The Post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part II: Clinical engagement and future directions for the national Post-Intensive care Rehabilitation Collaborative

Long-term outcomes in critically ill patients with acute respiratory failure

PURPOSE OF REVIEW

This review aims to explore the latest evidence on long-term outcomes in patients admitted to the ICU because of acute respiratory failure (ARF).

RECENT FINDINGS

As the survival rate of critically ill patients with acute respiratory failure improves, long-term mortality and disability still influence the quality of life of survivors and their caregivers. Patients admitted to the ICU because of ARF are at risk of developing the postintensive care syndrome, which presents with physical, cognitive and mental symptoms, all of which may impair their quality of life. Caregivers seem to be affected as well, which may lead to intergenerational trauma. The need for more care, including prone positioning, invasive support (e.g. mechanical ventilation, ECMO) and deep sedation are probably adjunctive risk factors for poor long-term outcomes.

SUMMARY

There is not much data on the long-term outcomes of patients who have survived ARF. More follow-up studies should be conducted, especially in centers providing higher levels of costly care (e.g. ECMO). Randomized controlled trials on interventions for ARF should include patient-centered long-term outcomes in addition to mortality rates. The high mortality rates associated with ARF mandate collaboration among multiple centers to achieve an adequate sample size for studying the long-term outcomes of survivors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mental Health Provision in PICU: An Analysis of Referrals to an Embedded Psychologist Over 20 Years at a Single Center

OBJECTIVES

The main aim of this study was to illustrate the type of mental health provision possible on PICU by describing the nature of referrals of child patients and their parents to an embedded psychologist over a 20-year period, adding to the literature on intervention and service development.

DESIGN

Retrospective evaluation of anonymized departmental database.

SETTING

Twelve-bed PICU at a teaching hospital in a major urban center.

PATIENTS

Five hundred forty-five consecutive referrals for support for parent and/or child by PICU staff between 1998 and 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Referrals increased from seven of 288 (2.4%) in 1998 to 85 of 643 (13.2%) in 2017. The majority were for parent support initially (456/545, 84%). Mean ( sd ) number of contacts was 4.5 (10.2), range 1 to 143, and mode was 1. Patient gender and age typical of the total PICU population, but referrals were more common where children had an oncology or trauma diagnosis ( p < 0.001). Comparisons with other inpatient referrals at the same hospital revealed a higher proportion of requests were made for parent support on PICU (456/545 [84%] vs 789/1,997 [40%]; p < 0.001) and that nurses were more likely to initiate referrals on PICU than on the other wards (437/543 [80%] vs 1,190/1,993 [60%]; p < 0.001). In other respects, the two groups were similar in terms of number of sessions, waiting times, and attendance rates.

CONCLUSIONS

Growing appreciation of the psychological impact of a child's admission to PICU has been associated with increasing referral to an embedded psychologist over a 20-year period, at this center. Clinical and service implications are outlined in the context of the latest research on the mitigation of post-intensive care syndrome in this population.

Critical care and pandemic preparedness and response

Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.

Effect of CICARE communication nursing model combined with motivational psychological intervention in patients with post-intensive care unit syndrome

BACKGROUND

Post-intensive care syndrome (PICS) is a term used to describe a constellation of new or worsened dysfunctions in the physical, cognitive, or mental health status of critically ill patients after their discharge from the intensive care unit (ICU). These dysfunctions persist beyond the acute phase of illness and have a significant impact on both the patient and their family. Connect, Introduce, Communicate, Ask, Respond, Exit (CICARE) communication advocates that patients should be respected and accepted when receiving medical services. Clinicians should attach importance to the communication mode of feelings, including connection, introduction, communication, ask, response, and exit 6 steps.

AIM

To assess the impact of CICARE communication on the reduction of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms in patients transitioning from the ICU to other care settings.

METHODS

This prospective, randomized, controlled study was performed between October 2021 and March 2023. Intensive Care Unit Memory Tool was used to evaluate patients' ICU memory. The Hospital Anxiety and Depression Scale was employed to determine the presence of anxiety or depression symptoms. Impact of Event Scale-Revised was utilized to assess the presence of PTSD. All data were processed and analyzed using R language software version 4.1.0. The measurement data were expressed as mean ± SD, and the t test was used. The count data were analyzed by the χ2 test and expressed as [n (%)].

RESULTS

In total, 248 subjects were included in this study. Among them, 206 were successfully followed up for three months after transfer from the ICU, and 42 cases were lost to follow-up. There was no significant difference in the composition of ICU memory between the two groups. The application of the CICARE communication nursing model combined with the motivational psychological intervention nursing model, as well as the adoption of only the motivational psychological intervention nursing model, demonstrated favorable effects on PICS. Both groups of patients showed a reduction in anxiety scores, depression scores, and PTSD scores following the implementation of these two nursing models. However, it is noteworthy that the experimental group exhibited greater improvements compared to the control group.

CONCLUSION

Our findings suggest that CICARE communication nursing mode may have good influence on relieving PICS.

Recovery from Covid-19 critical illness: A secondary analysis of the ISARIC4C CCP-UK cohort study and the RECOVER trial

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.

Therapy professionals in critical care: A UK wide workforce survey

Introduction

National guidelines suggest recommended staffing levels for therapies. The aim of this study was to capture information on existing staffing levels, roles and responsibilities and service structures.

Methods

An observational study using online surveys distributed to 245 critical care units across the United Kingdom (UK). Surveys consisted of a generic and five profession specific surveys.

Results

Eight hundred sixty-two responses were received from 197 critical care units across the UK. Of those that responded, over 96% of units had input from dietetics, physiotherapy and SLT. Whereas only 59.1% and 48.1% had an OT or psychology service respectively. Units with ring fenced services had improved therapist to patient ratios.

Discussion

There is significant variation in access to therapists for patients admitted to critical care in the UK, with many services not having services for core therapies such as psychology and OT. Where services do exist, they fall below the recommended guidance.

Can pioglitazone be used for optimization of nutrition in critical illness? A systematic review

BACKGROUND

Skeletal muscle wasting is a determinant of physical disability in survivors of critical illness. Intramuscular bioenergetic failure, altered substrate metabolim, and inflammation are likely underpinning mechanisms. We examined the effect of pioglitazone, a peroxisome proliferator-activated receptor γ agonist, on muscle-related outcomes in adults.

METHODS

We included randomized controlled trials in which pioglitazone was administered (no dose/dosage restrictions) and muscle-related outcomes were reported. We searched MEDLINE, CENTRAL, EMBASE, CINAHL, and trial registries. Risk of bias was assessed using RoB 2. Primary outcomes were physical function and symptoms, muscle mass and function, or body composition and muscular compositional change. Secondary outcomes included muscle insulin sensitivity, mitochondrial effects, and intramuscular inflammation.

RESULTS

Fourteen studies over 19 publications (n = 474 patients) were included. Lean body mass was unaffected in three studies (n = 126) and increased by 1.8-1.92 kg in two studies (P = 0.02 and 0.003, respectively; n = 48). Pioglitazone was associated with increased peripheral insulin sensitivity (+23%-72%, standardized mean difference of 0.97 from trial start point to end point [95% CI, 0.36-1.58; n = 213]). Treatment reduced intramuscular tumor necrosis factor-α (TNF-α) levels (-30%; P = 0.02; n = 29), with mixed effects on serum TNF-α and intramyocellular lipid concentrations. Treatment increased intramuscular markers of adenosine triphosphate (ATP) biosynthesis (ATP5A [+33%, P ≤ 0.05], ETFA [+60%, P ≤ 0.05], and CX6B1 [+ 33%, P = 0.01] [n = 24]), PGC1α and PGC1β messenger RNA expression (P < 0.05; n = 26), and AMPK phosphorylation (+38%, P < 0.05; n = 26). These data have low-quality evidence profiles owing to risk of bias.

CONCLUSIONS

Pioglitazone therapy increases skeletal muscle insulin sensitivity and can decrease intramuscular inflammation.

Validity, inter-rater reliability, and feasibility of the Chelsea Physical Assessment Tool for assessing physical function in post-acute COVID-19 patients: A cross-sectional study

BACKGROUND

Various tools have been created to measure physical function during intensive care unit (ICU) stay and after ICU discharge, but those have not been validated in coronavirus 2019 (COVID-19) patients. There is a need for a reliable, valid and feasible tool to define the rehabilitation needs of post-ICU COVID-19 patients entering the acute wards and then rehabilitation clinics.

OBJECTIVE

This study aims to investigate the validity, inter-rater reliability and feasibility of Chelsea Physical Assessment Tool (CPAx) in assessing the functional status of COVID-19 patients after discharge from the ICU.

METHODS

Demographic and clinical characteristics of the patients were recorded. Patients were evaluated using the modified Medical Research Council (MRC) dyspnea scale, Functional Oral Intake Scale, Glasgow Coma Scale, CPAx, Barthel Index, Katz Index and MRC sum score, measurements of grip strength obtained by dynamometer, the 5 time sit-to-stand test and 30 seconds and sit-to-stand test. CPAx and the other functional assessment tools were administered to 16 patients within 48 hours following ICU discharge. For inter-rater reliability, another physiatrist independently re-assessed the patients. MRC sum score, Barthel and Katz indexes were used to assess construct validity of CPAx. The discriminative validity of CPAx was determined by its ability to differentiate between patients with and without ICU acquired muscle weakness based on MRC sum score. The intra-class correlation coefficients (ICC) were calculated to determine inter-rater reliability for total scores of the functional assessment tools. Cohen's Kappa (κ) coefficient and weighed Kappa (κw) were calculated to determine inter-rater reliability of individual CPAx items. Ceiling and flooring effects were calculated by percentage frequency of lowest or highest possible score achieved. The number and percentages of the patients who were able to complete each tool were calculated to assess feasibility.

RESULTS

The CPAx score was strongly correlated with MRC sum score (rho: 0.83), Barthel Index (rho: 0.87) and Katz Index (rho: 0.89) (p< 0.001) showing construct validity. Area under the ROC curve demonstrated that cut off score for CPAx was ⩽ 12 to discriminate patients with MRC sum score < 48, with a sensitivity and a specificity of 100% and 63%, respectively (AUC = 0.859, p< 0.001). ICC was high for CPAx, MRC sum score, Barthel and Katz indexes, Glasgow Coma Scale, and hand grip strength measurement, with the highest value observed for CPAx (ICC, 0.96; 95% confidence interval (CI), 0.71-0.98). κ and κw analysis showed good to excellent inter-rater reliability for individual CPAx items. No floor or ceiling effect was observed at CPAx while floor effect was observed at Barthel Index scores (25%) and Katz Index scores (37.5%). All patients could be evaluated using CPAx while less were physically able to complete the 5 time sit-to-stand, 30 seconds sit-to-stand tests (n= 4) and MRC sum score (n= 14).

CONCLUSION

CPAx is a valid, reliable, and feasible tool to assess the physical functional state in COVID-19 patients following discharge from the ICU.

Mixed methods evaluation of the impact of the COVID-19 ICU remote-learning rehabilitation course for frontline health professionals during the COVID-19 pandemic in the UK

Background

Optimising outcomes for critically ill patients with COVID-19 patients requires early interdisciplinary rehabilitation. As admission numbers soared through the pandemic, the redeployed workforce needed rapid, effective training to deliver these rehabilitation interventions.

Methods

The COVID-19 ICU Remote-Learning Rehab Course (CIRLC-rehab) is a one-day interdisciplinary course developed after the success of CIRLC-acute. The aim of CIRLC-rehab was to rapidly train healthcare professionals to deliver physical, nutritional and psychological rehabilitation strategies in the ICU/acute setting. The course used blended learning with interactive tutorials delivered by shielding critical care professionals. CIRLC-rehab was evaluated through a mixed-methods approach, including questionnaires, and follow-up semi-structured interviews to evaluate perceived impact on clinical practice. Quantitative data are reported as n (%) and means (SD). Inductive descriptive thematic analysis with methodological triangulation was used to analyse the qualitative data from the questionnaires and interviews.

Results

805 candidates completed CIRLC-rehab. 627 (78.8%) completed the post-course questionnaire. 95% (n = 596) found CIRLC-rehab extremely or very useful and 96.0% (n = 602) said they were very likely to recommend the course to colleagues. Overall confidence rose from 2.78/5 to 4.14/5. The course promoted holistic and humanised care, facilitated informal networks, promoted interdisciplinary working and equipped the candidates with practical rehabilitation strategies that they implemented into clinical practice.

Conclusion

This pragmatic solution to educating redeployed staff during a pandemic increased candidates' confidence in the rehabilitation of critically ill patients. There was also evidence of modifications to clinical care utilising learning from the course that subjectively facilitated holistic and humanised rehabilitation, combined with the importance of recognising the humanity, of those working in ICU settings themselves. Whilst these data are self-reported, we believe that this work demonstrates the real-term benefits of remote, scalable and rapid educational delivery.

The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part I: Development and preliminary clinimetric evaluation

Background

Patients who have had prolonged stays in intensive care have ongoing rehabilitation needs. This is especially true of COVID-19 ICU patients, who can suffer diverse long-term ill effects. Currently there is no systematic data collection to guide the needs for therapy input for either of these groups nor to inform planning and development of rehabilitation services. These issues could be resolved in part by the systematic use of a clinical tool to support decision-making as patients progress from the Intensive Care Unit (ICU), through acute hospital care and onwards into rehabilitation. We describe (i) the development of such a tool (the Post-ICU Presentation Screen (PICUPS)) and (ii) the subsequent preparation of a person-centred Rehabilitation Prescription (RP) to travel with the patient as they continue down the care pathway.

Methods

PICUPS development was led by a core group of experienced clinicians representing the various disciplines involved in post-ICU rehabilitation. Key constructs and item-level descriptors were identified by group consensus. Piloting was performed as part of wider clinical engagement in 26 acute hospitals across England. Development and validation of such a tool requires clinimetric analysis, and this was based on classical test theory. Teams also provided feedback about the feasibility and utility of the tool.

Results

Initial PICUPS design yielded a 24-item tool. In piloting, a total of 552 records were collated from 314 patients, of which 121 (38.5%) had COVID-19. No obvious floor or ceiling effects were apparent. Exploratory factor analysis provided evidence of uni-dimensionality with strong loading on the first principal component accounting for 51% of the variance and Cronbach's alpha for the full-scale score 0.95 - although a 3-factor solution accounted for a further 21%. The PICUPS was responsive to change both at full scale- and item-level. In general, positive responses were seen regarding the tool's ability to describe the patients during their clinical course, engage and flag the relevant professionals needed, and to inform what should be included in an RP.

Conclusions

The PICUPS tool has robust scaling properties as a clinical measure and is potentially useful as a tool for identifying rehabilitation needs as patients step down from ICU and acute hospital care.

Nutritional priorities in patients with severe COVID-19

PURPOSE OF REVIEW

The COVID-19 pandemic has altered the profile of critical care services internationally, as professionals around the globe have struggled to rise to the unprecedented challenge faced, both in terms of individual patient management and the sheer volume of patients that require treatment and management in intensive care. This review article sets out key priorities in nutritional interventions during the patient journey, both in the acute and recovery phases.

RECENT FINDINGS

The current review covers the care of the acutely unwell patient, and the evidence base for nutritional interventions in the COVID-19 population. One of the biggest differences in caring for critically ill patients with acute respiratory failure from COVID-19 is often the time prior to intubation. This represents specific nutritional challenges, as does nursing patients in the prone position or in the setting of limited resources. This article goes on to discuss nutritional support for COVID-19 sufferers as they transition through hospital wards and into the community.

SUMMARY

Nutritional support of patients with severe COVID-19 is essential. Given the longer duration of their critical illness, combined with hypermetabolism and energy expenditure, patients with COVID-19 are at increased risk for malnutrition during and after their hospital stay.

Nutrition in postacute rehabilitation of COVID-19 survivors

PURPOSE OF REVIEW

Patients hospitalised with COVID-19 are at high nutrition risk and a significant number are likely to require ongoing nutrition rehabilitation. Here, we summarise guideline recommendations for nutritional rehabilitation in postacute COVID-19 infection, outline the rationale for nutrition rehabilitation for survivors of postacute COVID-19 in patients admitted to both the hospital ward and intensive care unit and discuss current evidence for interventions.

RECENT FINDINGS

Several guidelines exist outlining recommendations for nutrition care in hospital, critical care and the community setting. All have common themes pertaining to the importance of nutrition screening, nutrition assessment, appropriate choice of intervention and continuity of care across settings. While a plethora of data exists highlighting the high nutrition risk and prevalence of malnutrition in this population, minimal interventional studies have been published.

SUMMARY

Patients hospitalised with COVID-19 are at high nutrition risk. Future studies should focus on nutrition interventions for the rehabilitation period and determine whether nutrition needs differ between COVID-19 and non-COVID-19 survivors.

Strategies to ensure continuity of nutritional care in patients with COVID-19 infection on discharge from hospital: A rapid review

BACKGROUND & AIMS

The risk of malnutrition in people with COVID-19 is high; prevalence is reported as 37% in general medical inpatients, 53% in elderly inpatients and 67% in ICU. Thus, nutrition is a crucial element of assessment and treatment. This rapid review aimed to evaluate what evidence is available to inform evidence-based decision making on the nutritional care of patients hospitalised with COVID-19 infection.

METHODS

Cochrane Rapid Reviews guidance was followed; the protocol was registered (CRD42020208448). Studies were selected that included patients with COVID-19, pneumonia, respiratory distress syndrome and acute respiratory failure, in hospital or the community, and which examined nutritional support. All types of studies were eligible for inclusion except non-systematic reviews, commentaries, editorials and single case studies. Six electronic databases were searched: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PubMed, CINAHL and MedRxiv.

RESULTS

Twenty-six articles on COVID-19 were retrieved, including 11 observational studies, five guidelines and 10 opinion articles. Seven further articles on pneumonia included three RCTs, one unblinded trial, three observational studies, and one systematic review on rehabilitation post-ICU admission for respiratory illness. The evidence from these articles is presented narratively and used to guide the nutritional and dietetic care process.

CONCLUSIONS

Older patients with COVID-19 infection are at risk of malnutrition and addressing this may be important in recovery. The use of nutritional management strategies applicable to other acute conditions are recommended. However, traditional screening and implementation techniques need to be modified to ensure infection control measures can be maintained. The most effective nutritional interventions require further research and more detailed guidance on nutritional management post-discharge to support long-term recovery is needed.