project Management, Universidad Internacional Iberoamericana, Campeche 24560, Mexico
- Department of Project Management, Universidad de La Romana, La Romana 22000, Dominican Republic
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, Universidad de Valladolid, 47011 Valladolid, Spain; (C.d.P.V.); (F.M.-R.)
- Advanced Life Support, Emergency Medical Services (SACYL), 47007 Valladolid, Spain; (I.S.S.); (J.F.D.B.)
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Bourne RS, Herridge MS, Burry LD. Less inappropriate medication: first steps in medication optimization to improve post-intensive care patient recovery. Intensive Care Med 2024; 50:982-985. [PMID: 38635046 DOI: 10.1007/s00134-024-07405-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Richard S Bourne
- Departments of Pharmacy and Critical Care, Northern General Hospital, Herries Road, Sheffield, UK
- Faculty of Biology, Medicine and Health, Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Oxford Road, Manchester, UK
| | - Margaret S Herridge
- Respiratory and Critical Care Medicine, Temerty Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Lisa D Burry
- Department of Pharmacy and Medicine, Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care Medicine, Sinai Health, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacy, Mount Sinai Hospital, Room 18-300E, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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Masterson JA, Adamestam I, Beatty M, Boardman JP, Chislett L, Johnston P, Joss J, Lawrence H, Litchfield K, Plummer N, Rhode S, Walsh T, Wise A, Wood R, Weir CJ, Lone NI. Measuring the impact of maternal critical care admission on short- and longer-term maternal and birth outcomes. Intensive Care Med 2024; 50:890-900. [PMID: 38844640 DOI: 10.1007/s00134-024-07417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/28/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE Factors increasing the risk of maternal critical illness are rising in prevalence in maternity populations. Studies of general critical care populations highlight that severe illness is associated with longer-term physical and psychological morbidity. We aimed to compare short- and longer-term outcomes between women who required critical care admission during pregnancy/puerperium and those who did not. METHODS This is a cohort study including all women delivering in Scottish hospitals between 01/01/2005 and 31/12/2018, using national healthcare databases. The primary exposure was intensive care unit (ICU) admission, while secondary exposures included high dependency unit admission. Outcomes included hospital readmission (1-year post-hospital discharge, 1-year mortality, psychiatric hospital admission, stillbirth, and neonatal critical care admission). Multivariable Cox and logistic regression were used to report hazard ratios (HR) and odds ratios (OR) of association between ICU admission and outcomes. RESULTS Of 762,918 deliveries, 1449 (0.18%) women were admitted to ICU, most commonly due to post-partum hemorrhage (225, 15.5%) followed by eclampsia/pre-eclampsia (133, 9.2%). Over-half (53.8%) required mechanical ventilation. One-year hospital readmission was more frequent in women admitted to ICU compared with non-ICU populations [24.5% (n = 299) vs 8.9% (n = 68,029)]. This association persisted after confounder adjustment (HR 1.93, 95% confidence interval [CI] 1.33, 2.81, p < 0.001). Furthermore, maternal ICU admission was associated with increased 1-year mortality (HR 40.06, 95% CI 24.04, 66.76, p < 0.001), stillbirth (OR 12.31, 95% CI 7.95,19.08, p < 0.001) and neonatal critical care admission (OR 6.99, 95% CI 5.64,8.67, p < 0.001) after confounder adjustment. CONCLUSION Critical care admission increases the risk of adverse short-term and long-term maternal, pregnancy and neonatal outcomes. Optimizing long-term post-partum care may benefit maternal critical illness survivors.
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Affiliation(s)
- John A Masterson
- Department of Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Imad Adamestam
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Monika Beatty
- Department of Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - James P Boardman
- Centre for Reproductive Health, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK
| | - Louis Chislett
- Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Pamela Johnston
- Department of Anaesthesia, Critical Care, and Pain Medicine, Ninewells Hospital, Dundee, UK
| | - Judith Joss
- Department of Anaesthesia, Critical Care, and Pain Medicine, Ninewells Hospital, Dundee, UK
| | - Heather Lawrence
- Patient Representative, The University of Edinburgh, Edinburgh, UK
| | - Kerry Litchfield
- Department of Anaesthesia, Critical Care, and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Nicholas Plummer
- Department of Critical Care, Nottingham University Hospitals, Nottingham, UK
| | - Stella Rhode
- Usher Institute, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Timothy Walsh
- Department of Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Arlene Wise
- Department of Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Rachael Wood
- Usher Institute, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- Public Health Scotland, Glasgow, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Nazir I Lone
- Department of Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK.
- Usher Institute, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.
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Subramaniam A. The truism of 'life limiting illness' in ICU. CRIT CARE RESUSC 2024; 26:61-63. [PMID: 39072239 PMCID: PMC11282326 DOI: 10.1016/j.ccrj.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 07/30/2024]
Affiliation(s)
- Ashwin Subramaniam
- Corresponding author at: Department of Intensive Care, Dandenong Hospital, Monash Health, 135 David Street, Dandenong, Victoria 3175, Australia. Tel.: +61 3 9784 7422. Twitter icon@catchdrash
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Mansi ET, Rentsch CT, Bourne RS, Guthrie B, Lone NI. Psychotropic prescribing after hospital discharge in survivors of critical illness, a retrospective cohort study (2012-2019). J Intensive Care Soc 2024; 25:171-180. [PMID: 38737305 PMCID: PMC11081855 DOI: 10.1177/17511437231223470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background Many people survive critical illness with the burden of new or worsened mental health issues and sleep disturbances. We examined the frequency of psychotropic prescribing after critical illness, comparing critical care to non-critical care hospitalised survivors, and whether this varied in important subgroups. Methods This retrospective cohort study included 23,340 critical care and 367,185 non-critical care hospitalised adults from 2012 through 2019 in Lothian, Scotland, who survived to discharge. Results One-third of critical care survivors (32%; 7527/23,340) received a psychotropic prescription within 90 days after hospital discharge (25% antidepressants; 14% anxiolytics/hypnotics; 4% antipsychotics/mania medicines). In contrast, 15% (54,589/367,185) of non-critical care survivors received a psychotropic prescription (12% antidepressants; 5% anxiolytics/hypnotics; 2% antipsychotics/mania medicines). Among patients without psychotropic prescriptions within 180 days prior to hospitalisation, after hospital discharge, the critical care group had a higher incidence of psychotropic prescription (10.3%; 1610/15,609) compared with the non-critical care group (3.2%; 9743/307,429); unadjusted hazard ratio (HR) 3.39, 95% CI: 3.22-3.57. After adjustment for potential confounders, the risk remained elevated (adjusted HR 2.03, 95% CI: 1.91-2.16), persisted later in follow-up (90-365 days; adjusted HR 1.38, 95% CI: 1.30-1.46), and was more pronounced in those without recorded comorbidities (adjusted HR 3.49, 95% CI: 3.22-3.78). Conclusions Critical care survivors have a higher risk of receiving psychotropic prescriptions than hospitalised patients, with a significant proportion receiving benzodiazepines and other hypnotics. Future research should focus on the requirement for and safety of psychotropic medicines in survivors of critical illness, to help guide policy for clinical practice.
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Affiliation(s)
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Richard S Bourne
- Departments of Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Advanced Care Research Centre, University of Edinburgh, Edinburgh, UK
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
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10
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Kang J, Lee MH. Incidence rate and risk factors for post-intensive care syndrome subtypes among critical care survivors three months after discharge: A prospective cohort study. Intensive Crit Care Nurs 2024; 81:103605. [PMID: 38157567 DOI: 10.1016/j.iccn.2023.103605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/16/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To investigate the incidence of post-intensive care syndrome subtypes and their risk factors among intensive care unit survivors. RESEARCH METHODOLOGY/DESIGN This prospective observational cohort study assessed post-intensive care syndrome at three months after discharge in 475 survivors (median age of 62 years, 59.4 % male) admitted for more than 24 hours to 19 intensive care units. SETTING 19 intensive care units at four university hospitals in Korea. MAIN OUTCOME MEASURES Three months after discharge, the Hospital Anxiety and Depression Scale, Posttraumatic Diagnosis Scale, Montreal Cognitive Assessment, and Activities of Daily Living were used to evaluate post-intensive care syndrome. RESULTS Participants exhibited eight subtypes of post-intensive care syndrome: post-intensive care syndrome free (50.3 %), impaired in physical (3.4 %), mental (13.5 %), cognitive (12.4 %), physical and mental (7.8 %), physical and cognitive (2.3 %), mental and cognitive (4.0 %) and all three domains (6.3 %). Age, unemployment, education, comorbidities, unplanned admission, longer stay, and place of discharge were risk factors for each domain. Age ≥ 65 years (OR 9.234, p < .001), female gender (OR = 5.143, p = .002), two or more comorbidities (OR = 8.701, p = .002), and discharge to an extended care facility (OR = 36.040, p < .001) were associated with increased probability of impairment in all three domains. CONCLUSION The type with impaired in both mental and physical domains was the most prevalent in cases of co-occurrence. Discharge to an extended care facility was one of the most significant risk factor for the occurrence of each domain and intensity of post-intensive care syndrome. IMPLICATIONS FOR CLINICAL PRACTICE Nurses must promote prevention strategies by proactively evaluating intensive care unit survivors for post-intensive care syndrome risk factors. Additionally, it is necessary to raise healthcare providers' awareness of post-intensive care syndrome evaluation and management in extended care facilities.
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Affiliation(s)
- Jiyeon Kang
- College of Nursing, Dong-A University, Busan, South Korea
| | - Min Hye Lee
- College of Nursing, Dong-A University, Busan, South Korea.
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11
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Kang J, Lee KM. Three-year mortality, readmission, and medical expenses in critical care survivors: A population-based cohort study. Aust Crit Care 2024; 37:251-257. [PMID: 37574386 DOI: 10.1016/j.aucc.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 07/10/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Due to the increasing number of critical care survivors, population-based studies on the long-term outcomes after discharge are necessary to inform local decision-making. OBJECTIVES This study aimed to investigate mortality and its risk factors, readmissions, and medical expenses of intensive care unit survivors for 3 years after hospital discharge. METHODS This retrospective study analysed data from the National Health Insurance Service-National Sample Cohort in Korea. Of the 195,702 patients who survived and were discharged from hospital in 2012, 2693 intensive care unit patients were assigned to the case group for the study, and the remaining 193,009 were assigned to the comparison group. The primary outcome was all-cause mortality for 3 years after discharge. Secondary outcomes were all-cause hospital readmission and medical expenses in 3 years. We analysed risk factors for mortality using the Cox proportional hazard regression. The differences in hospital readmission and medical expenses between the case and comparison groups were analysed by multivariate logistic regression and independent t-tests. RESULTS The 1-year, 2-year, and 3-year cumulative mortality rates in the case group were 15.9%, 20.5%, and 24.4%, respectively, and older age, disability, medical admission, and longer hospital stay increased mortality. Almost 40% of intensive care unit survivors were readmitted to hospital within 6 months of discharge, and their odds of being readmitted were significantly higher than those of the comparison group. Medical expenses were also significantly higher in the case group, with the highest paid within 6 months. CONCLUSIONS Mortality, hospital readmission, and medical expenses for intensive care unit survivors were the worst within 6 months of discharge. In light of the long-term recovery trajectory of critical illness, it is necessary to investigate what factors may have contributed to the negative outcome during this period. Further research is needed to determine which services primarily contributed to the increase in medical expenses.
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Affiliation(s)
- Jiyeon Kang
- College of Nursing, Dong-A University, Busan, South Korea.
| | - Kwang Min Lee
- Industry-Academy Cooperation, Dong-A University, Busan, South Korea
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12
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Salluh JIF, Quintairos A, Dongelmans DA, Aryal D, Bagshaw S, Beane A, Burghi G, López MDPA, Finazzi S, Guidet B, Hashimoto S, Ichihara N, Litton E, Lone NI, Pari V, Sendagire C, Vijayaraghavan BKT, Haniffa R, Pisani L, Pilcher D. National ICU Registries as Enablers of Clinical Research and Quality Improvement. Crit Care Med 2024; 52:125-135. [PMID: 37698452 DOI: 10.1097/ccm.0000000000006050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Dave A Dongelmans
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diptesh Aryal
- National Coordinator, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Sean Bagshaw
- Department of Medicine, Faculty of Medicine and Dentistry (Ling, Bagshaw), University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Division of Internal Medicine (Villeneuve), Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta and Grey Nuns Hospitals, Edmonton, AB, Canada
| | - Abigail Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Del Pilar Arias López
- Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
- Intermediate Care Unit, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, Paris, France
| | - Satoru Hashimoto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Scottish Intensive Care Society Audit Group, United Kingdom
| | - Vrindha Pari
- Chennai Critical Care Consultants, Pvt Ltd, Chennai, India
| | - Cornelius Sendagire
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Anesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - David Pilcher
- University College Hospital, London, United Kingdom
- Department of Intensive Care, Alfred Health, Prahran, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell, Australia
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Stewart J, Bradley J, Smith S, McPeake J, Walsh T, Haines K, Leggett N, Hart N, McAuley D. Do critical illness survivors with multimorbidity need a different model of care? Crit Care 2023; 27:485. [PMID: 38066562 PMCID: PMC10709866 DOI: 10.1186/s13054-023-04770-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
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.
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Affiliation(s)
- Jonathan Stewart
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland.
| | - Judy Bradley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Susan Smith
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Timothy Walsh
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kimberley Haines
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Nina Leggett
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Nigel Hart
- Centre for Medical Education, Queen's University Belfast, Belfast, Northern Ireland
| | - Danny McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
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14
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Garrity K, Gaw S, Blewitt A, Canon P, McCall P, McPeake J. Cardiac dysfunction in survivors of sepsis: a scoping review. Open Heart 2023; 10:e002454. [PMID: 38065588 PMCID: PMC10711866 DOI: 10.1136/openhrt-2023-002454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Sepsis is associated with an increased risk of adverse cardiovascular events in a magnitude comparable to other major cardiovascular risk factors. Sepsis is one of the most common reasons for intensive care admission and survivors often have significant functional limitations following discharge. However, it is not clear to what extent chronic cardiovascular dysfunction might mediate these functional impairments, or how we might screen and manage these patients at risk of chronic cardiovascular disease. We conducted a scoping review to map existing evidence and identify research gaps relating to cardiovascular dysfunction following sepsis. METHODS We conducted a systematic search of MEDLINE, Embase and CINAHL databases using a concept, context, population (CoCoPop) framework. Studies examining cardiovascular outcomes or symptoms following an episode of sepsis in adults were included. Data were mapped based on the population assessed, cardiovascular outcomes examined, inclusion of objective measures of cardiac dysfunction such as biomarkers or cardiovascular imaging, or whether cardiovascular symptoms or patient-reported functional outcomes measures were recorded. RESULTS We identified 11 210 articles of which 70 were eligible for full text review and 28 were included in final analysis. Across our dataset, a wide range of incident cardiovascular outcomes were reported in the literature including incidence of congestive heart failure (13/28), arrhythmia (6/28), myocardial infarction (24/28) or cardiovascular death or all-cause mortality (20/28). Only 39% (11/28) of articles reported objective measures of cardiovascular function and only one article related cardiovascular function to functional impairment via patient-reported outcome measures. CONCLUSION There are significant gaps in our understanding of cardiac dysfunction following sepsis . While the research highlights the strong association of sepsis with a variety of adverse cardiovascular outcomes, further prospective work is required to understand the mechanisms that mediate this phenomenon and how we can best identify and manage patients at risk.
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Affiliation(s)
- Kevin Garrity
- University of Glasgow, Glasgow, UK
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | | | - Philip McCall
- University of Glasgow, Glasgow, UK
- NHS Golden Jubilee, Glasgow, UK
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15
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Mayer KP, Silva S, Beaty A, Davenport A, Minniti M, Dorn SU, White LS, Sabol VK, Pastva AM. Relationship of Age And Mobility Levels During Physical Rehabilitation With Clinical Outcomes in Critical Illness. Arch Rehabil Res Clin Transl 2023; 5:100305. [PMID: 38163032 PMCID: PMC10757188 DOI: 10.1016/j.arrct.2023.100305] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Objective To determine whether age, mobility level, and change in mobility level across the first 3 physical rehabilitation sessions associate with clinical outcomes of patients who are critically ill. Design Retrospective, observational cohort study. Setting Medical Intensive Care Unit (MICU). Participants Hospitalized adults (n = 132) who received 3 or more, consecutive rehabilitation sessions in the MICU. Interventions Not applicable. Measurements and Main Results Sample included 132 patients with 60 (45%) classified as younger (18-59 years) and 72 (55%) as older (60+ years). The most common diagnosis was sepsis/septicemia (32.6%). Older relative to younger patients had a significantly slower rate of improvement in ICU Mobility Scale (IMS) scores across rehabilitation sessions (mean slope coefficient 0.3 vs 0.6 points, P<.001), were less likely to be discharged to home (30.6% vs 55.0%, P=.005), and were more likely to die within 12 months (41.7% vs 25.0%, P=.046). Covariate-adjusted models indicated greater early improvement in IMS scores were associated with discharge home (P=.005). Longer time to first rehabilitation session, lower initial IMS scores, and slower improvement in IMS scores were associated with increased ICU days (all P<.03). Conclusion Older age and not achieving the mobility milestone of sitting at edge of bed or limited progression of mobility across sessions is associated with poor patient outcomes. Our findings suggest that age and mobility level contribute to outcome prognostication, and can aide in clinical phenotyping and rehabilitative service allocation.
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Affiliation(s)
- Kirby P. Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY
| | - Susan Silva
- Duke University School of Nursing, Duke University, Durham, NC
| | - Amanda Beaty
- Physical Therapy Division, Duke University School of Medicine, Durham, NC
- Department of Rehabilitation Services, Duke Health, Durham, NC
| | - Anne Davenport
- Physical Therapy Division, Duke University School of Medicine, Durham, NC
- Department of Rehabilitation Therapy, Sky Lakes Medical Center, Klamath Falls, OR
| | - Melissa Minniti
- Physical Therapy Division, Duke University School of Medicine, Durham, NC
- Department of Physical Medicine and Rehabilitation Services, James A Haley VA, Tampa, FL
| | - Sara Uribe Dorn
- Department of Rehabilitation Services, Duke Health, Durham, NC
| | - Lane S. White
- Department of Rehabilitation Services, Duke Health, Durham, NC
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD
| | | | - Amy M. Pastva
- Physical Therapy Division, Duke University School of Medicine, Durham, NC
- Duke Claude D. Pepper Older Americans Independence Center, Duke University School of Medicine, Durham, NC
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16
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Martínez E, Aguilera C, Márquez D, Ziegler G, Plumet J, Tschopp L, Cominotti C, Sturzenegger V, Cimino C, Escobar H, Pereyra C, Hidalgo E, Adanza SP, Morelli DM, Masevicius FD. Post intensive care syndrome in survivors of COVID-19 who required mechanical ventilation during the third wave of the pandemic: A prospective study. Heart Lung 2023; 62:72-80. [PMID: 37348211 PMCID: PMC10277848 DOI: 10.1016/j.hrtlng.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/29/2023] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Post intensive care syndrome is defined as the presence of any impairment affecting the physical, psychiatric, or cognitive domains as a result of critical illnesses. OBJECTIVES To explore functional, cognitive and psychological outcomes at 30 days post hospital discharge among survivors of COVID-19-associated acute respiratory distress syndrome, who required mechanical ventilation. METHODS Prospective cohort study. We included adult patients with COVID-19-associated acute respiratory distress syndrome, invasively ventilated in two ICUs in Buenos Aires. We measured functional, cognitive and psychological impairments with Barthel index, Montreal Cognitive Assessment test, Patient Health Questionnaire-9 and General Anxiety Disorder-7. Primary outcome was post-intensive care syndrome. Secondary outcome was mortality at 60 days. RESULTS We admitted 40 patients, median age was 69 (60-75) and mostly male (75%). Mortality at 60 days was 37%. Cox regression analysis identified diabetes and Apache II as independent predictors of mortality. Out of 22 patients studied, 14 (64%) developed PICS after discharge. With a physical, cognitive and psychological impairment in 64%, 41% and 32% of patients, respectively. Obesity, days of mechanical ventilation, Apache II, vasopressors use, delirium duration and cumulative midazolam dose were associated with functional dependence. CONCLUSIONS We identified a high prevalence of functional, cognitive and mental impairment at 30 days after hospital discharge in COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated. The physical domain was the most frequently affected. These findings suggest the need for long-term follow-up of this population.
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Affiliation(s)
- Ezequiel Martínez
- Hospital Juan A Fernández, Buenos Aires, Argentina; Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina.
| | | | | | - Gabriela Ziegler
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Javier Plumet
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Lorena Tschopp
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Claudia Cominotti
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Viviana Sturzenegger
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Carlos Cimino
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Hernán Escobar
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | - Cecilia Pereyra
- Sanatorio de la Trinidad Ramos Mejía, Ramos Mejía, (CP: 1704) Ramos Mejía, Buenos Aires 13264, Argentina
| | | | | | - Daniela Moraes Morelli
- Institute for Clinical Effectiveness and Health Politicy (IECS), Buenos Aires, Argentina
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Gesser AF, Campos ML, Artismo RS, Karloh M, Matte DL. Impact of COVID-19 critical illness on functional status, fatigue symptoms, and health-related quality of life one-year after hospital discharge: a systematic review and meta-analysis. Disabil Rehabil 2023:1-12. [PMID: 37818936 DOI: 10.1080/09638288.2023.2266365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
Purpose: To estimate the prevalence and severity of impairments in functional status, fatigue, and health-related quality of life (HRQoL) among critical COVID-19 survivors one-year after hospital discharge. Methods: A systematic review was conducted following PRISMA statement and registered in PROSPERO (CRD42021258356), with searches in eight databases. Observational studies were selected. The prevalence meta-analysis of abnormalities was performed using random-effects models. Risk of bias was evaluated using the National Heart, Lung, and Blood Institute tool. Results: Twenty studies were included, with data collected between 12 and 13.5 months after hospital discharge and a total of 1828 participants. Of these, 71% were men, and 77.7% were intubated in the intensive care unit (ICU). Impairments and sequelae were identified in varying prevalence and degrees, with greater impact on functional capacity and physical components of fatigue and HRQoL. The prevalence of abnormalities of 32.3% [95% CI 23.9; 41.9] found in the meta-analysis is substantially high. Most studies were classified as having fair and poor quality. Conclusion: Critical COVID-19 survivors experience impairments in functional status, fatigue, and HRQoL to varying degrees one-year after hospital discharge, particularly among patients who stayed in the ICU and on MV for a prolonged period.
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Affiliation(s)
- Ana Flávia Gesser
- Master's Program in Physiotherapy, University of the State of Santa Catarina, Florianópolis, Brazil
| | - Mariana Lanzoni Campos
- Master's Program in Physiotherapy, University of the State of Santa Catarina, Florianópolis, Brazil
| | - Regiana Santos Artismo
- Master's Program in Physiotherapy, University of the State of Santa Catarina, Florianópolis, Brazil
- Postgraduate Program in Human Movement Sciences, University of the State of Santa Catarina, Florianópolis, Brazil
| | - Manuela Karloh
- Master's Program in Physiotherapy, University of the State of Santa Catarina, Florianópolis, Brazil
- Department of Physiotherapy, Center of Health and Sport Sciences, University of the State of Santa Catarina, Florianópolis, Brazil
| | - Darlan Laurício Matte
- Master's Program in Physiotherapy, University of the State of Santa Catarina, Florianópolis, Brazil
- Postgraduate Program in Human Movement Sciences, University of the State of Santa Catarina, Florianópolis, Brazil
- Department of Physiotherapy, Center of Health and Sport Sciences, University of the State of Santa Catarina, Florianópolis, Brazil
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Mohamed AAS, Mai L, Rao G, Fan S, Mashrah MA, Holkom MAM, Pan C, Lin Z. Perioperative risk factors impact on intensive care unit length of stay (ICU length of stay) in oral squamous cell carcinoma. BMC Oral Health 2023; 23:624. [PMID: 37658335 PMCID: PMC10474623 DOI: 10.1186/s12903-023-03304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/11/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The trend in postoperative care for free flap patients is to deescalate from routine ICU admission into a specialty recovery unit. This study aims to investigate the predictive parameters in a routine perioperative clinical assessment that are expected to be directly correlated with prolonged ICU length of stay in at-risk patients who received oral reconstructive surgery for squamous cell carcinoma (OSCC). METHODS All patients who underwent ablative surgery for OSCC with free flap reconstruction and were managed in the ICU were included in this study. The primary outcome was ICU-length of stay. Perioperative, operative and postoperative parameters were analyzed using single test ( t-test, ANOVA analysis, correlation coefficients, effect size) and multivariate regression test. The P-value was set as < 0.005 to be considered statically significant. RESULTS The study included 136 homogeneous patients, with a mean ICU length of stay of 4.5 (± 4.43 day). Patients with pre-operative positive renal dysfunction (P = 0.004), peripheral vascular disease (P < 0.001), postoperative complications (P = 0.028) or positive heart failure class III (P < 0.001 ) were recognized as at-risk patients for a significantly longer ICU length of stay. CONCLUSION Patients with perioperative severe renal dysfunction, peripheral vascular disease, postoperative complication or high NYHA class are prone to have a significantly longer ICU length of stay. Several factors were considered as confounders contributing to increased ICU management time in combination with other variables. Additionally, in highly risk patient, the presence of the highly trained medical support, including the appropriate nursing care, is more critical than those patients without these risk factors.
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Affiliation(s)
- Abdo Ahmed Saleh Mohamed
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ibb University, Ibb, Yemen
| | - Lianxi Mai
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Guangxin Rao
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Song Fan
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Mubarak Ahmed Mashrah
- Department of Oral Implant, Guangdong Engineering Research of Oral Restoration and reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Mohamed Ali Mahyoub Holkom
- Department of Oral & Maxillofacial Surgery- head & neck oncology, School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Chaobin Pan
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
| | - Zhouyu Lin
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
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Puxty KA, Blayney M, Kaye C, McPeake J, Stewart N, Paton M, Hall R, Donaldson L, Lone N. Use of protracted CPAP as supportive treatment for COVID-19 pneumonitis and associated outcomes: a national cohort study. Br J Anaesth 2023; 131:617-625. [PMID: 37349238 PMCID: PMC10209449 DOI: 10.1016/j.bja.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) has been increasingly deployed to manage patients with COVID-19 and acute respiratory failure, often for protracted periods. However, concerns about protracted CPAP have been raised. This study aimed to examine the use of CPAP for patients with COVID-19 and the outcomes after protracted use. METHODS This was a national cohort study of all adults admitted to Scottish critical care units with COVID-19 from March 1, 2020 to December 25, 2021 who received CPAP. Protracted CPAP was defined as ≥ 5 continuous days of CPAP. Outcomes included CPAP failure rate (institution of invasive mechanical ventilation [IMV] or death), mortality, and outcomes after institution of IMV. Multivariable logistic regression was performed to assess the impact of protracted CPAP on mortality after IMV. RESULTS A total of 1961 patients with COVID-19 received CPAP for COVID-19 pneumonitis, with 733 patients (37.4%) receiving protracted CPAP. CPAP failure occurred in 891 (45.4%): 544 patients (27.7%) received IMV and 347 patients (17.7%) died in critical care without IMV. Hospital mortality rate was 41.3% for the population. For patients who subsequently commenced IMV, hospital mortality was 58.7% for the standard duration CPAP group and 73.9% for the protracted duration CPAP group (P=0.003); however, there was no statistical difference in hospital mortality after adjustment for confounders (odds ratio 1.4, 95% confidence interval 0.84-2.33, P=0.195). CONCLUSIONS Protracted CPAP was used frequently for managing patients with COVID-19. Whilst it was not associated with worse outcomes for those patients who subsequently required IMV, this might be due to residual confounding and differences in processes of care.
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Affiliation(s)
- Kathryn A Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
| | | | - Callum Kaye
- Department of Critical Care, NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Joanne McPeake
- Healthcare Improvement Scotland (Improvement Hub), Glasgow, UK; The Institute of Healthcare Improvement Studies, University of Cambridge, Cambridge, UK
| | - Neil Stewart
- Department of Critical Care, NHS Forth Valley, Forth Valley Royal Hospital, Larbert, UK
| | | | | | | | - Nazir Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK; Department of Critical Care, NHS Lothian, Edinburgh Royal Infirmary, UK
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20
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Hägglöf E, Bell M, Zettersten E, Engerström L, Larsson E. Long-term survival after intensive care for COVID-19: a nationwide cohort study of more than 8000 patients. Ann Intensive Care 2023; 13:76. [PMID: 37642833 PMCID: PMC10465451 DOI: 10.1186/s13613-023-01156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/13/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Was it worth it-what is the outcome after the extended ICU (intensive care unit) length of stay for COVID-19 patients? Surprisingly, data on long-term mortality in large cohorts are lacking. We investigate long-term mortality including differences between men and women, as previous studies show that men generally suffer a more severe course of COVID-19 in terms of severity of illness and short-term mortality. METHODS Nationwide cohort including all adult COVID-19 patients admitted to Swedish ICUs until August 12, 2022. Primary outcome was 360-day mortality after ICU admission. Logistic regression was used to estimate associations between demographics, comorbidities, clinical characteristics and mortality. RESULTS In total, 8392 patients were included. Median (IQR) age was 63 (52-72) years and the majority (70.1%) were men. Among the 7390 patients with complete 360-day mortality data, 1775 (24.4%) patients died within 30 days, 2125 (28.8%) within 90 days and 2206 (29.8%) within 360 days from ICU admission. 360-day mortality was 27.1% in women and 31.0% in men. Multivariable logistic regression analysis showed increased risk of 360-day mortality in men compared to women (OR: 1.33, 95% CI: 1.17-1.52). Other variables associated with poor 360-day mortality were age, cardiac disease, COPD/asthma, diabetes, immune deficiency, chronic kidney disease, neuromuscular disease, and malignancy. CONCLUSION This study confirms the increased severity of disease in critically ill men with COVID-19, even in a long-term perspective. However, mortality beyond 90 days was strikingly low, indicating high probability of survival after the acute phase of illness.
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Affiliation(s)
- Elsa Hägglöf
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Max Bell
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Erik Zettersten
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Lars Engerström
- Department of Anesthesiology and Intensive Care in Norrköping and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Cardiothoracic and Surgery Anaesthesia and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- The Swedish Intensive Care Registry, Linköping, Sweden
| | - Emma Larsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden
- The Swedish Intensive Care Registry, Linköping, Sweden
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21
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Haines RW, Fowler AJ, Liang K, Pearse RM, Larsson AO, Puthucheary Z, Prowle JR. Comparison of Cystatin C and Creatinine in the Assessment of Measured Kidney Function during Critical Illness. Clin J Am Soc Nephrol 2023; 18:997-1005. [PMID: 37256861 PMCID: PMC10564373 DOI: 10.2215/cjn.0000000000000203] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Incomplete recovery of kidney function is an important adverse outcome in survivors of critical illness. However, unlike eGFR creatinine, eGFR cystatin C is not confounded by muscle loss and may improve identification of persistent kidney dysfunction. METHODS To assess kidney function during prolonged critical illness, we enrolled 38 mechanically ventilated patients with an expected length of stay of >72 hours near admission to intensive care unit (ICU) in a single academic medical center. We assessed sequential kidney function using creatinine, cystatin C, and iohexol clearance measurements. The primary outcome was difference between eGFR creatinine and eGFR cystatin C at ICU discharge using Bayesian regression modeling. We simultaneously measured muscle mass by ultrasound of the rectus femoris to assess the confounding effect on serum creatinine generation. RESULTS Longer length of ICU stay was associated with greater difference between eGFR creatinine and eGFR cystatin C at a predicted rate of 2 ml/min per 1.73 m 2 per day (95% confidence interval [CI], 1 to 2). By ICU discharge, the posterior mean difference between creatinine and cystatin C eGFR was 33 ml/min per 1.73 m 2 (95% credible interval [CrI], 24 to 42). In 27 patients with iohexol clearance measured close to ICU discharge, eGFR creatinine was on average two-fold greater than the iohexol gold standard, and posterior mean difference was 59 ml/min per 1.73 m 2 (95% CrI, 49 to 69). The posterior mean for eGFR cystatin C suggested a 22 ml/min per 1.73 m 2 (95% CrI, 13 to 31) overestimation of measured GFR. Each day in ICU resulted in a predicted 2% (95% CI, 1% to 3%) decrease in muscle area. Change in creatinine-to-cystatin C ratio showed good longitudinal, repeated measures correlation with muscle loss, R =0.61 (95% CI, 0.50 to 0.72). CONCLUSIONS eGFR creatinine systematically overestimated kidney function after prolonged critical illness. Cystatin C better estimated true kidney function because it seemed unaffected by the muscle loss from prolonged critical illness. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Skeletal Muscle Wasting and Renal Dysfunction After Critical Illness Trauma - Outcomes Study (KRATOS), NCT03736005 .
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Affiliation(s)
- Ryan W. Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alex J. Fowler
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Kaifeng Liang
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
| | - Rupert M. Pearse
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Anders O. Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - John R. Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
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22
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Docherty AB, Farrell J, Thorpe M, Egan C, Dunn S, Norman L, Shaw CA, Law A, Leeming G, Norris L, Brooks A, Prodan B, MacLeod R, Baxter R, Morris C, Rennie D, Oosthuyzen W, Semple MG, Baillie JK, Pius R, Seth S, Harrison EM, Lone NI. Patient emergency health-care use before hospital admission for COVID-19 and long-term outcomes in Scotland: a national cohort study. Lancet Digit Health 2023; 5:e446-e457. [PMID: 37391265 PMCID: PMC10306342 DOI: 10.1016/s2589-7500(23)00051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND It is unclear what effect the pattern of health-care use before admission to hospital with COVID-19 (index admission) has on the long-term outcomes for patients. We sought to describe mortality and emergency readmission to hospital after discharge following the index admission (index discharge), and to assess associations between these outcomes and patterns of health-care use before such admissions. METHODS We did a national, retrospective, complete cohort study by extracting data from several national databases and linking the databases for all adult patients admitted to hospital in Scotland with COVID-19. We used latent class trajectory modelling to identify distinct clusters of patients on the basis of their emergency admissions to hospital in the 2 years before the index admission. The primary outcomes were mortality and emergency readmission up to 1 year after index admission. We used multivariable regression models to explore associations between these outcomes and patient demographics, vaccination status, level of care received in hospital, and previous emergency hospital use. FINDINGS Between March 1, 2020, and Oct 25, 2021, 33 580 patients were admitted to hospital with COVID-19 in Scotland. Overall, the Kaplan-Meier estimate of mortality within 1 year of index admission was 29·6% (95% CI 29·1-30·2). The cumulative incidence of emergency hospital readmission within 30 days of index discharge was 14·4% (95% CI 14·0-14·8), with the number increasing to 35·6% (34·9-36·3) patients at 1 year. Among the 33 580 patients, we identified four distinct patterns of previous emergency hospital use: no admissions (n=18 772 [55·9%]); minimal admissions (n=12 057 [35·9%]); recently high admissions (n=1931 [5·8%]), and persistently high admissions (n=820 [2·4%]). Patients with recently or persistently high admissions were older, more multimorbid, and more likely to have hospital-acquired COVID-19 than patients with no or minimal admissions. People in the minimal, recently high, and persistently high admissions groups had an increased risk of mortality and hospital readmission compared with those in the no admissions group. Compared with the no admissions group, mortality was highest in the recently high admissions group (post-hospital mortality HR 2·70 [95% CI 2·35-2·81]; p<0·0001) and the risk of readmission was highest in the persistently high admissions group (3·23 [2·89-3·61]; p<0·0001). INTERPRETATION Long-term mortality and readmission rates for patients hospitalised with COVID-19 were high; within 1 year, one in three patients had died and a third had been readmitted as an emergency. Patterns of hospital use before index admission were strongly predictive of mortality and readmission risk, independent of age, pre-existing comorbidities, and COVID-19 vaccination status. This increasingly precise identification of individuals at high risk of poor outcomes from COVID-19 will enable targeted support. FUNDING Chief Scientist Office Scotland, UK National Institute for Health Research, and UK Research and Innovation.
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Affiliation(s)
- Annemarie B Docherty
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - James Farrell
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Mathew Thorpe
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Conor Egan
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah Dunn
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Lisa Norman
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Catherine A Shaw
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Law
- Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Gary Leeming
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Lucy Norris
- Bayes Centre, University of Edinburgh, Edinburgh, UK
| | - Andrew Brooks
- Bayes Centre, University of Edinburgh, Edinburgh, UK
| | - Bianca Prodan
- Bayes Centre, University of Edinburgh, Edinburgh, UK
| | | | - Robert Baxter
- Bayes Centre, University of Edinburgh, Edinburgh, UK
| | | | | | | | - Malcolm G Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | - Riinu Pius
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sohan Seth
- School of Informatics, University of Edinburgh, Edinburgh, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Nazir I Lone
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
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23
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Reyes LF, Garcia E, Ibáñez-Prada ED, Serrano-Mayorga CC, Fuentes YV, Rodríguez A, Moreno G, Bastidas A, Gómez J, Gonzalez A, Frei CR, Celi LA, Martin-Loeches I, Waterer G. Impact of macrolide treatment on long-term mortality in patients admitted to the ICU due to CAP: a targeted maximum likelihood estimation and survival analysis. Crit Care 2023; 27:212. [PMID: 37259125 DOI: 10.1186/s13054-023-04466-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Patients with community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU) have high mortality rates during the acute infection and up to ten years thereafter. Recommendations from international CAP guidelines include macrolide-based treatment. However, there is no data on the long-term outcomes of this recommendation. Therefore, we aimed to determine the impact of macrolide-based therapy on long-term mortality in this population. METHODS Registered patients in the MIMIC-IV database 16 years or older and admitted to the ICU due to CAP were included. Multivariate analysis, targeted maximum likelihood estimation (TMLE) to simulate a randomised controlled trial, and survival analyses were conducted to test the effect of macrolide-based treatment on mortality six-month (6 m) and twelve-month (12 m) after hospital admission. A sensitivity analysis was performed excluding patients with Pseudomonas aeruginosa or MRSA pneumonia to control for Healthcare-Associated Pneumonia (HCAP). RESULTS 3775 patients were included, and 1154 were treated with a macrolide-based treatment. The non-macrolide-based group had worse long-term clinical outcomes, represented by 6 m [31.5 (363/1154) vs 39.5 (1035/2621), p < 0.001] and 12 m mortality [39.0 (450/1154) vs 45.7 (1198/2621), p < 0.001]. The main risk factors associated with long-term mortality were Charlson comorbidity index, SAPS II, septic shock, and respiratory failure. Macrolide-based treatment reduced the risk of dying at 6 m [HR (95% CI) 0.69 (0.60, 0.78), p < 0.001] and 12 m [0.72 (0.64, 0.81), p < 0.001]. After TMLE, the protective effect continued with an additive effect estimate of - 0.069. CONCLUSION Macrolide-based treatment reduced the hazard risk of long-term mortality by almost one-third. This effect remains after simulating an RCT with TMLE and the sensitivity analysis for the HCAP classification.
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Affiliation(s)
- Luis Felipe Reyes
- Universidad de La Sabana, Campus Puente del Común, KM 7.5 Autopista Norte de Bogotá, Chía, Colombia.
- Clínica Universidad de La Sabana, Chía, Colombia.
- University of Oxford, Oxford, UK.
| | - Esteban Garcia
- Universidad de La Sabana, Campus Puente del Común, KM 7.5 Autopista Norte de Bogotá, Chía, Colombia
| | | | | | - Yuli V Fuentes
- Universidad de La Sabana, Campus Puente del Común, KM 7.5 Autopista Norte de Bogotá, Chía, Colombia
- Clínica Universidad de La Sabana, Chía, Colombia
| | - Alejandro Rodríguez
- Hospital Universitari Joan XXIII, Critical Care Medicine, Rovira and Virgili University and CIBERES (Biomedical Research Network of Respiratory Disease), Tarragona, Spain
| | - Gerard Moreno
- Hospital Universitari Joan XXIII, Critical Care Medicine, Rovira and Virgili University and CIBERES (Biomedical Research Network of Respiratory Disease), Tarragona, Spain
| | - Alirio Bastidas
- Universidad de La Sabana, Campus Puente del Común, KM 7.5 Autopista Norte de Bogotá, Chía, Colombia
| | - Josep Gómez
- Hospital Universitari Joan XXIII, Critical Care Medicine, Rovira and Virgili University and CIBERES (Biomedical Research Network of Respiratory Disease), Tarragona, Spain
| | - Angélica Gonzalez
- Universidad de La Sabana, Campus Puente del Común, KM 7.5 Autopista Norte de Bogotá, Chía, Colombia
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA
- School of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Leo Anthony Celi
- Massachusetts Institute of Technology, Cambridge, USA
- Beth Israel Deaconess Medical Center, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St. James's Hospital, Dublin, Ireland
| | - Grant Waterer
- Royal Perth Bentley Hospital Group, University of Western Australia, Perth, Australia
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24
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Bourne RS, Jeffries M, Phipps DL, Jennings JK, Boxall E, Wilson F, March H, Ashcroft DM. Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study. BMJ Open 2023; 13:e066757. [PMID: 37130684 PMCID: PMC10163459 DOI: 10.1136/bmjopen-2022-066757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVE To understand the sociotechnical factors affecting medication safety when intensive care patients are transferred to a hospital ward. Consideration of these medication safety factors would provide a theoretical basis, on which future interventions can be developed and evaluated to improve patient care. DESIGN Qualitative study using semistructured interviews of intensive care and hospital ward-based healthcare professionals. Transcripts were anonymised prior to thematic analysis using the London Protocol and Systems Engineering in Patient Safety V.3.0 model frameworks. SETTING Four north of England National Health Service hospitals. All hospitals used electronic prescribing in intensive care and hospital ward settings. PARTICIPANTS Intensive care and hospital ward healthcare professionals (intensive care medical staff, advanced practitioners, pharmacists and outreach team members; ward-based medical staff and clinical pharmacists). RESULTS Twenty-two healthcare professionals were interviewed. We identified 13 factors within five broad themes, describing the interactions that most strongly influenced the performance of the intensive care to hospital ward system interface. The themes were: Complexity of process performance and interactions; Time pressures and considerations; Communication processes and challenges; Technology and systems and Beliefs about consequences for the patient and organisation. CONCLUSIONS The complexity of the interactions on the system performance and time dependency was clear. We make several recommendations for policy change and further research based on improving: availability of hospital-wide integrated and functional electronic prescribing systems, patient flow systems, sufficient multiprofessional critical care staffing, knowledge and skills of staff, team performance, communication and collaboration and patient and family engagement.
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Affiliation(s)
- Richard S Bourne
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Mark Jeffries
- Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - Denham L Phipps
- Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Jennifer K Jennings
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Emma Boxall
- Department of Pharmacy, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Franki Wilson
- Department of Pharmacy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Helen March
- Department of Pharmacy, Royal Oldham Hospital, Northern Care Alliance NHS Foundation Trust, Oldham, UK
| | - Darren M Ashcroft
- Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
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25
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Pauley E, Drake TM, Griffith DM, Sigfrid L, Lone NI, Harrison EM, Baillie JK, Scott JT, Walsh TS, Semple MG, Docherty AB. Recovery from Covid-19 critical illness: A secondary analysis of the ISARIC4C CCP-UK cohort study and the RECOVER trial. J Intensive Care Soc 2023; 24:162-169. [PMID: 37255989 PMCID: PMC10225805 DOI: 10.1177/17511437211052226] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Background We aimed to compare the prevalence and severity of fatigue in survivors of Covid-19 versus non-Covid-19 critical illness, and to explore potential associations between baseline characteristics and worse recovery. Methods We conducted a secondary analysis of two prospectively collected datasets. The population included was 92 patients who received invasive mechanical ventilation (IMV) with Covid-19, and 240 patients who received IMV with non-Covid-19 illness before the pandemic. Follow-up data were collected post-hospital discharge using self-reported questionnaires. The main outcome measures were self-reported fatigue severity and the prevalence of severe fatigue (severity >7/10) 3 and 12-months post-hospital discharge. Results Covid-19 IMV-patients were significantly younger with less prior comorbidity, and more males, than pre-pandemic IMV-patients. At 3-months, the prevalence (38.9% [7/18] vs. 27.1% [51/188]) and severity (median 5.5/10 vs 5.0/10) of fatigue were similar between the Covid-19 and pre-pandemic populations, respectively. At 6-months, the prevalence (10.3% [3/29] vs. 32.5% [54/166]) and severity (median 2.0/10 vs. 5.7/10) of fatigue were less in the Covid-19 cohort. In the total sample of IMV-patients included (i.e. all Covid-19 and pre-pandemic patients), having Covid-19 was significantly associated with less severe fatigue (severity <7/10) after adjusting for age, sex and prior comorbidity (adjusted OR 0.35 (95%CI 0.15-0.76, p=0.01). Conclusion Fatigue may be less severe after Covid-19 than after other critical illness.
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Affiliation(s)
- Ellen Pauley
- , Edinburgh, UKUniversity of Edinburgh Medical School
| | - Thomas M Drake
- Centre for Medical Informatics, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
| | - David M Griffith
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
| | - Louise Sigfrid
- Centre for Tropical Medicine and Global Health, , Oxford, UKUniversity of Oxford
| | - Nazir I Lone
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
- Centre for Population Health Sciences, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
| | - Ewen M Harrison
- Centre for Medical Informatics, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
| | - J Kenneth Baillie
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
- Roslin Institute, , Edinburgh, UKUniversity of Edinburgh
| | - Janet T Scott
- , Glasgow, UKMRC-University of Glasgow Centre for Virus Research
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
| | - Malcolm G Semple
- NIHR Health Protection Unit in Emerging Infectious Diseases, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, , Liverpool, UKUniversity of Liverpool
| | - Annemarie B Docherty
- Centre for Medical Informatics, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
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Satyavolu R, Ruknuddeen MI, Soar N, Edwards SM. Dosage and clinical outcomes of medical emergency team and conventional referral mediated unplanned intensive care admissions. J Intensive Care Soc 2023; 24:178-185. [PMID: 37260436 PMCID: PMC10227895 DOI: 10.1177/17511437211060157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Background: Unplanned intensive care unit (ICU) admission occurs via activation of medical emergency team (MET) and conventional ICU referral (CIR), i.e., ICU consultation. We aimed to compare the dosage, association with unplanned ICU admissions and hospital mortality between MET and CIR systems. Methods: We performed a retrospective, single centre observational study on unplanned ICU admissions from hospital wards between July 2017 and June 2018. We evaluated the dosage (expressed per 1000 admissions) and association of CIR and MET system with unplanned ICU admission using Chi-square test. The relationship (unadjusted and adjusted to Australia and New Zealand risk of death (ANZROD) and lead time) between unplanned ICU admission pathway (MET vs CIR) and hospital mortality was tested by binary logistic regression analysis [Odds ratio (OR) with 95% confidence interval (CI)]. Results: Out of 38,628 patients hospitalised, 679 had unplanned ICU admission (2%) with an ICU admission rate of 18 per 1000 ward admissions. There were 2153 MET and 453 CIR activations, producing a dosage of 56 and 12 per 1000 admissions, respectively. Higher unplanned ICU admission was significantly associated with CIR compared to MET activation (324/453 (71.5%) vs 355/2153 (16.5%) p < 0.001). On binary logistic regression, MET system was significantly associated with higher hospital mortality on unadjusted analysis (OR 1.65 (95% CI: 1.09-2.48) p = 0.02) but not after adjustment with ANZROD and lead time (OR 1.15 (95% CI: 0.71-1.86), p = 0.58). Conclusions: Compared to CIR, MET system had higher dosage but lower frequency of unplanned ICU admissions and lacked independent association with hospital mortality.
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Affiliation(s)
| | | | - Natalie Soar
- Intensive Care Unit, Lyell Mc Ewin Hospital, Elizabeth Vale, Australia
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Angriman F, Rosella LC, Lawler PR, Ko DT, Martin CM, Wunsch H, Scales DC. Risk Factors for Major Cardiovascular Events in Adult Sepsis Survivors: A Population-Based Cohort Study. Crit Care Med 2023; 51:471-483. [PMID: 36790198 DOI: 10.1097/ccm.0000000000005793] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES To describe risk factors for major cardiovascular events in adults following hospital discharge after sepsis. DESIGN Population-based cohort study. SETTING Ontario, Canada (2008-2017). PATIENTS Adult patients (age 18 yr or older) who survived a first sepsis hospitalization without preexisting cardiovascular disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary composite outcome was myocardial infarction, stroke, or cardiovascular death up to 5 years following hospital discharge. We used cause-specific Cox proportional hazards models that accounted for the competing risk of noncardiovascular death to describe factors associated with major cardiovascular events. We identified 268,259 adult patients without cardiovascular disease (median age, 72 yr), of whom 10.4% experienced a major cardiovascular event during a median follow-up of 3 years. After multivariable adjustment, age (hazard ratio [HR], 1.53 for every 10 yr; 95% CI, 1.51-1.54), male sex (HR, 1.23; 95% CI, 1.20-1.26), diabetes mellitus (HR, 1.24; 95% CI, 1.21-1.27), hypertension (HR, 1.34; 95% CI, 1.30-1.38), prevalent atrial fibrillation (HR, 1.46; 95% CI, 1.40-1.52), and chronic kidney disease (HR, 1.11; 95% CI, 1.06-1.16) were associated with major cardiovascular events during long-term follow-up. Sepsis characteristics such as site of infection (pneumonia vs other: HR, 1.09; 95% CI, 1.05-1.12), septic shock (HR, 1.08; 95% CI, 1.05-1.11), and renal replacement therapy (HR, 1.51; 95% CI, 1.38-1.64) were also associated with subsequent cardiovascular events. In an analysis restricting to patients with troponin values measured during the hospitalization (26,400 patients), an elevated troponin was also associated with subsequent cardiovascular events (HR, 1.23; 95% CI, 1.13-1.33). CONCLUSIONS Classic cardiovascular risk factors, comorbid conditions, and characteristics of the sepsis episode were associated with a higher hazard of major cardiovascular events in adult sepsis survivors. These findings may inform enrichment strategies for future studies.
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Laura C Rosella
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Dennis T Ko
- ICES, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Hannah Wunsch
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Damon C Scales
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Liou A, Schweickert WD, Files DC, Bakhru RN. A Survey to Assess Primary Care Physician Awareness of Complications Following Critical Illness. J Intensive Care Med 2023:8850666231164303. [PMID: 36972501 DOI: 10.1177/08850666231164303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Background: Survivors of critical illness are at risk for post-intensive care syndrome (PICS, comprised of physical dysfunction, cognitive impairment, and neuropsychiatric disorders including anxiety, depression, and post-traumatic stress). Their family members and caregivers are at risk for PICS-F (PICS-family, comprised of anxiety, depression, post-traumatic stress). PICS and PICS-F are increasingly recognized in critical care; however, the awareness among primary providers of the domains and the terms of PICS/PICS-F is unknown. Objectives: To determine current practice patterns and knowledge among primary care physicians in regards to patients recovering from critical illness; to determine barriers to care of post-critically ill patients. Methods: A paper and electronic survey were developed and randomly distributed to a subset of North Carolina primary care physicians. Survey questions consisted of the following domains: demographics, current practice, barriers to providing care, knowledge of common issues/complications following critical illness, and interest in changing care for survivors of critical illness. Results: One hundred and ninety-six surveys were delivered and 77 completed surveys (39% response rate) were analyzed. Respondents confirmed significant barriers to care of post-critically ill patients including lack of awareness of PICS/PICS-F terminology, insufficient time to spend with patients, and inadequate education of patients/families about recovery after critical illness. Fifty-seven percent of respondents thought a specialized transitional post-ICU clinic would be helpful. Sixty-two percent reported feeling comfortable caring for patients after a critical illness and 75% felt they were aware of common problems encountered after critical illness. However, 84% also thought more education about PICS/PICS-F would be helpful as would a list of common problems seen after critical illness (91%). Conclusions: Significant gaps and barriers to providing optimal post-ICU care by PCPs exist. Providers identified time constraints and educational gaps as domains needing attention. Dedicated post-ICU clinics might provide a bridge to transition care post-critical illness back to primary care providers.
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Affiliation(s)
- Ashley Liou
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, USA
| | - William D Schweickert
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - D Clark Files
- Department of Internal Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University School of Medicine, Winston-Salem, USA
- Critical Illness Injury and Recovery Research Center, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Rita N Bakhru
- Department of Internal Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University School of Medicine, Winston-Salem, USA
- Critical Illness Injury and Recovery Research Center, Wake Forest University School of Medicine, Winston-Salem, USA
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Affiliation(s)
- Margaret S Herridge
- From Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto; and Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris
| | - Élie Azoulay
- From Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto; and Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris
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Zhuravleva MV, Chulanov VP, Gagarina JV, Shabalina EA. Pharmacoeconomic evaluation of the tixagevimab and cilgavimab combination using for pre-exposure prophylaxis of COVID-19. TERAPEVT ARKH 2023; 95:66-77. [PMID: 37167117 DOI: 10.26442/00403660.2023.01.202065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 02/26/2023]
Abstract
Aim. To evaluate pharmacoeconomic feasibility using of the tixagevimab and cilgavimab combination for pre-exposure prophylaxis of COVID-19 in immunocompromised patients.
Materials and methods. Cost-effectiveness of tixagevimab and cilgavimab in persons 12 years old who weigh 40 kg and have either a history of allergy that prevents their vaccination against COVID-19 or moderate or immunocompromised was assessed based on PROVENT phase III study results. The quantity of life years or quality-adjusted life years gained was calculated. Direct medical cost associated with prophylaxis of COVID-19, treatment of infected patients and those experiencing long COVID post infection were assessed. Results were compared with wiliness-to-pay threshold, measured as tripled gross domestic product per capita and equal to 2.69 mln RUB in 2022.
Results. Pre-exposure prophylaxis of COVID-19 results in additional 0.0287 life years or 0.0247 quality-adjusted life years. The cost of additional life year gained is equal to 1.12 mln RUB, the cost of additional quality-adjusted life years is 1.30 mln RUB. Both costs of additional life year and cost of quality-adjusted life years appeared to be significantly less compared to wiliness-to-pay threshold.
Conclusion. Pre-exposure prophylaxis of COVID-19 with combination of tixagevimab and cilgavimab is economically feasible and may be recommended for wide use in Russian healthcare system.
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Gonçalves-Pereira J, Oliveira A, Vieira T, Rodrigues AR, Pinto MJ, Pipa S, Martinho A, Ribeiro S, Paiva JA. Critically ill patient mortality by age: long-term follow-up (CIMbA-LT). Ann Intensive Care 2023; 13:7. [PMID: 36764980 PMCID: PMC9918627 DOI: 10.1186/s13613-023-01102-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/25/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND The past years have witnessed dramatic changes in the population admitted to the intensive care unit (ICU). Older and sicker patients are now commonly treated in this setting due to the newly available sophisticated life support. However, the short- and long-term benefit of this strategy is scarcely studied. METHODS The Critically Ill patients' mortality by age: Long-Term follow-up (CIMbA-LT) was a multicentric, nationwide, retrospective, observational study addressing short- and long-term prognosis of patients admitted to Portuguese multipurpose ICUs, during 4 years, according to their age and disease severity. Patients were followed for two years after ICU admission. The standardized hospital mortality ratio (SMR) was calculated according to the Simplified Acute Physiology Score (SAPS) II and the follow-up risk, for patients discharged alive from the hospital, according to official demographic national data for age and gender. Survival curves were plotted according to age group. RESULTS We included 37.118 patients, including 15.8% over 80 years old. The mean SAPS II score was 42.8 ± 19.4. The ICU all-cause mortality was 16.1% and 76% of all patients survive until hospital discharge. The SAPS II score overestimated hospital mortality [SMR at hospital discharge 0.7; 95% confidence interval (CI) 0.63-0.76] but accurately predicted one-year all-cause mortality [1-year SMR 1.01; (95% CI 0.98-1.08)]. Survival curves showed a peak in mortality, during the first 30 days, followed by a much slower survival decline thereafter. Older patients had higher short- and long-term mortality and their hospital SMR was also slightly higher (0.76 vs. 0.69). Patients discharged alive from the hospital had a 1-year relative mortality risk of 6.3; [95% CI 5.8-6.7]. This increased risk was higher for younger patients [21.1; (95% CI 15.1-39.6) vs. 2.4; (95% CI 2.2-2.7) for older patients]. CONCLUSIONS Critically ill patients' mortality peaked in the first 30 days after ICU admission. Older critically ill patients had higher all-cause mortality, including a higher hospital SMR. A long-term increased relative mortality risk was noted in patients discharged alive from the hospital, but this was more noticeable in younger patients.
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Affiliation(s)
- João Gonçalves-Pereira
- Intensive Care Unit, Hospital Vila Franca de Xira, Estrada Carlos Lima Costa, N2, 2600-009, Vila Franca de Xira, Portugal. .,Nova Medical School, Universidade Nova de Lisboa, Lisbon, Portugal. .,Grupo de Investigação e Desenvolvimento em Infeção e Sépsis (GISID), Porto, Portugal.
| | - André Oliveira
- grid.477365.40000 0004 4904 8806Intensive Care Unit, Hospital Vila Franca de Xira, Estrada Carlos Lima Costa, N2, 2600-009 Vila Franca de Xira, Portugal
| | - Tatiana Vieira
- Intensive Care Department, Centro Hospitalar Universitário de S. João, Porto, Portugal
| | - Ana Rita Rodrigues
- grid.9983.b0000 0001 2181 4263Intensive Care Department, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Maria João Pinto
- grid.433402.2Intensive Care Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Sara Pipa
- grid.418336.b0000 0000 8902 4519Intensive Care Department, Centro Hospitalar Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
| | - Ana Martinho
- grid.28911.330000000106861985Intensive Care Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Sofia Ribeiro
- grid.517631.7Intensive Care Department, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - José-Artur Paiva
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis (GISID), Porto, Portugal ,Intensive Care Department, Centro Hospitalar Universitário de S. João, Porto, Portugal ,grid.5808.50000 0001 1503 7226Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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Secombe PJ, Brown A, Bailey MJ, Huckson S, Chavan S, Litton E, Pilcher D. Twelve-month mortality outcomes for Indigenous and non-Indigenous people admitted to intensive care units in Australia: a registry-based data linkage study. Med J Aust 2023; 218:77-83. [PMID: 36310397 PMCID: PMC10092659 DOI: 10.5694/mja2.51763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/07/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To compare longer term (12-month) mortality outcomes for Indigenous and non-Indigenous people admitted to intensive care units (ICUs) in Australia. DESIGN, SETTING, PARTICIPANTS Retrospective registry-based data linkage cohort study; analysis of all admissions of adults (16 years or older) to Australian ICUs, 1 January 2017 - 31 December 2019, as recorded in the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD), linked using the SLK-581 key to National Death Index data. MAIN OUTCOME MEASURES Unadjusted and adjusted mortality risk, censored at twelve months from the start of index ICU admission. Secondary outcomes were unadjusted and adjusted mortality twelve months from admission to the ICU. RESULTS The APD recorded 330 712 eligible ICU admissions during 2017-2019 (65% of all ICU admissions registered), of which 11 322 were of Indigenous people (3.4%). Median age at admission was lower for Indigenous patients (51.2 [IQR, 36.7-63.6] years) than for non-Indigenous patients (66.5 [IQR, 52.7-76.1] years). Unadjusted mortality risk was similar for Indigenous and non-Indigenous patients (hazard ratio, 1.01; 95% CI, 0.97-1.06), but was higher for Indigenous patients after adjusting for age, admission diagnosis, illness severity, hospital type, jurisdiction, remoteness and socio-economic status (adjusted hazard ratio, 1.20; 95% CI, 1.14-1.27). Twelve-month mortality was higher for Indigenous than non-Indigenous patients (adjusted odds ratio, 1.24; 95% CI, 1.16-1.33). CONCLUSIONS Twelve-month mortality outcomes are poorer for people admitted to ICUs in Australia than for the general population. Further, after adjusting for age and other factors, survival outcomes are poorer for Indigenous than non-Indigenous people admitted to ICUs. Critical illness may therefore contribute to shorter life expectancy among Indigenous Australians.
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Affiliation(s)
- Paul J Secombe
- Alice Springs Hospital, Alice Springs, NT.,Monash University, Melbourne, VIC
| | - Alex Brown
- Australian National University, Canberra, ACT.,South Australian Health and Medical Research Institute, Adelaide, SA
| | | | - Sue Huckson
- Centre for Outcome and Resource Evaluation (CORE), Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, VIC
| | - Shaila Chavan
- Centre for Outcome and Resource Evaluation (CORE), Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, VIC
| | - Edward Litton
- Centre for Outcome and Resource Evaluation (CORE), Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, VIC.,Fiona Stanley Hospital, Perth, WA
| | - David Pilcher
- Centre for Outcome and Resource Evaluation (CORE), Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
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Russell CD, Lone NI, Baillie JK. Comorbidities, multimorbidity and COVID-19. Nat Med 2023; 29:334-343. [PMID: 36797482 DOI: 10.1038/s41591-022-02156-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/25/2022] [Indexed: 02/18/2023]
Abstract
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.
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Affiliation(s)
- Clark D Russell
- Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK.
- Intensive Care Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.
| | - J Kenneth Baillie
- Intensive Care Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.
- Baillie Gifford Pandemic Science Hub, Centre for Inflammation Research, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK.
- Roslin Institute, University of Edinburgh, Easter Bush, Midlothian, UK.
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Patterns of Healthcare Resource Utilisation of Critical Care Survivors between 2006 and 2017 in Wales: A Population-Based Study. J Clin Med 2023; 12:jcm12030872. [PMID: 36769519 PMCID: PMC9917699 DOI: 10.3390/jcm12030872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/06/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
In this retrospective cohort study, we used the Secure Anonymised Information Linkage (SAIL) Databank to characterise and identify predictors of the one-year post-discharge healthcare resource utilisation (HRU) of adults who were admitted to critical care units in Wales between 1 April 2006 and 31 December 2017. We modelled one-year post-critical-care HRU using negative binomial models and used linear models for the difference from one-year pre-critical-care HRU. We estimated the association between critical illness and post-hospitalisation HRU using multilevel negative binomial models among people hospitalised in 2015. We studied 55,151 patients. Post-critical-care HRU was 11-87% greater than pre-critical-care levels, whereas emergency department (ED) attendances decreased by 30%. Age ≥50 years was generally associated with greater post-critical-care HRU; those over 80 had three times longer hospital readmissions than those younger than 50 (incidence rate ratio (IRR): 2.96, 95% CI: 2.84, 3.09). However, ED attendances were higher in those younger than 50. High comorbidity was associated with 22-62% greater post-critical-care HRU than no or low comorbidity. The most socioeconomically deprived quintile was associated with 24% more ED attendances (IRR: 1.24 [1.16, 1.32]) and 13% longer hospital stays (IRR: 1.13 [1.09, 1.17]) than the least deprived quintile. Critical care survivors had greater 1-year post-discharge HRU than non-critical inpatients, including 68% longer hospital stays (IRR: 1.68 [1.63, 1.74]). Critical care survivors, particularly those with older ages, high comorbidity, and socioeconomic deprivation, used significantly more primary and secondary care resources after discharge compared with their baseline and non-critical inpatients. Interventions are needed to ensure that key subgroups are identified and adequately supported.
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Long-Term Outcome of Severe Metabolic Acidemia in ICU Patients, a BICAR-ICU Trial Post Hoc Analysis. Crit Care Med 2023; 51:e1-e12. [PMID: 36351174 DOI: 10.1097/ccm.0000000000005706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Long-term prognosis of ICU survivors is a major issue. Severe acidemia upon ICU admission is associated with very high short-term mortality. Since the long-term prognosis of these patients is unknown, we aimed to determine the long-term health-related quality of life and survival of these patients. DESIGN Post hoc analysis of a multicenter, randomized, controlled trial. SETTING Twenty-six French ICUs. PATIENTS Day 28 critically ill survivors admitted with severe acidemia and enrolled in the BICAR-ICU trial. INTERVENTION Sodium bicarbonate versus no sodium bicarbonate infusion according to the randomization group. MEASUREMENTS AND MAIN RESULTS The primary outcome was health-related quality of life (HRQoL) measured with the 36-item Short Form Health Survey and the EuroQol 5-D questionnaires. Secondary outcomes were mortality, end-stage renal disease treated with renal replacement therapy or renal transplantation, place of residence, professional status, and ICU readmission. HRQoL was reduced with no significant difference between the two groups. HRQoL was reduced particularly in the role-physical health domain (64/100 ± 41 in the control group and 49/100 ± 43 in the bicarbonate group, p = 0.28), but it was conserved in the emotional domains (96/100 ± 19 in the control group and 86/100 ± 34 in the bicarbonate group, p = 0.44). Forty percent of the survivors described moderate to severe problems walking, and half of the survivors described moderate to severe problems dealing with usual activities. Moderate to severe anxiety or depression symptoms were present in one third of the survivors. Compared with the French general population, HRQoL was decreased in the survivors mostly in the physical domains. The 5-year overall survival rate was 30% with no significant difference between groups. CONCLUSIONS Long-term HRQoL was decreased in both the control and the sodium bicarbonate groups of the BICAR-ICU trial and was lower than the general population, especially in the physical domains.
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Oh TK, Song IA. The economic burden and long-term mortality in survivors of extracorporeal membrane oxygenation in South Korea. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1266. [PMID: 36618782 PMCID: PMC9816823 DOI: 10.21037/atm-22-2721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/30/2022] [Indexed: 11/21/2022]
Abstract
Background The economic burden for extracorporeal membrane oxygenation (ECMO) survivors is a critical issue. We investigated the total healthcare costs for one year following ECMO support and its association with three-year all-cause mortality. Methods This population-based cohort study used data from the National Health Insurance Service (NHIS) in South Korea. Adult ECMO survivors (age ≥18 years who were alive ≥365 days following ECMO support) from January 1, 2005, to December 31, 2018, were included. The total healthcare costs for one year included all the expenses for hospital and outpatient clinic visits after discharge. Results In total, 6,044 patients were included in the final analysis comprising 3,566 (59.0%) in the cardiac indication group, 658 (10.9%) in the respiratory indication group, and 1,820 (30.1%) in the "other" group. The median total healthcare cost was United States Dollars (USD) 46,308.0 [interquartile range (IQR): 25,727.0-86,924.8]. The median ECMO support and hospital stay durations were three (IQR: 1-7) days and 25 (IQR: 15-31) days. In the multivariable Cox regression model, a USD 1,000 increase in the total healthcare cost was associated with an increase in the three-year all-cause mortality (hazard ratio, 1.01; 95% CI: 1.00-1.01; P=0.015). Conclusions After one year, ECMO survivors accrued USD 46,308 in healthcare costs in South Korea. An increase in the total healthcare cost was associated with a higher risk of three-year all-cause mortality among ECMO survivors.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea;,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea;,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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Affiliation(s)
- Aluko A Hope
- Aluko A. Hope is coeditor in chief of the American Journal of Critical Care. He is an associate professor and physician scientist at Oregon Health and Science University in Portland, Oregon
| | - Cindy L Munro
- Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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38
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Location and outcomes of rehospitalizations after critical illness in a single-payer healthcare system. J Crit Care 2022; 71:154089. [PMID: 35778320 DOI: 10.1016/j.jcrc.2022.154089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Unplanned rehospitalization at a hospital other than the initial hospital may contribute to poor outcomes. We examined the location of rehospitalizations and assessed outcomes following critical illness in a single-payer healthcare system. MATERIALS AND METHODS Population-based retrospective cohort study using linked datasets (2012-2017) from Ontario, Canada including adults (≥18 years) with an unplanned rehospitalization within 30-days after an index hospitalization that included an ICU stay with mechanical ventilation. Outcomes were the percentage of 30-day rehospitalizations at non-index hospitals, mortality and costs. We employed logistic regression and generalized linear models to assess associations. RESULTS There were 14,997 (16.4%) 30-day rehospitalizations. Of these 2765 (18.4%) occurred in a non-index hospital. Distance of home residence from the index hospital was the strongest predictor of a non-index rehospitalization (adjusted odds ratio (aOR) 8.40, 95%CI 7.05-10.01, highest vs. lowest distance quintile). Within 30-days of rehospitalization, deaths (aOR 0.91, 95%CI (0.80-1.04)) and total healthcare costs (adjusted relative risk 1.03 (1.00-1.06)), were similar for patients readmitted to the index or a non-index hospital. CONCLUSION Non-index rehospitalization within 30-days of initial discharge is common following critical illness. These rehospitalizations were not significantly associated with an increased risk of harm or higher costs in a single-payer healthcare system.
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Dalton NS, Kippen RJ, Leach MJ, Knott CI, Doherty ZB, Downie JM, Fletcher JA. Long term survival following a medical emergency team call at an Australian regional hospital. CRIT CARE RESUSC 2022; 24:163-174. [PMID: 38045599 PMCID: PMC10692633 DOI: 10.51893/2022.2.oa6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To investigate the long term survival of medical emergency team (MET) patients at an Australian regional hospital and describe associated patient and MET call characteristics. Design: Retrospective cohort study. Data linkage to the statewide death registry was performed to allow for long term survival analysis, including multivariable Cox proportional hazards regression and production of Kaplan-Meier survival curves. Setting: A large Australian regional hospital. Participants: Adult patients who received a MET call from 1 July 2012 to 3 March 2020. Main outcome measures: Survival to 30, 90 and 180 days; one year; and 5-years after index MET call. Results: The study included 6499 eligible patients. The cohort median age was 71 years, and 52.4% of the patients were female. Surgical (39.6%) and medical (36.9%) patients comprised most of the cohort. Thirty-day survival was 86.5% one-year survival was 66.1%. Among patients aged < 75 years, factors independently associated with significantly higher long term mortality included age (hazard ratio [HR], 3.26 [95% CI, 2.63-4.06]; for patients aged 65-74 v 18-54 years), male sex (HR, 0.71 [95% CI, 0.61-0.83]; for females) and pre-existing limitation of medical therapy (HR, 2.76; 95% CI, 2.28-3.35). Among patients aged ≥ 75 years, factors independently associated with significantly higher long term mortality included age (HR, 1.46 [95% CI, 1.29-1.65]; for patients aged ≥ 85 years), male sex (HR, 0.74 [95% CI, 0.66-0.83]; for females), and altered MET criteria (HR, 1.33; 95% CI, 1.03-1.71). Conclusions: Long term survival probabilities of MET call patients are affected by factors including age, sex, and limitation of medical therapy status. These data may be useful for clinicians conducting end-of-life discussions with patients.
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Affiliation(s)
- Nathan S. Dalton
- School of Rural Health, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Bendigo Health, Bendigo, VIC, Australia
| | - Rebecca J. Kippen
- School of Rural Health, Monash University, Melbourne, VIC, Australia
| | - Michael J. Leach
- School of Rural Health, Monash University, Melbourne, VIC, Australia
| | - Cameron I. Knott
- School of Rural Health, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Bendigo Health, Bendigo, VIC, Australia
- Rural Clinical School, Bendigo campus, University of Melbourne, Bendigo, VIC, Australia
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
| | - Zakary B. Doherty
- School of Rural Health, Monash University, Melbourne, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
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Waak M, Gibbons K, Sparkes L, Harnischfeger J, Gurr S, Schibler A, Slater A, Malone S. Real-time seizure detection in paediatric intensive care patients: the RESET child brain protocol. BMJ Open 2022; 12:e059301. [PMID: 36691237 PMCID: PMC9171209 DOI: 10.1136/bmjopen-2021-059301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/19/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Approximately 20%-40% of comatose children with risk factors in intensive care have electrographic-only seizures; these go unrecognised due to the absence of continuous electroencephalography (EEG) monitoring (cEEG). Utility of cEEG with high-quality assessment is currently limited due to high-resource requirements. New software analysis tools are available to facilitate bedside cEEG assessment using quantitative EEG (QEEG) trends. The primary aim of this study is to describe accuracy of interpretation of QEEG trends by paediatric intensive care unit (PICU) nurses compared with cEEG assessment by neurologist (standard clinical care) in children at risk of seizures and status epilepticus utilising diagnostic test statistics. The secondary aims are to determine time to seizure detection for QEEG users compared with standard clinical care and describe impact of confounders on accuracy of seizure detection. METHODS AND ANALYSIS This will be a single-centre, prospective observational cohort study evaluating a paediatric QEEG programme utilising the full 19 electrode set. The setting will be a 36-bed quaternary PICU with medical, cardiac and general surgical cases. cEEG studies in PICU patients identified as 'at risk of seizures' will be analysed. Trained bedside clinical nurses will interpret the QEEG. Seizure events will be marked as seizures if >3 QEEG criteria occur. Post-hoc dedicated neurologists, who remain blinded to the QEEG analysis, will interpret the cEEG. Determination of standard test characteristics will assess the primary hypothesis. To calculate 95% (CIs) around the sensitivity and specificity estimates with a CI width of 10%, the sample size needed for sensitivity is 80 patients assuming each EEG will have approximately 9 to 18 1-hour epochs. ETHICS AND DISSEMINATION The study has received approval by the Children's Health Queensland Human Research Ethics Committee (HREC/19/QCHQ/58145). Results will be made available to the funders, critical care survivors and their caregivers, the relevant societies, and other researchers. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ANZCTR) 12621001471875.
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Affiliation(s)
- Michaela Waak
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Centre for Children's Health Research, Brisbane, Queensland, Australia
- The University of Queensland, Saint Lucia, Queensland, Australia
| | - Louise Sparkes
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Jane Harnischfeger
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Sandra Gurr
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Andreas Schibler
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia
| | - Anthony Slater
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Stephen Malone
- The University of Queensland, Saint Lucia, Queensland, Australia
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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Blayney MC, Stewart NI, Kaye CT, Puxty K, Chan Seem R, Donaldson L, Haddow C, Hall R, Martin C, Paton M, Lone NI, McPeake J. Prevalence, characteristics, and longer-term outcomes of patients with persistent critical illness attributable to COVID-19 in Scotland: a national cohort study. Br J Anaesth 2022; 128:980-989. [PMID: 35465954 PMCID: PMC8942655 DOI: 10.1016/j.bja.2022.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/12/2022] [Accepted: 03/13/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Michael C Blayney
- Usher Institute, University of Edinburgh, Edinburgh, UK; Public Health Scotland, UK; Department of Critical Care, NHS Lothian, Edinburgh, UK
| | - Neil I Stewart
- Department of Critical Care, NHS Forth Valley, Larbert, UK
| | - Callum T Kaye
- Department of Critical Care, NHS Grampian, Aberdeen, UK
| | - Kathryn Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | | | | | | | | | | | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK; Department of Critical Care, NHS Lothian, Edinburgh, UK.
| | - Joanne McPeake
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Hodgson CL, Higgins AM, Bailey MJ, Mather AM, Beach L, Bellomo R, Bissett B, Boden IJ, Bradley S, Burrell A, Cooper DJ, Fulcher BJ, Haines KJ, Hodgson IT, Hopkins J, Jones AYM, Lane S, Lawrence D, van der Lee L, Liacos J, Linke NJ, Gomes LM, Nickels M, Ntoumenopoulos G, Myles PS, Patman S, Paton M, Pound G, Rai S, Rix A, Rollinson TC, Tipping CJ, Thomas P, Trapani T, Udy AA, Whitehead C, Anderson S, Neto AS. Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness. Am J Respir Crit Care Med 2022; 205:1159-1168. [PMID: 35258437 PMCID: PMC9872799 DOI: 10.1164/rccm.202110-2335oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).
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Affiliation(s)
- Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and,Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Michael J. Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Anne M. Mather
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Lisa Beach
- Department of Physiotherapy (Allied Health), the Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Critical Care, School of Medicine, and,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, University of Canberra, Canberra, Australian Capital Territory, Australia;,Physiotherapy Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Ianthe J. Boden
- Physiotherapy Department, Launceston General Hospital, Launceston, Tasmania, Australia;,School of Medicine, University of Tasmania, Tasmania, Australia
| | - Scott Bradley
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and
| | - Bentley J. Fulcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Kimberley J. Haines
- Department of Critical Care, School of Medicine, and,Physiotherapy Department, Western Health, Melbourne, Victoria, Australia
| | - Isabelle T. Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Jack Hopkins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Alice Y. M. Jones
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Stuart Lane
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Intensive Care Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Drew Lawrence
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | | | - Jennifer Liacos
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Natalie J. Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Lonni Marques Gomes
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Marc Nickels
- Physiotherapy Department, Princess Alexandra Hospital, Metro South Health, Queensland, Australia
| | | | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Shane Patman
- Faculty of Medicine, Nursing and Midwifery, Health Sciences, and Physiotherapy, the University of Notre Dame Australia, Perth, Western Australia, Australia
| | - Michelle Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Physiotherapy, Monash Health, Melbourne, Victoria, Australia
| | - Gemma Pound
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Physiotherapy Department, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Sumeet Rai
- Canberra Health Services, Canberra, Australian Capital Territory, Australia;,Medical School, Australia National University, Canberra, Australian Capital Territory, Australia
| | - Alana Rix
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Thomas C. Rollinson
- Medical School, Australia National University, Canberra, Australian Capital Territory, Australia;,Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Victoria, Australia
| | - Claire J. Tipping
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Peter Thomas
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and
| | - Christina Whitehead
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Intensive Care Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Shannah Anderson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Critical Care, School of Medicine, and,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia;,Department of Physiotherapy, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia; and
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Cusack R, Bates A, Mitchell K, van Willigen Z, Denehy L, Hart N, Dushianthan A, Reading I, Chorozoglou M, Sturmey G, Davey I, Grocott M. Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial. BMJ Open 2022; 12:e055285. [PMID: 35428629 PMCID: PMC9014051 DOI: 10.1136/bmjopen-2021-055285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study. METHODS AND ANALYSIS 90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score. ETHICS AND DISSEMINATION The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03771014.
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Affiliation(s)
- Rebecca Cusack
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Intensive Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew Bates
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kay Mitchell
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zoe van Willigen
- Department of Physiotherapy, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Linda Denehy
- Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
- Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Nicholas Hart
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- Respiratory and Critical Care, King's College London, London, UK
| | - Ahilanandan Dushianthan
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Intensive Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Isabel Reading
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Gordon Sturmey
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Iain Davey
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Grocott
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Intensive Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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McPeake J, Bateson M, Christie F, Robinson C, Cannon P, Mikkelsen M, Iwashyna TJ, Leyland AH, Shaw M, Quasim T. Hospital re-admission after critical care survival: a systematic review and meta-analysis. Anaesthesia 2022; 77:475-485. [PMID: 34967011 DOI: 10.1111/anae.15644] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/22/2022]
Abstract
Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.
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Affiliation(s)
- J McPeake
- Intensive Care Unit, Glasgow Royal Infirmary and School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | - M Bateson
- University of the West of Scotland, Glasgow, UK
| | - F Christie
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - C Robinson
- Belfast Health and Social Care Trust, Belfast, UK
| | - P Cannon
- University of Glasgow Library, Glasgow, UK
| | - M Mikkelsen
- Center for Clinical Epidemiology and Biostatistics, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - T J Iwashyna
- Centre for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - A H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - M Shaw
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - T Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.,Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
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Doherty Z, Kippen R, Bevan D, Duke G, Williams S, Wilson A, Pilcher D. Long-term outcomes of hospital survivors following an ICU stay: A multi-centre retrospective cohort study. PLoS One 2022; 17:e0266038. [PMID: 35344543 PMCID: PMC8959167 DOI: 10.1371/journal.pone.0266038] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 03/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background The focus of much Intensive Care research has been on short-term survival, which has demonstrated clear improvements over time. Less work has investigated long-term survival, and its correlates. This study describes long-term survival and identifies factors associated with time to death, in patients who initially survived an Intensive Care admission in Victoria, Australia. Methods We conducted a retrospective cohort study of adult patients discharged alive from hospital following admission to all Intensive Care Units (ICUs) in the state of Victoria, Australia between July 2007 and June 2018. Using the Victorian Death Registry, we determined survival of patients beyond hospital discharge. Comparisons between age matched cohorts of the general population were made. Cox regression was employed to investigate factors associated with long-term survival. Results A total of 130,775 patients from 23 ICUs were included (median follow-up 3.6 years post-discharge). At 1-year post-discharge, survival was 90% compared to the age-matched cohort of 98%. All sub-groups had worse long-term survival than their age-matched general population cohort, apart from elderly patients admitted following cardiac surgery who had better or equal survival. Multiple demographic, socio-economic, diagnostic, acute and chronic illness factors were associated with long-term survival. Conclusions Australian patients admitted to ICU who survive to discharge have worse long-term survival than the general population, except for the elderly admitted to ICU following cardiac surgery. These findings may assist during goal-of-care discussions with patients during an ICU admission.
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Affiliation(s)
- Zakary Doherty
- School of Rural Health, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
| | - Rebecca Kippen
- School of Rural Health, Monash University, Melbourne, Victoria, Australia
| | - David Bevan
- Department of Health and Human Services, Melbourne, Victoria, Australia
| | - Graeme Duke
- Eastern Health, Melbourne, Victoria, Australia
| | - Sharon Williams
- Department of Health and Human Services, Melbourne, Victoria, Australia
| | | | - David Pilcher
- Alfred Health, Melbourne, Victoria, Australia
- Safer Care Victoria, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Walsh TS, Pauley E, Donaghy E, Thompson J, Barclay L, Parker RA, Weir C, Marple J. 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. BMJ Open 2022; 12:e056524. [PMID: 35321894 PMCID: PMC8943772 DOI: 10.1136/bmjopen-2021-056524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 02/22/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Timothy Simon Walsh
- Critical Care Medicine; Usher Institute of Population Health Sciences, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Ellen Pauley
- Department of Anaesthesia, Critical Care & Pain Medicine, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Eddie Donaghy
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
| | - Joanne Thompson
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
| | - Lucy Barclay
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
| | | | - Christopher Weir
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - James Marple
- Department of Anaesthesia, Critical Care & Pain Medicine, NHS Lothian, Edinburgh, UK
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Abstract
The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States.
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de Vos J, Visser LA, de Beer AA, Fornasa M, Thoral PJ, Elbers PWG, Cinà G. The Potential Cost-Effectiveness of a Machine Learning Tool That Can Prevent Untimely Intensive Care Unit Discharge. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:359-367. [PMID: 35227446 DOI: 10.1016/j.jval.2021.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/06/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The machine learning prediction model Pacmed Critical (PC), currently under development, may guide intensivists in their decision-making process on the most appropriate time to discharge a patient from the intensive care unit (ICU). Given the financial pressure on healthcare budgets, this study assessed whether PC has the potential to be cost-effective compared with standard care, without the use of PC, for Dutch patients in the ICU from a societal perspective. METHODS A 1-year, 7-state Markov model reflecting the ICU care pathway and incorporating the PC decision tool was developed. A hypothetical cohort of 1000 adult Dutch patients admitted in the ICU was entered in the model. We used the literature, expert opinion, and data from Amsterdam University Medical Center for model parameters. The uncertainty surrounding the incremental cost-effectiveness ratio was assessed using deterministic and probabilistic sensitivity analyses and scenario analyses. RESULTS PC was a cost-effective strategy with an incremental cost-effectiveness ratio of €18 507 per quality-adjusted life-year. PC remained cost-effective over standard care in multiple scenarios and sensitivity analyses. The likelihood that PC will be cost-effective was 71% at a willingness-to-pay threshold of €30 000 per quality-adjusted life-year. The key driver of the results was the parameter "reduction in ICU length of stay." CONCLUSIONS We showed that PC has the potential to be cost-effective for Dutch ICUs in a time horizon of 1 year. This study is one of the first cost-effectiveness analyses of a machine learning device. Further research is needed to validate the effectiveness of PC, thereby focusing on the key parameter "reduction in ICU length of stay" and potential spill-over effects.
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Affiliation(s)
- Juliette de Vos
- Pacmed B.V., Amsterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Laurenske A Visser
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Patrick J Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Rose L, Dvorani E, Homenauth E, Istanboulian L, Fraser I. Mortality, Health Care Use, and Costs of Weaning Center Survivors and Matched Prolonged ICU Stay Controls. Respir Care 2022; 67:291-300. [PMID: 35078929 PMCID: PMC9993494 DOI: 10.4187/respcare.09438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Quantification of long-term survival, health care utilization, and costs of prolonged ventilator dependence informs patient/family decision-making, health care policy, and understanding of specialized weaning centers (SWCs) as alternate care models. Our objective was to compare survival trajectory, health care utilization, and costs of SWC survivors with a matched cohort of ≥ 21-d-stay ICU patients. METHODS This was a retrospective longitudinal (12 y) case-control study linking to health administrative databases with matching on age, sex, Charlson comorbidity index, income quintiles, and days in ICU and hospital in preceding 12 months. RESULTS We matched 201 SWC subjects to 201 prolonged ICU survivors (402-subject cohort); 42% had a Charlson score of > 4. Risk of death at 12 months was lower in SWC subjects (hazard ratio [HR] 0.70 [95% CI 0.54-0.91]) adjusting for length of hospital admission (HR 1.02 [95% CI 1.00-1.04]) and number of care location transfers (HR 0.84 [95% CI 0.75-0.93]). By follow-up end, more SWC subjects died, 149 (73%) versus 127 (62%). We found no difference in discharge to home. At 12 months, acute health care utilization was comparable for the entire cohort, except hospital readmission rates (median interquartile range [IQR] 2 [1-3) vs 1 [1-2] d). Median (IQR) cost 12 months after unit discharge was CAD $68,165 ($19,894-$153,475). 12-month costs were higher in the SWC survivors (CAD $82,874 [$29,942-$224,965] vs CAD $55,574 [$6,572-$128,962], P < .001). SWC survivors had higher community health care utilization. Regression modeling demonstrated cost was associated with stay and care transfers but not SWC admission. Over 12-y follow-up, health care utilization and costs were higher in SWC survivors. CONCLUSIONS SWC admission may confer some medium-term survival advantage; however, this may be influenced by selection bias associated with admission criteria.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom; Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Hospital Trust, London, United Kingdom; and Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, Canada.
| | - Erind Dvorani
- Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Esha Homenauth
- Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - Laura Istanboulian
- Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, Canada; and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ian Fraser
- Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, Canada; and Faculty of Medicine, University of Toronto, Toronto, Canada
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Beyond "In the Red": Building the Business Case for a Post-COVID Clinic. Ann Am Thorac Soc 2022; 19:1257-1259. [PMID: 35231201 PMCID: PMC9353964 DOI: 10.1513/annalsats.202111-1270ps] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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