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Contreras M, Silva B, Shickel B, Davidson A, Ozrazgat-Baslanti T, Ren Y, Guan Z, Balch J, Zhang J, Bandyopadhyay S, Loftus T, Khezeli K, Nerella S, Bihorac A, Rashidi P. APRICOT-Mamba: Acuity Prediction in Intensive Care Unit (ICU): Development and Validation of a Stability, Transitions, and Life-Sustaining Therapies Prediction Model. RESEARCH SQUARE 2024:rs.3.rs-4790824. [PMID: 39149454 PMCID: PMC11326394 DOI: 10.21203/rs.3.rs-4790824/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
On average, more than 5 million patients are admitted to intensive care units (ICUs) in the US, with mortality rates ranging from 10 to 29%. The acuity state of patients in the ICU can quickly change from stable to unstable, sometimes leading to life-threatening conditions. Early detection of deteriorating conditions can assist in more timely interventions and improved survival rates. While Artificial Intelligence (AI)-based models show potential for assessing acuity in a more granular and automated manner, they typically use mortality as a proxy of acuity in the ICU. Furthermore, these methods do not determine the acuity state of a patient (i.e., stable or unstable), the transition between acuity states, or the need for life-sustaining therapies. In this study, we propose APRICOT-M (Acuity Prediction in Intensive Care Unit-Mamba), a 1M-parameter state space-based neural network to predict acuity state, transitions, and the need for life-sustaining therapies in real-time among ICU patients. The model integrates ICU data in the preceding four hours (including vital signs, laboratory results, assessment scores, and medications) and patient characteristics (age, sex, race, and comorbidities) to predict the acuity outcomes in the next four hours. Our state space-based model can process sparse and irregularly sampled data without manual imputation, thus reducing the noise in input data and increasing inference speed. The model was trained on data from 107,473 patients (142,062 ICU admissions) from 55 hospitals between 2014-2017 and validated externally on data from 74,901 patients (101,356 ICU admissions) from 143 hospitals. Additionally, it was validated temporally on data from 12,927 patients (15,940 ICU admissions) from one hospital in 2018-2019 and prospectively on data from 215 patients (369 ICU admissions) from one hospital in 2021-2023. Three datasets were used for training and evaluation: the University of Florida Health (UFH) dataset, the electronic ICU Collaborative Research Database (eICU), and the Medical Information Mart for Intensive Care (MIMIC)-IV dataset. APRICOT-M significantly outperforms the baseline acuity assessment, Sequential Organ Failure Assessment (SOFA), for mortality prediction in both external (AUROC 0.95 CI: 0.94-0.95 compared to 0.78 CI: 0.78-0.79) and prospective (AUROC 0.99 CI: 0.97-1.00 compared to 0.80 CI: 0.65-0.92) cohorts, as well as for instability prediction (external AUROC 0.75 CI: 0.74-0.75 compared to 0.51 CI: 0.51-0.51, and prospective AUROC 0.69 CI: 0.64-0.74 compared to 0.53 CI: 0.50-0.57). This tool has the potential to help clinicians make timely interventions by predicting the transition between acuity states and decision-making on life-sustaining within the next four hours in the ICU.
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Affiliation(s)
- Miguel Contreras
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Brandon Silva
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Benjamin Shickel
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Andrea Davidson
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Tezcan Ozrazgat-Baslanti
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Yuanfang Ren
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Ziyuan Guan
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Jeremy Balch
- Department of Surgery, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Jiaqing Zhang
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | | | - Tyler Loftus
- Department of Surgery, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Kia Khezeli
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Subhash Nerella
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Azra Bihorac
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Parisa Rashidi
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
- Intelligent Clinical Care Center (IC3), University of Florida, Gainesville, FL, USA
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Yoon U, Mojica J, Wiltshire M, Torjman M. Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room. J Intensive Care Med 2024; 39:751-757. [PMID: 38303148 DOI: 10.1177/08850666241230022] [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: 02/03/2024]
Abstract
BACKGROUND Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings. METHODS A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality. RESULTS A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002). CONCLUSION Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeffrey Mojica
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Matthew Wiltshire
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marc Torjman
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Antonucci E, Garcia B, Chen D, Matthay MA, Liu KD, Legrand M. Incidence of acute kidney injury and attributive mortality in acute respiratory distress syndrome randomized trials. Intensive Care Med 2024; 50:1240-1250. [PMID: 38864911 PMCID: PMC11306535 DOI: 10.1007/s00134-024-07485-6] [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: 04/18/2024] [Accepted: 05/06/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE The development of acute kidney injury (AKI) after the acute respiratory distress syndrome (ARDS) reduces the chance of organ recovery and survival. The purpose of this study was to examine the AKI rate and attributable mortality in ARDS patients. METHODS We performed an individual patient-data analysis including 10 multicenter randomized controlled trials conducted over 20 years. We employed a Super Learner ensemble technique, including a time-dependent analysis, to estimate the adjusted risk of AKI. We calculated the mortality attributable to AKI using an inverse probability of treatment weighting estimator integrated with the Super Learner. RESULTS There were 5148 patients included in this study. The overall incidence of AKI was 43.7% (n = 2251). The adjusted risk of AKI ranged from 38.8% (95% confidence interval [CI], 35.7 to 41.9%) in ARMA, to 55.8% in ROSE (95% CI, 51.9 to 59.6%). 37.1% recovered rapidly from AKI, with a significantly lower recovery rate in recent trials (P < 0.001). The 90-day excess in mortality attributable to AKI was 15.4% (95% CI, 12.8 to 17.9%). It decreased from 25.4% in ARMA (95% CI, 18.7 to 32%), to 11.8% in FACTT (95% CI, 5.5 to 18%) and then remained rather stable over time. The 90-day overall excess in mortality attributable to acute kidney disease was 28.4% (95% CI, 25.3 to 31.5%). CONCLUSIONS The incidence of AKI appears to be stable over time in patients with ARDS enrolled in randomized trials. The development of AKI remains a significant contributing factor to mortality. These estimates are essential for designing future clinical trials for AKI prevention or treatment.
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Affiliation(s)
- Edoardo Antonucci
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Department of Anesthesia and Critical Care Medicine, University of Milan, Milan, Italy
| | - Bruno Garcia
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - David Chen
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Michael A Matthay
- Cardiovascular Research Institute (CVRI), University of California San Francisco, Medicine and Anesthesia, San Francisco, CA, USA
| | - Kathleen D Liu
- Department of Medicine and Anesthesia, Division of Nephrology and Critical Care Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
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Sayde GE, Shapiro PA, Kronish I, Agarwal S. A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors. J Crit Care 2024; 82:154798. [PMID: 38537526 DOI: 10.1016/j.jcrc.2024.154798] [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: 12/18/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 06/01/2024]
Abstract
Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.
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Affiliation(s)
- George E Sayde
- Division of Consultation-Liaison Psychiatry, Department of Psychiatry, Columbia University Irving Medical Center, 622 West 168(th) Street, PH 16-Center, New York, NY 10032, USA.
| | - Peter A Shapiro
- Division of Consultation-Liaison Psychiatry, Department of Psychiatry, Columbia University Irving Medical Center, 622 West 168(th) Street, PH 16-Center, New York, NY 10032, USA.
| | - Ian Kronish
- Center for Behavioral Cardiovascular Health, Division of General Medicine, Columbia University Irving Medical Center, 622 West 168(th) Street, PH9-311, New York, NY 10032, USA.
| | - Sachin Agarwal
- Department of Neurology, Division of Critical Care and Hospitalist Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, 8GS-300, New York, NY 10032, USA.
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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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O'Shea AM, Reisinger HS, Panos R, Goede M, Fortis S. Association of interactions between tele-critical care and bedside with length of stay and mortality. J Telemed Telecare 2024; 30:961-968. [PMID: 35770292 DOI: 10.1177/1357633x221107993] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization. METHODS We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes. RESULTS Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay. DISCUSSION Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.
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Affiliation(s)
- Amy Mj O'Shea
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Ralph Panos
- Pulmonary, Critical Care, and Sleep Division and Cincinnati Tele-CC, Cincinnati VAMC, Cincinnati, OH, USA
- Pulmonary, Critical Care, and Sleep Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matt Goede
- VA Tele-Critical. Care West, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Surgery, Division of Acute Care Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Spyridon Fortis
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- VA Tele-Critical. Care West, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Smaisim N, Rijsdijk M, van der Does Y, Slooter AJC. Pain and psychopathology after intensive care unit admission. Anaesth Intensive Care 2024; 52:232-240. [PMID: 38879797 PMCID: PMC11290044 DOI: 10.1177/0310057x241226716] [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: 07/31/2024]
Abstract
Pain and psychopathology are observed in 18% and 55% of patients, respectively, 1 year after intensive care unit (ICU) admission. It is well known that chronic pain and psychopathology have a bidirectional relation in the general population, but it is not known whether this holds true for ICU survivors. The aim of this study was to investigate whether pain before, during and after ICU admission is related to psychopathology in ICU survivors 1 year after discharge. We performed a cohort study in a mixed ICU in the Netherlands between 2013 and 2016. At 1-year follow-up, patients completed the Hospital Anxiety and Depression Scale, the Impact of Event Scale/Impact of Event Scale-Revised, and answered standardised questions regarding pain. Psychopathology was defined as having anxiety, depressive and/or post-traumatic stress disorder symptoms. We used multivariable logistic regression analysis to evaluate the association of pain before, during and after ICU admission with psychopathology at 1 year follow-up. We included 1105 patients of whom 558 (50%) (95% confidence interval (CI) 0.48 to 0.54) had psychopathology at 1 year follow-up. Pain before ICU admission (odds ratio (OR) 1.18; 95% CI 1.10 to 1.26) and pain after ICU admission (OR 2.38; 95% CI 1.68 to 3.35) were associated with psychopathology. Pain during ICU stay was not associated with psychopathology, but the memory of insufficient pain management during ICU stay was (OR 2.19; 95% CI 1.39 to 3.45). Paying attention to pain and pain treatment experiences related to ICU admission may therefore contribute to early identification of ICU survivors at risk of psychopathology development.
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Affiliation(s)
- Nour Smaisim
- Pain Clinic, Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Yuri van der Does
- UMC Utrecht Brain Centre, University Medical Centre, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen JC Slooter
- UMC Utrecht Brain Centre, University Medical Centre, Utrecht University, Utrecht, the Netherlands
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Likhvantsev VV, Berikashvili LB, Yadgarov MY, Yakovlev AA, Kuzovlev AN. The Tri-Steps Model of Critical Conditions in Intensive Care: Introducing a New Paradigm for Chronic Critical Illness. J Clin Med 2024; 13:3683. [PMID: 38999249 PMCID: PMC11242724 DOI: 10.3390/jcm13133683] [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: 05/03/2024] [Revised: 06/15/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The prevailing model for understanding chronic critical illness is a biphasic model, suggesting phases of acute and chronic critical conditions. A major challenge within this model is the difficulty in determining the timing of the process chronicity. It is likely that the triad of symptoms (inflammation, catabolism, and immunosuppression [ICIS]) could be associated with this particular point. We aimed to explore the impact of the symptom triad (inflammation, catabolism, immunosuppression) on the outcomes of patients hospitalized in intensive care units (ICUs). Methods: The eICU-CRD database with 200,859 ICU admissions was analyzed. Adult patients with the ICIS triad, identified by elevated CRP (>20 mg/L), reduced albumin (<30 g/L), and low lymphocyte counts (<0.8 × 109/L), were included. The cumulative risk of developing ICIS was assessed using the Nelson-Aalen estimator. Results: This retrospective cohort study included 894 patients (485 males, 54%), with 60 (6.7%) developing ICIS. The cumulative risk of ICIS by day 21 was 22.5%, with incidence peaks on days 2-3 and 10-12 after ICU admission. Patients with the ICIS triad had a 2.5-fold higher mortality risk (p = 0.009) and double the likelihood of using vasopressors (p = 0.008). The triad onset day did not significantly affect mortality (p = 0.104). Patients with ICIS also experienced extended hospital (p = 0.041) and ICU stays (p < 0.001). Conclusions: The symptom triad (inflammation, catabolism, immunosuppression) during hospitalization increases mortality risk by 2.5 times (p = 0.009) and reflects the chronicity of the critical condition. Identifying two incidence peaks allows the proposal of a new Tri-steps model of chronic critical illness with acute, extended, and chronic phases.
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Affiliation(s)
- Valery V Likhvantsev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Levan B Berikashvili
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Mikhail Ya Yadgarov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Alexey A Yakovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Artem N Kuzovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
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You H, Docherty SL, Ashana DC, Oyesanya TO. Transition of Intensive Care Unit Patients and Their Families to Home After Acute Hospital Care. AACN Adv Crit Care 2024; 35:97-108. [PMID: 38848572 DOI: 10.4037/aacnacc2024982] [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: 06/09/2024]
Abstract
Patients in the intensive care unit (ICU) increasingly are expected to eventually return home after acute hospital care. Yet transitional care for ICU patients and their families is often delayed until the patient is about to be transferred to another location or level of care. Transitions theory is a middle-range nursing theory that aims to provide guidance for safe and effective nursing care and research while an individual experiences a transition. Intensive care unit nurses are well positioned to provide ICU transitional care planning early. This article applies the transitions theory as a theoretical model to guide the study of the transition to home after acute hospital care for ICU patients and their families. This theory application can help ICU nurses provide holistic patient- and family-centered transitional care to achieve optimal outcomes by addressing the predischarge and postdischarge needs of patients and families.
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Affiliation(s)
- HyunBin You
- HyunBin You is a PhD candidate, School of Nursing, Duke University, DUMC 3322, 307 Trent Drive, Durham, NC 27710
| | - Sharron L Docherty
- Sharron L. Docherty is Associate Professor, School of Nursing, and Associate Professor, Department of Medicine, Duke University, Durham, North Carolina
| | - Deepshikha C Ashana
- Deepshikha C. Ashana is Assistant Professor, Department of Medicine; Core Faculty Member, Duke-Margolis Center for Health Policy; and Assistant Professor, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Tolu O Oyesanya
- Tolu O. Oyesanya is Associate Professor, School of Nursing, Duke University, Durham, North Carolina
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Lin F, Liu L. Effects of strengthening prospective nursing practice on sleep quality, anxiety, and depression of awake patients in intensive care unit. World J Psychiatry 2024; 14:735-741. [PMID: 38808089 PMCID: PMC11129147 DOI: 10.5498/wjp.v14.i5.735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/08/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The intensive care unit (ICU) is a specialized hospital department. Awake patients in the ICU frequently encounter adverse psychological states, such as anxiety and fear, often accompanied by poor sleep quality. This situation has garnered significant attention within the medical community. AIM To investigate the impact of prospective nursing intervention strategies on the sleep quality and negative emotional state of conscious ICU patients. METHODS One hundred and twenty ICU awake patients admitted to our hospital were selected and randomly divided into control (n = 60) and observation (n = 60) groups. Patients in the control group were cared for using the conventional nursing model, while patients in the observation group were cared for using the prospective nursing model. Sleep improvement was assessed using the International Standardized Sleep Efficiency Formula and Pittsburgh Sleep Quality Index (PSQI). The PSQI, Generalized Anxiety Disorder 7-item (GAD-7) scale, Self-Depression Scale (SDS), and satisfaction before and after treatment were used to assess the negative emotional states of patients under the two care models. RESULTS Patient satisfaction in the observation group was significantly higher than in the control group. The GAD-7 and SDS scores in the observation group were significantly lower than those in the control group, and the total effective rate of sleep improvement in the observation group was significantly higher than in the control group. After treatment, the PSQI scores of the two groups significantly decreased (P < 0.05). The decrease in the observation group was more significant than that in the control group, and the difference between the two groups was statistically significant. CONCLUSION Prospective nursing interventions can improve sleep quality and psychological levels and significantly affect conscious patients in the ICU, which is worthy of clinical application.
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Affiliation(s)
- Fei Lin
- Department of Intensive Care Unit, Dushu Lake Hospital Affiliated to Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Lei Liu
- Department of Intensive Care Unit, Dushu Lake Hospital Affiliated to Soochow University, Suzhou 215000, Jiangsu Province, China
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Wi S, Shin HI, Hyun SE, Sung KS, Lee WH. Feasibility and safety of in-bed cycling/stepping in critically ill patients: A study protocol for a pilot randomized controlled clinical trial. PLoS One 2024; 19:e0301368. [PMID: 38728323 PMCID: PMC11086822 DOI: 10.1371/journal.pone.0301368] [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: 09/27/2023] [Accepted: 03/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) is one of the most common complications of post-ICU syndrome. It is the leading cause of gait disturbance, decreased activities of daily living, and poor health-related quality of life. The early rehabilitation of critically ill patients can reduce the ICU-AW. We designed a protocol to investigate the feasibility and safety of conventional rehabilitation with additional in-bed cycling/stepping in critically ill patients. METHODS The study is designed as a single-center, single-blind, pilot, randomized, parallel-group study. After the screening, participants are randomly allocated to two groups, stratified by mechanical ventilation status. The intervention group will be provided with exercises of in-bed cycling/stepping according to the level of consciousness, motor power, and function in addition to conventional rehabilitation. In contrast, the control group will be provided with only conventional rehabilitation. The length of intervention is from ICU admission to discharge, and interventions will be conducted for 20 minutes, a maximum of three sessions per day. RESULTS The outcomes are the number and percentage of completed in-bed cycling/stepping sessions, the duration and percentage of in-bed cycling/stepping sessions, and the number of cessations of in-bed cycling/stepping sessions, the interval from ICU admission to the first session of in-bed cycling/stepping, the number and percentage of completed conventional rehabilitation sessions, the duration and percentage of conventional rehabilitation sessions, the number of cessations of conventional rehabilitation sessions, the number of adverse events, level of consciousness, functional mobility, muscle strength, activities of daily living, and quality of life. DISCUSSION This study is a pilot clinical trial to investigate the feasibility and safety of conventional rehabilitation with additional in-bed cycling/stepping in critically ill patients. If the expected results are achieved in this study, the methods of ICU rehabilitation will be enriched. TRIAL REGISTRATION clinicialtrials.gov, Clinical Trials Registration #NCT05868070.
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Affiliation(s)
- Soohyun Wi
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sung Eun Hyun
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kwan-Sik Sung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
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Alamaw AW, Abebe GK, Abate BB, Tilahun BD, Yilak G, Birara WA, Azmeraw M, Habtie TE, Zemariam AB. MORTALITY AND ASSOCIATED FACTORS AMONG INTENSIVE CARE UNIT ADMITTED ADULT PATIENTS WITH MECHANICAL VENTILATION IN ETHIOPIA: A SYSTEMATIC REVIEW AND META-ANALYSIS. Shock 2024; 61:660-665. [PMID: 38662674 DOI: 10.1097/shk.0000000000002340] [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: 05/01/2024]
Abstract
ABSTRACT Introduction: The global demand for intensive care has risen, given its effectiveness in lowering mortality rates. Mechanical ventilation (MV) is integral to intensive care but introduces risks such as ventilator-associated complications. Ethiopia experiences a high intensive care unit (ICU) mortality rate. Objective: This systematic review and meta-analysis aim to comprehensively synthesize evidence on the mortality of adults undergoing MV in Ethiopia and identify associated factors. Methods: The study extensively searched databases and gray literature for research on MV outcomes, trends, and associated factors in adult ICUs. Adhering to the 2020 PRISMA checklist, a systematic review and meta-analysis sought to establish the mortality rate and key determinants among adult ICU patients on MV. The search incorporated keywords and MeSH terms, excluding studies with unsound methodologies or missing data. Data extraction, quality assessment, and analysis followed established protocols, including the JBI tool for methodological quality evaluation. STATA version 17.0 facilitated analysis, assessing heterogeneity, publication bias, and performing sensitivity and meta-regression analyses. Results: The pooled mortality rate among adult ICU patients undergoing MV was 48.61% (95% CI: 40.82, 56.40%). Significant mortality-contributing factors included medical diagnosis, Glasgow Coma Scale score, sepsis/septic shock, sedation use, multiple-organ dysfunction syndrome, and cardiovascular disease. Although some pooled odds ratios seemed insignificant, closer examination revealed significant associations in individual studies. Conclusion : The study underscores the urgent need for further research, improved ICU infrastructure, and healthcare personnel training in Ethiopia to enhance outcomes for mechanically ventilated patients. Identified factors offer valuable insights for targeted interventions, guiding tailored treatment strategies to reduce mortality. This study contributes to understanding mortality and associated factors in MV patients, informing initiatives to improve critical care outcomes in Ethiopia.
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Affiliation(s)
| | - Gebremeskel Kibret Abebe
- Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Biruk Beletew Abate
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Befkad Derese Tilahun
- Department of Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Gizachew Yilak
- Department of Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Wagaw Abebe Birara
- Department Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Molla Azmeraw
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Tesfaye Engdaw Habtie
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Alemu Birara Zemariam
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
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Lehman R, Moriarty H. Limited English Proficiency and Outcomes in the Intensive Care Unit: An Integrated Review. J Transcult Nurs 2024; 35:226-236. [PMID: 38351583 DOI: 10.1177/10436596241229485] [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: 05/05/2024] Open
Abstract
INTRODUCTION Language barriers place patients at risk of substandard care. Hospitalized patients with limited English proficiency (LEP) face unique challenges, especially in the intensive care unit (ICU). The purpose of this review is to critique and synthesize quantitative evidence on LEP and ICU outcomes. METHODOLOGY Quantitative studies published in English between 1999 and 2022 were queried using intentional terminology. RESULTS Searches yielded 138 results, with 12 meeting inclusion criteria. The analysis resulted in the extrapolation of five themes pertinent to outcomes of ICU patients or families with LEP: (a) knowledge deficit relating to conditions and care; (b) lack of language-appropriate care; (c) alienation from care process; (d) decreased confidence and ownership of care; and (e) relationship to clinical quality indicators. DISCUSSION Outcomes associated with LEP were largely negative and revealed unmet needs for ICU patients with LEP. More research is needed to improve linguistically and culturally congruent care in the ICU.
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Atumanya P, Agaba PK, Mukisa J, Nakibuuka J, Kwizera A, Sendagire C. Characteristics and outcomes of patients admitted to intensive care units in Uganda: a descriptive nationwide multicentre prospective study. Sci Rep 2024; 14:9963. [PMID: 38693185 PMCID: PMC11063042 DOI: 10.1038/s41598-024-59031-5] [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: 01/05/2023] [Accepted: 04/05/2024] [Indexed: 05/03/2024] Open
Abstract
Intensive care unit (ICU) mortality rates have decreased over time. However, in low-and lower-middle income countries (LMICs), there remains an excess ICU mortality with limited understanding of patient characteristics, treatments, and outcomes from small single centre studies. We aimed therefore, to describe the characteristics, therapies and outcomes of patients admitted to all intensive care units in Uganda. A nationwide prospective observational study including all patients admitted Uganda's ICUs with available daily charts was conducted from 8th January 2018 to 1st April 2018. Socio-demographics and clinical characteristics including worst vital signs in the first 24 h of admission were recorded with calculation of the National Early Warning Score (NEWS-2) and quick Sequential Organ Function Assessment (qSOFA) score. ICU interventions were recorded during the ICU stay and patients were followed up to 28 days in ICU. The primary outcome was 28 day ICU mortality. Three-hundred fifty-one patients were analysed with mean age 39 (24.1) years, 205 (58.4%) males with 197 (56%) surgical admissions. The commonest indication for ICU admission was postoperative care (42.9%), 214 (61%) had at least one comorbidity, with hypertension 104 (48.6%) most prevalent and 35 (10%) HIV positive. The 28 day ICU mortality was 90/351 (25.6%) with a median ICU stay of 3 (1-7) days. The highest probability of death occurred during the first 10 days with more non-survivors receiving mechanical ventilation (80% vs 34%; p < 0.001), sedation/paralysis (70% vs 50%; p < 0.001), inotropic/vasopressor support (56.7% vs 22.2%; p < 0.001) and renal replacement therapy (14.4% vs 4.2%; p < 0.001). Independent predictors of ICU mortality included mechanical ventilation (HR 3.34, 95% CI 1.48-7.52), sedation/paralysis (HR 2.68, 95% CI 1.39-5.16), inotropes/vasopressor (HR 3.17,95% CI 1.89-5.29) and an HIV positive status (HR 2.28, 95% CI 1.14-4.56). This study provides a comprehensive description of ICU patient characteristics, treatment patterns, and outcomes in Uganda. It not only adds to the global body of knowledge on ICU care in resource-limited settings but also serves as a foundation for future research and policy initiatives aimed at optimizing ICU care in Sub-Saharan Africa.
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Affiliation(s)
| | | | | | | | | | - Cornelius Sendagire
- Makerere University, Kampala, Uganda.
- Uganda Heart Institute, Kampala, Uganda.
- Intensive Care Medicine, D'or Institute for Research and Education, Rio de Janeiro, Brazil.
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15
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Bose S, Groat D, Stollings JL, Barney P, Dinglas VD, Goodspeed VM, Carmichael H, Mir-Kasimov M, Jackson JC, Needham DM, Brown SM, Sevin CM. Prescription of potentially inappropriate medications after an intensive care unit stay for acute respiratory failure. Aust Crit Care 2024:S1036-7314(24)00030-4. [PMID: 38688808 DOI: 10.1016/j.aucc.2024.02.001] [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: 10/27/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Among survivors of critical illness, prescription of potentially inappropriate medications (PIM) at hospital discharge is thought to be an important, modifiable patient safety concern. To date, there are little empirical data evaluating this issue. RESEARCH QUESTION The objective of this study was to determine the frequency of PIM prescribed to survivors of acute respiratory failure (ARF) at hospital discharge and explore their association with readmissions or death within 90 days of hospital discharge. STUDY DESIGN AND METHODS Prospective multicenter cohort study of ARF survivors admitted to ICUs and discharged home. Prospective of new PIMs with a high-adverse-effect profile ("high impact") at discharge was the primary exposure. Potential inappropriateness was determined by a structured consensus process using Screening Tool of Older Persons' Prescriptions-Screening Tool to Alert to Right Treatment, Beers' criteria, and clinical context of prescriptions by a multidisciplinary team. Covariate balancing propensity score was used for the primary analysis. RESULTS Of the 195 Addressing Post Intensive Care Syndrome-01 (APICS-01) patients, 169 (87%) had ≥1 new medications prescribed at discharge, with 154 (91.1%) prescribed with one or more high-impact (HI) medications. Patients were prescribed a median of 5 [3-7] medications, of which 3 [1-4] were HI. Twenty percent of HI medications were potentially inappropriate. Medications with significant central nervous system side-effects were most prescribed potentially inappropriately. Forty-six (30%) patients experienced readmission or death within 90 days of hospital discharge. After adjusting for prespecified covariates, the association between prescription of potentially inappropriate HI medications and the composite primary outcome did not meet the prespecified threshold for statistical significance (risk ratio: 0.54; 0.26-1.13; p = 0.095) or with the constituent endpoints: readmission (risk ratio: 0.57, 0.27-1.11) or death (0.7, 0.05-9.32). CONCLUSION At hospital discharge, most ARF survivors are prescribed medications with a high-adverse-effect profile and approximately one-fifth are potentially inappropriate. Although prescription of such medications was not associated with 90-day readmissions and mortality, these results highlight an area for additional investigation.
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Affiliation(s)
- Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Danielle Groat
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Patrick Barney
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Valerie M Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Harris Carmichael
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Mustafa Mir-Kasimov
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA; Section of Pulmonary and Critical Care Medicine, George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - James C Jackson
- Division of Allergy, Pulmonary, & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Samuel M Brown
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carla M Sevin
- Division of Allergy, Pulmonary, & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Young DL, Al-Ani A, Lakhmalla M, Raman V, Fatima A, Friedman LA, Challa SR, Vasishta S, Koneru M, Colantuoni E, Needham DM, Dinglas VD. Participant retention in follow-up studies of intensive care unit survivors - A scoping review. Aust Crit Care 2024:S1036-7314(24)00031-6. [PMID: 38582625 DOI: 10.1016/j.aucc.2024.02.002] [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: 10/22/2023] [Revised: 12/27/2023] [Accepted: 02/04/2024] [Indexed: 04/08/2024] Open
Abstract
OBJECTIVE To synthesize participant retention data and related reporting in studies evaluating post-hospital outcomes of survivors of critical illness after an intensive care unit (ICU) stay. REVIEW METHOD USED A synthesis of literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. DATA SOURCES PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Controlled Trials Registry. Hand searched reference lists and personal files of relevant narrative and systematic review articles. REVIEW METHODS Articles were screened by pairs of independent reviewers. Similarly, data were abstracted by pairs of data collectors, with conflicts resolved by consensus or by a third reviewer. RESULTS We included 243 publications, from 225 unique studies of 87,602 participants. Participant retention could not be calculated for any time-points in 13% of studies nor in 22% of all follow-up time-points. Retention ranged from 18-100%. When compared to follow-up before 1-month, retention at each later timepoint was not significantly different. Age and sex were not associated with retention and more recent studies had decreased retention (odds ratio: 0.94 [95% confidence interval: 0.92-0.96; p < 0.001]). Reporting of retention-related study methodology was inconsistent. CONCLUSION Retention rate could not be calculated for 22% of study follow-up time-points, with retention at the remaining time-points generally being high (≥85%), but with high variability (18% - 100%). ICU survivorship research could be improved via: (i) more detailed guidance on reporting participant retention, and (ii) use of existing resources and best practices to facilitate better study design and to improve participant retention to preserve statistical power and reduce selection bias.
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Affiliation(s)
- Daniel L Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA; Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, USA
| | - Awsse Al-Ani
- Preventive Cardiology Department, Brigham and Women's Hospital, Boston, MA, USA
| | - Mounika Lakhmalla
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, USA
| | - Vaishnavi Raman
- Division of Geriatric Medicine, Department of Medicine, Grand River Hospital and St. Mary's General Hospital, Kitchener, Ontario, Canada
| | - Arooj Fatima
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, USA
| | - Lisa Aronson Friedman
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, USA
| | | | - Sumana Vasishta
- NHS Wales Shared Service Partnership (NWSSP), Wales, United Kingdom
| | - Mounica Koneru
- Department of Pediatrics, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, USA; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, USA.
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Darkwah S, Kotey FCN, Ahenkorah J, Adutwum-Ofosu KK, Donkor ES. Sepsis-Related Lung Injury and the Complication of Extrapulmonary Pneumococcal Pneumonia. Diseases 2024; 12:72. [PMID: 38667530 PMCID: PMC11049144 DOI: 10.3390/diseases12040072] [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: 10/03/2023] [Revised: 11/18/2023] [Accepted: 11/26/2023] [Indexed: 04/28/2024] Open
Abstract
Globally, sepsis and pneumonia account for significant mortality and morbidity. A complex interplay of immune-molecular pathways underlies both sepsis and pneumonia, resulting in similar and overlapping disease characteristics. Sepsis could result from unmanaged pneumonia. Similarly, sepsis patients have pneumonia as a common complication in the intensive care unit. A significant percentage of pneumonia is misdiagnosed as septic shock. Therefore, our knowledge of the clinical relationship between pneumonia and sepsis is imperative to the proper management of these syndromes. Regarding pathogenesis and etiology, pneumococcus is one of the leading pathogens implicated in both pneumonia and sepsis syndromes. Growing evidence suggests that pneumococcal pneumonia can potentially disseminate and consequently induce systemic inflammation and severe sepsis. Streptococcus pneumoniae could potentially exploit the function of dendritic cells (DCs) to facilitate bacterial dissemination. This highlights the importance of pathogen-immune cell crosstalk in the pathophysiology of sepsis and pneumonia. The role of DCs in pneumococcal infections and sepsis is not well understood. Therefore, studying the immunologic crosstalk between pneumococcus and host immune mediators is crucial to elucidating the pathophysiology of pneumonia-induced lung injury and sepsis. This knowledge would help mitigate clinical diagnosis and management challenges.
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Affiliation(s)
- Samuel Darkwah
- Department of Medical Microbiology, University of Ghana Medical School, Accra P.O. Box KB 4236, Ghana; (F.C.N.K.); (E.S.D.)
| | - Fleischer C. N. Kotey
- Department of Medical Microbiology, University of Ghana Medical School, Accra P.O. Box KB 4236, Ghana; (F.C.N.K.); (E.S.D.)
| | - John Ahenkorah
- Department of Anatomy, University of Ghana Medical School, Accra P.O. Box KB 4236, Ghana; (J.A.); (K.K.A.-O.)
| | - Kevin Kofi Adutwum-Ofosu
- Department of Anatomy, University of Ghana Medical School, Accra P.O. Box KB 4236, Ghana; (J.A.); (K.K.A.-O.)
| | - Eric S. Donkor
- Department of Medical Microbiology, University of Ghana Medical School, Accra P.O. Box KB 4236, Ghana; (F.C.N.K.); (E.S.D.)
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An SJ, Smith C, Davis D, Gallaher J, Tignanelli CJ, Charles A. Predictors of Functional Decline Among Critically Ill Surgical Patients: A National Analysis. J Surg Res 2024; 296:209-216. [PMID: 38281356 DOI: 10.1016/j.jss.2023.12.038] [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: 08/15/2023] [Revised: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Functional decline is associated with critical illness, though this relationship in surgical patients is unclear. This study aims to characterize functional decline after intensive care unit (ICU) admission among surgical patients. METHODS We performed a retrospective analysis of surgical patients admitted to the ICU in the Cerner Acute Physiology and Chronic Health Evaluation database, which includes 236 hospitals, from 2007 to 2017. Patients with and without functional decline were compared. Predictors of decline were modeled. RESULTS A total of 52,838 patients were included; 19,310 (36.5%) experienced a functional decline. Median ages of the decline and nondecline groups were 69 (interquartile range 59-78) and 63 (interquartile range 52-72) years, respectively (P < 0.01). The nondecline group had a larger proportion of males (59.1% versus 55.3% in the decline group, P < 0.01). After controlling for sociodemographic covariates, comorbidities, and disease severity upon ICU admission, patients undergoing pulmonary (odds ratio [OR] 6.54, 95% confidence interval [CI] 2.67-16.02), musculoskeletal (OR 4.13, CI 3.51-4.87), neurological (OR 2.67, CI 2.39-2.98), gastrointestinal (OR 1.61, CI 1.38-1.88), and skin and soft tissue (OR 1.35, CI 1.08-1.68) compared to cardiovascular surgeries had increased odds of decline. CONCLUSIONS More than one in three critically ill surgical patients experienced a functional decline. Pulmonary, musculoskeletal, and neurological procedures conferred the greatest risk. Additional resources should be targeted toward the rehabilitation of these patients.
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Affiliation(s)
- Selena J An
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charlotte Smith
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dylane Davis
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Heybati K, Ochal D, Hogan W, Al-Khateeb H, Sklar D, Herasevich S, Litzow M, Shah M, Torghabeh MH, Durani U, Bauer P, Gajic O, Yadav H. Temporal trends in critical care utilization and outcomes in allogeneic hematopoietic stem cell transplant recipients. Ann Hematol 2024; 103:957-967. [PMID: 38170240 DOI: 10.1007/s00277-023-05612-9] [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: 09/28/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024]
Abstract
Historically, the prognosis of allogeneic hematopoietic stem cell transplant (allo-HCT) recipients who require intensive care unit (ICU) admission has been poor. We aimed to describe the epidemiological trends of ICU utilization and outcomes in allo-HCT patients. We conducted a retrospective cohort study including adults (≥ 18) undergoing allo-HCT between 01/01/2005 and 31/12/2020 at Mayo Clinic, Rochester. Temporal trends in outcomes were assessed by robust linear regression modelling. Risk factors for hospital mortality were chosen a priori and assessed with multivariable logistic regression modelling. Of 1,249 subjects, there were 486 ICU admissions among 287 individuals. Although older patients underwent allo-HCT (1.64 [95% CI: 1.11 to 2.45] years per year; P = 0.025), there was no change in ICU utilization over time (P = 0.91). The ICU and hospital mortality rates were 19.2% (55/287) and 28.2% (81/287), respectively. There was a decline in ICU mortality (-0.38% [95% CI: -0.70 to -0.06%] per year; P = 0.035). The 1-year post-HCT mortality for those requiring ICU admission was 56.1% (161/287), with no significant difference over time, versus 15.8% (141/891, 71 missing) among those who did not. The frequency and duration of invasive mechanical ventilation (IMV) declined. In multivariable analyses, higher serum lactate, higher sequential organ failure assessment (SOFA) scores, acute respiratory distress (ARDS), and need for IMV were associated with greater odds of hospital mortality. Over time, rates of ICU utilization have remained stable, despite increasing patient age. Several trends suggest improvement in outcomes, notably lower ICU mortality and frequency of IMV. However, long-term survival remains unchanged. Further work is needed to improve long-term outcomes in this population.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Domenic Ochal
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - David Sklar
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Svetlana Herasevich
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Mithun Shah
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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McPeake J, Iwashyna TJ, MacTavish P, Devine H, Henderson P, Quasim T, Shaw M. Could an integrated model of health and social care after critical illness reduce socioeconomic disparities in outcomes? A Bayesian analysis. BJA OPEN 2024; 9:100259. [PMID: 38322488 PMCID: PMC10844938 DOI: 10.1016/j.bjao.2024.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024]
Abstract
Background There is limited evidence to understand what impact, if any, recovery services might have for patients across the socioeconomic spectrum after critical illness. We analysed data from a multicentre critical care recovery programme to understand the impact of this programme across the socioeconomic spectrum. Methods The setting for this pre-planned secondary analysis was a critical care rehabilitation programme-Intensive Care Syndrome: Promoting Independence and Return to Employment. Data were collected from five hospital sites running this programme. We utilised a Bayesian approach to analysis and explore any possible effect of the InS:PIRE intervention on Health-Related Quality of Life (HRQoL) across the socioeconomic gradient. A Bayesian quantile, non-linear mixed effects regression model, using a compound symmetry covariance structure, accounting for multiple timepoints was utilised. The Scottish Index of Multiple Deprivation (SIMD) was used to measure socioeconomic status and HRQoL was measured using the EQ-5D-5L. Results In the initial baseline cohort of 182 patients, 55% of patients were male, the median age was 58 yr (inter-quartile range: 50-66 yr) and 129 (79%) patients had two or more comorbidities at ICU admission. Using the neutral prior, there was an overall probability of intervention benefit of 100% (β=0.71, 95% credible interval: 0.34-1.09) over 12 months to those in the SIMD≤3 cohort, and an 98.6% (β=-1.38, 95% credible interval: -2.62 to -0.16) probability of greater benefit (i.e. a steeper increase in improvement) at 12 months in the SIMD≤3 vs SIMD≥4 cohort in the EQ-visual analogue scale. Conclusions Using multicentre data, this re-analysis suggests, but does not prove, that an integrated health and social care intervention is likely to improve outcomes across the socioeconomic gradient after critical illness, with a potentially greater benefit for those from deprived communities. Future research designed to prospectively analyse how critical care recovery programmes could potentially improve outcomes across the socioeconomic gradient is warranted.
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Affiliation(s)
- Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | | | - Pamela MacTavish
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Helen Devine
- Crosshouse University Teaching Hospital, NHS Ayrshire and Arran, Kilmarnock, UK
| | - Phil Henderson
- Royal Alexandria Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Tara Quasim
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
- University of Glasgow, School of Medicine, Dentistry and Nursing, Glasgow, UK
| | - Martin Shaw
- University of Glasgow, School of Medicine, Dentistry and Nursing, Glasgow, UK
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK
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Mason CK, Adie SK, Shea MJ, Konerman MC, Thomas MP, McSparron JI, Iwashyna TJ, Prescott HC, Thompson AD. Post-intensive cardiac care outpatient long-term outreach clinic (PICCOLO clinic): Defining health care needs and outcomes among coronary care unit survivors. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 38:100363. [PMID: 38434252 PMCID: PMC10906849 DOI: 10.1016/j.ahjo.2024.100363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 03/05/2024]
Abstract
Objective Patients who survive critical illness endure complex physical and mental health conditions, referred to as post-intensive care syndrome (PICS). The University of Michigan's post-intensive cardiac care outpatient long-term outreach (PICCOLO) clinic is designed for patients recently admitted to the coronary care unit (CCU). The long-term goal of this clinic is to understand post-CCU patients' needs and design targeted interventions to reduce their morbidity and mortality post-discharge. As a first step toward this goal, we aimed to define the post-discharge needs of CCU survivors. Design setting particpants We retrospectively reviewed case-mix data (including rates of depression, PTSD, disability, and cognitive abnormalities) and health outcomes for patients referred to the PICCOLO clinic from July 1, 2018, through June 30, 2021 at Michigan Medicine. Results Of the 134 referred patients meeting inclusion criteria, 74 (55 %) patients were seen in the PICCOLO clinic within 30 days of discharge. Patients seen in the clinic frequently screened positive for depression (PHQ-2 score ≥3, 21.4 %) and cognitive impairment (MOCA <26, 38.8 %). Further, patients also reported high rates of physical difficulty (mean WHODAS 2.0 score 28.4 %, consistent with moderate physical difficulty). Consistent with medical intensive care unit (ICU) patients, CCU survivors experience PICS. Conclusion This work highlights the feasibility of an outpatient care model and the need to leverage information gathered from this care model to develop treatment strategies and pathways to address symptoms of PICS in CCU survivors, including depression, cognitive impairment, and physical disability.
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Affiliation(s)
- Christopher K. Mason
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Sara K. Adie
- Department of Pharmacy Service, University of Michigan, Ann Arbor, MI, United States of America
| | - Michael J. Shea
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI, United States of America
| | - Matthew C. Konerman
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI, United States of America
| | - Michael P. Thomas
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI, United States of America
| | - Jakob I. McSparron
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Ann Arbor, MI, United States of America
| | - Theodore J. Iwashyna
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Johns Hopkins Medicine, Baltimore, MD, United States of America
| | - Hallie C. Prescott
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Ann Arbor, MI, United States of America
- VA Center for Clinical Management Research, Ann Arbor, MI, United States of America
| | - Andrea D. Thompson
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI, United States of America
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Naik H, Murray TM, Khan M, Daly-Grafstein D, Liu G, Kassen BO, Onrot J, Sutherland JM, Staples JA. Population-Based Trends in Complexity of Hospital Inpatients. JAMA Intern Med 2024; 184:183-192. [PMID: 38190179 PMCID: PMC10775081 DOI: 10.1001/jamainternmed.2023.7410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/11/2023] [Indexed: 01/09/2024]
Abstract
Importance Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression. Objective To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period. Design, Setting and Participants This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023. Exposure The passage of time (15-year study interval). Main Outcomes and Measures Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval. Results The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively). Conclusions and Relevance By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.
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Affiliation(s)
- Hiten Naik
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tyler M. Murray
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayesha Khan
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Guiping Liu
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Barry O. Kassen
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jake Onrot
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M. Sutherland
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - John A. Staples
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada
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Stedman W, Donaldson L, Garside T, Green S, Donoghoe SF, Whitfield VE, Bass F, Delaney A, Hammond N. The feasibility and acceptability of a physician-led ICU follow-up service: A prospective cohort study. Aust Crit Care 2024; 37:3-11. [PMID: 38065794 DOI: 10.1016/j.aucc.2023.10.003] [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: 05/16/2023] [Revised: 08/24/2023] [Accepted: 10/11/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Increased recognition of post-intensive care syndrome has led to widespread development of intensive care follow-up services internationally. OBJECTIVE The objective of this study was to determine the feasibility and acceptability of an intensive care unit (ICU) follow-up clinic in Australia for patients and their caregivers and to describe satisfaction with this service. METHODS This was a prospective cohort study in a mixed tertiary ICU in Australia. Eligible patients were adults admitted to the ICU for 7 days or more and/or ventilated for 48 h or more, as well as their primary caregiver. Patients and their primary caregivers were invited to attend a follow-up clinic 4-8 weeks after hospital discharge. The clinic appointment was attended by an ICU physician and nurse, with multidisciplinary support. Feasibility and acceptability were defined as the proportion of clinic attendance and frequency of interventions initiated at the clinic. Satisfaction was measured by a 5-point satisfaction survey (very dissatisfied to very satisfied). The burden of ongoing disease was reported via multiple validated instruments. RESULTS From April 2020-July 2021, 386 patients met the inclusion criteria. Only 146 patients were approached for consent due to site staffing limitations. Eighty-three patients and 32 caregivers consented to attend the clinic. Seventy percent (54/77) of patients attended scheduled appointments and 50% (16/32) of caregivers. For patients, 23 medical referrals were made, 8 patients had medication changes, and 10 patients were offered social work support. Satisfaction surveys were completed by 65% (35/54) of attending patients; 97% (34) patients reported either being 'very satisfied' or 'satisfied' with the service. All responding caregivers (10) were either 'very satisfied' or 'satisfied' with the clinic. CONCLUSION There were a large number of patients meeting the inclusion criteria to the ICU follow-up clinic, and clinic attendance was moderate for patients but lower for caregivers. Reported satisfaction with the service was high for both patients and their caregiver.
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Affiliation(s)
- Wade Stedman
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia.
| | - Lachlan Donaldson
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Australia
| | - Tessa Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Australia
| | - Sarah Green
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Pharmacy Department, Royal North Shore Hospital, Sydney, Australia
| | - Stephanie F Donoghoe
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Victoria E Whitfield
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Frances Bass
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Australia
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Australia
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Flam B, Andersson Franko M, Skrifvars MB, Djärv T, Cronhjort M, Jonsson Fagerlund M, Mårtensson J. Trends in Incidence and Outcomes of Cardiac Arrest Occurring in Swedish ICUs. Crit Care Med 2024; 52:e11-e20. [PMID: 37747306 DOI: 10.1097/ccm.0000000000006067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To determine temporal trends in the incidence of cardiac arrest occurring in the ICU (ICU-CA) and its associated long-term mortality. DESIGN Retrospective observational study. SETTING Swedish ICUs, between 2011 and 2017. PATIENTS Adult patients (≥18 yr old) recorded in the Swedish Intensive Care Registry (SIR). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ICU-CA was defined as a first episode of cardiopulmonary resuscitation and/or defibrillation following an ICU admission, as recorded in SIR or the Swedish Cardiopulmonary Resuscitation Registry. Annual adjusted ICU-CA incidence trend (all admissions) was estimated using propensity score-weighted analysis. Six-month mortality trends (first admissions) were assessed using multivariable mixed-effects logistic regression. Analyses were adjusted for pre-admission characteristics (sex, age, socioeconomic status, comorbidities, medications, and healthcare utilization), illness severity on ICU admission, and admitting unit. We included 231,427 adult ICU admissions. Crude ICU-CA incidence was 16.1 per 1,000 admissions, with no significant annual trend in the propensity score-weighted analysis. Among 186,530 first admissions, crude 6-month mortality in ICU-CA patients was 74.7% (95% CI, 70.1-78.9) in 2011 and 68.8% (95% CI, 64.4-73.0) in 2017. When controlling for multiple potential confounders, the adjusted 6-month mortality odds of ICU-CA patients decreased by 6% per year (95% CI, 2-10). Patients admitted after out-of-hospital or in-hospital cardiac arrest had the highest ICU-CA incidence (136.1/1,000) and subsequent 6-month mortality (76.0% [95% CI, 73.6-78.4]). CONCLUSIONS In our nationwide Swedish cohort, the adjusted incidence of ICU-CA remained unchanged between 2011 and 2017. More than two-thirds of patients with ICU-CA did not survive to 6 months following admission, but a slight improvement appears to have occurred over time.
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Affiliation(s)
- Benjamin Flam
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Andersson Franko
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Therese Djärv
- Medical Unit Acute/Emergency Department, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology and Intensive Care, South General Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Mårtensson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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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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Henson CP, Weaver SM. Systems of Care Delivery and Optimization in the Intensive Care Unit. Anesthesiol Clin 2023; 41:863-873. [PMID: 37838389 DOI: 10.1016/j.anclin.2023.06.006] [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: 10/16/2023]
Abstract
As the volume and complexity of patients requiring intensive care grows, so do the barriers and challenges to the delivery of that care. This article summarizes these challenges, outlines strategies used to overcome them, and presents new developments and concepts within the care of the ICU patient.
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Affiliation(s)
- Christopher Patrick Henson
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South - MCE 3161, Nashville, TN 37232, USA.
| | - Sheena M Weaver
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South - MCE 3161, Nashville, TN 37232, USA
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Zhang C, Hou TH, Wang F, Hao CJ, Ning M, Shen HC, Chen Y, Liu YW. Effect of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers on In-Hospital Outcomes Based on Renal Function Among Critically Ill Patients: Findings From the Medical Information Mart for Intensive Care IV Database. J Clin Pharmacol 2023; 63:1344-1351. [PMID: 37408508 DOI: 10.1002/jcph.2302] [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: 04/17/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023]
Abstract
Renal dysfunction is associated with increased mortality and length of hospital stay in critically ill patients. However, it remains unclear whether the early administration of an angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) for intensive care unit patients with renal dysfunction is associated with reduced in-hospital mortality. We conducted a retrospective analysis of critically ill patients who received early administration of an ACEI/ARB within 72 hours after being hospitalized. Patients were selected from the Medical Information Mart for Intensive Care IV database. We included 18,986 critically ill patients in our analysis. After propensity score matching, our final study cohort of 4974 patients consisted of patients who received early administration of an ACEI/ARB (n = 2487) and nonusers (n = 2487). Results of logistic regression showed that early administration of an ACEI/ARB was associated with reduced risk of in-hospital mortality (odds ratio, 0.64; 95% confidence interval, 0.53-0.77; P < .001) and intensive care unit death (odds ratio, 0.56; 95% confidence interval, 0.45-0.70; P < .001) when compared to nonusers. There was no meaningful interaction for early administration of an ACEI/ARB versus nonusers across estimated glomerular filtration rate in outcomes. Sensitivity analysis showed there was no difference in the outcomes between early administration of ACEI and that of ARB. In this study, we found that early administration of an ACEI/ARB was associated with a reduced risk of in-hospital adverse outcomes based on renal function among critically ill patients. There was no interaction between early administration of an ACEI/ARB and in-hospital adverse outcomes across estimated glomerular filtration rate.
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Affiliation(s)
- Chong Zhang
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Tian-Hua Hou
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Fei Wang
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Cui-Jun Hao
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Meng Ning
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - He-Chen Shen
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Yi Chen
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Ying-Wu Liu
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
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28
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You SB, Ulrich CM. Ethical considerations in evaluating discharge readiness from the intensive care unit. Nurs Ethics 2023:9697330231212338. [PMID: 37950598 DOI: 10.1177/09697330231212338] [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: 11/12/2023]
Abstract
Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients' readiness can conflict with perceptions of what readiness means for patients, families, and healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families.
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Affiliation(s)
- Sang Bin You
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Connie M Ulrich
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Langouche L, Téblick A, Gunst J, Van den Berghe G. The Hypothalamus-pituitary-adrenocortical Response to Critical Illness: A Concept in Need of Revision. Endocr Rev 2023; 44:1096-1106. [PMID: 37409973 PMCID: PMC10638597 DOI: 10.1210/endrev/bnad021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
Based on insights obtained during the past decade, the classical concept of an activated hypothalamus-pituitary-adrenocortical axis in response to critical illness is in need of revision. After a brief central hypothalamus-pituitary-adrenocortical axis activation, the vital maintenance of increased systemic cortisol availability and action in response to critical illness is predominantly driven by peripheral adaptations rather than by an ongoing centrally activated several-fold increased production and secretion of cortisol. Besides the known reduction of cortisol-binding proteins that increases free cortisol, these peripheral responses comprise suppressed cortisol metabolism in liver and kidney, prolonging cortisol half-life, and local alterations in expression of 11βHSD1, glucocorticoid receptor-α (GRα), and FK506 binding protein 5 (FKBP51) that appear to titrate increased GRα action in vital organs and tissues while reducing GRα action in neutrophils, possibly preventing immune-suppressive off-target effects of increased systemic cortisol availability. Peripherally increased cortisol exerts negative feed-back inhibition at the pituitary level impairing processing of pro-opiomelanocortin into ACTH, thereby reducing ACTH-driven cortisol secretion, whereas ongoing central activation results in increased circulating pro-opiomelanocortin. These alterations seem adaptive and beneficial for the host in the short term. However, as a consequence, patients with prolonged critical illness who require intensive care for weeks or longer may develop a form of central adrenal insufficiency. The new findings supersede earlier concepts such as "relative," as opposed to "absolute," adrenal insufficiency and generalized systemic glucocorticoid resistance in the critically ill. The findings also question the scientific basis for broad implementation of stress dose hydrocortisone treatment of patients suffering from acute septic shock solely based on assumption of cortisol insufficiency.
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Affiliation(s)
- Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
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Piret SE, Khan S, Fairuz F, Gholami S, Davis M, Kim CK, Espinoza M, Foster D, Kellum JA, Ahmad S, Kalogeropoulos AP, Mallipattu SK. Endotoxemia Correlates with Kidney Function and Length of Stay in Critically Ill Patients. Blood Purif 2023; 53:30-39. [PMID: 37918364 DOI: 10.1159/000534107] [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: 05/08/2023] [Accepted: 09/10/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Endotoxin is a key driver of sepsis, which frequently causes acute kidney injury (AKI). However, endotoxins may also be found in non-bacteremic critically ill patients, likely from intestinal translocation. Preclinical models show that endotoxins can directly injure the kidneys, and in COVID-19 patients, endotoxemia correlated with AKI. We sought to determine correlations between endotoxemia and kidney and hospital outcomes in a broad group of critically ill patients. METHODS In this single-center, serial prospective study, 124 predominantly Caucasian adult patients were recruited within 48 h of admission to Stony Brook University Hospital Intensive Care Unit (ICU). Demographics, vital signs, laboratory data, and outcomes were collected. Circulating endotoxin was measured on days 1, 4, and 8 using the endotoxin activity assay (EAA). The association of EAA with outcomes was examined with EAA: (1) categorized as <0.6, ≥0.6, and nonresponders (NRs); and (2) used as a continuous variable. RESULTS Patients with EAA ≥0.6 had a higher prevalence of proteinuria, and lower arterial oxygen saturation (SaO2) to fraction of inspired oxygen (FiO2) (SaO2/FiO2) ratio versus patients with EAA <0.6. EAA levels positively correlated with serum creatinine (sCr) levels on day 1. Patients whose EAA level stayed ≥0.6 had a slower decline in sCr compared to those whose EAA started at ≥0.6 and subsequently declined. Patients with AKI stage 1 and EAA ≥0.6 on day 1 showed slower decline in sCr compared to patients with stage 1 AKI and EAA <0.6. EAA ≥0.6 and NR patients had longer hospital stay and delayed ICU discharge versus EAA <0.6. CONCLUSIONS High EAA levels correlated with worse kidney function and outcomes. Patients whose EAA levels fell, and those with AKI stage I and day 1 EAA <0.6 recovered more quickly compared to those with EAA ≥0.6, suggesting that removal of circulating endotoxins may be beneficial in critically ill patients.
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Affiliation(s)
- Sian E Piret
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Sobia Khan
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Fabliha Fairuz
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Samaneh Gholami
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Merin Davis
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Chang Kyung Kim
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Melissa Espinoza
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | | | | | - Sahar Ahmad
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Andreas P Kalogeropoulos
- Division of Cardiology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Sandeep K Mallipattu
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
- Renal Section, Northport VA Medical Center, Northport, New York, USA
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Proffitt T, Menzies V, Grap MJ, Orr T, Thacker L, Ameringer S. Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors. Am J Crit Care 2023; 32:410-420. [PMID: 37907379 DOI: 10.4037/ajcc2023946] [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: 11/02/2023]
Abstract
BACKGROUND Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium. OBJECTIVES To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later. METHODS A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests. RESULTS Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04). CONCLUSIONS The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.
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Affiliation(s)
- Tracye Proffitt
- Tracye Proffitt is an assistant professor at Virginia Commonwealth University School of Nursing, Richmond, Virginia
| | - Victoria Menzies
- Victoria Menzies is an associate professor at University of Florida College of Nursing, Gainesville, Florida
| | - Mary Jo Grap
- Mary Jo Grap is a professor emeritus at Virginia Commonwealth University School of Nursing
| | - Tamara Orr
- Tamara Orr is a clinical health psychologist at Virginia Commonwealth University School of Medicine, Richmond
| | - Leroy Thacker
- Leroy Thacker II is an associate professor, Department of Biostatistics, Virginia Commonwealth University School of Medicine
| | - Suzanne Ameringer
- Suzanne Ameringer is a professor and associate dean for academic affairs at Virginia Commonwealth University School of Nursing
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Tronstad O, Flaws D, Patterson S, Holdsworth R, Fraser JF. Creating the ICU of the future: patient-centred design to optimise recovery. Crit Care 2023; 27:402. [PMID: 37865760 PMCID: PMC10589962 DOI: 10.1186/s13054-023-04685-2] [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: 09/05/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Intensive Care survival continues to improve, and the number of ICU services is increasing globally. However, there is a growing awareness of the detrimental impact of the ICU environment on patients, families, and staff. Excessive noise and suboptimal lighting especially have been shown to adversely impact physical and mental recovery during and after an ICU admission. Current ICU designs have not kept up with advances in medical technology and models of care, and there is no current 'gold-standard' ICU design. Improvements in ICU designs are needed to optimise care delivery and patient outcomes. METHODS This manuscript describes a mixed-methods, multi-staged participatory design project aimed at redesigning and implementing two innovative ICU bedspaces. Guided by the action effect method and the consolidated framework for implementation research, the manuscript describes the processes taken to ensure the patient-centred problems were properly understood, the steps taken to develop and integrate solutions to identified problems, and the process of implementation planning and rebuilding in a live ICU. RESULTS Two innovative ICU bedspaces were rebuilt and implemented. They feature solutions to address all identified problems, including noise reduction, optimisation of lighting, access to nature via digital solutions, and patient connectivity and engagement, with solutions developed from various specialty fields, including IT improvements, technological innovations, and design and architectural solutions. Early evaluation demonstrates an improved lighting and acoustic environment. CONCLUSIONS Optimising the ICU bedspace environment and improving the lighting and acoustic environment is possible. The impact on patient outcomes needs to be evaluated.
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Affiliation(s)
- Oystein Tronstad
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, QLD, Australia.
| | - Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Department of Mental Health, Metro North Mental Health, Caboolture Hospital, Caboolture, QLD, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sue Patterson
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- School of Dentistry, University of Queensland, Brisbane, QLD, Australia
| | - Robert Holdsworth
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Teixeira RMP, Oliveira JC, de Andrade MAB, Pinheiro FGDMS, Vieira RDCA, Santana-Santos E. Are patient volume and care level in teaching hospitals variables affecting clinical outcomes in adult intensive care units? EINSTEIN-SAO PAULO 2023; 21:eAO0406. [PMID: 37820201 PMCID: PMC10519666 DOI: 10.31744/einstein_journal/2023ao0406] [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: 12/06/2022] [Accepted: 02/07/2023] [Indexed: 10/13/2023] Open
Abstract
Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical. OBJECTIVE To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals. METHODS In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital. CONCLUSION Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.
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Affiliation(s)
| | - Jussiely Cunha Oliveira
- Universidade Federal de SergipeSão CristovãoSEBrazil Universidade Federal de Sergipe, São Cristovão, SE, Brazil.
| | | | | | | | - Eduesley Santana-Santos
- Universidade Federal de SergipeSão CristovãoSEBrazil Universidade Federal de Sergipe, São Cristovão, SE, Brazil.
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Nakanishi N, Yoshihiro S, Kawamura Y, Aikawa G, Shida H, Shimizu M, Fujinami Y, Matsuoka A, Watanabe S, Taito S, Inoue S. Effect of Neuromuscular Electrical Stimulation in Patients With Critical Illness: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1386-1396. [PMID: 37232695 DOI: 10.1097/ccm.0000000000005941] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Neuromuscular electrical stimulation (NMES) is used in the rehabilitation of patients with critical illness. However, it is unclear whether NMES prevents ICU-acquired weakness (ICU-AW). For this purpose, we conducted an updated systematic review and meta-analysis. DATA SOURCES We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases from April 2019 to November 2022 to identify new randomized controlled trials to the previous meta-analysis. STUDY SELECTION We systematically searched the literature for all randomized controlled trials on the effect of NMES in patients with critical illness. DATA EXTRACTION Two authors independently selected the studies and extracted data. They calculated the pooled effect estimates associated with the occurrence of ICU-AW and adverse events as primary outcomes and muscle mass change, muscle strength, length of ICU stay, mortality, and quality of life as secondary outcomes. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS Overall, eight studies were added to the previous 10 studies. Evidence suggests that the use of NMES reduces the occurrence of ICU-AW (six trials; risk ratio [RR], 0.48; 95% CI, 0.32-0.72); however, NMES may have little to no effect on pricking sensation in patients (eight trials; RR, 6.87; 95% CI, 0.84-56.50). NMES is likely to reduce the change in muscle mass (four trials; mean difference, -10.01; 95% CI, -15.54 to -4.48) and may increase muscle strength (six trials; standardized mean difference, 0.43; 95% CI, 0.19-0.68). Further, NMES may result in little to no difference in the length of ICU stay, and the evidence is uncertain about the effect on mortality and quality of life. CONCLUSIONS This updated meta-analysis revealed that the use of NMES may result in a lower occurrence of ICU-AW in patients with critical illness, but its use may have little to no effect on pricking sensation in patients.
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Affiliation(s)
- Nobuto Nakanishi
- Department of Disaster and Emergency Medicine, Kobe University, Hyogo, Japan
| | - Shodai Yoshihiro
- Department of Pharmacy, Onomichi General Hospital, Hiroshima, Japan
| | - Yusuke Kawamura
- Department of Rehabilitation, Showa General Hospital, Tokyo, Japan
| | - Gen Aikawa
- Department of Nursing, University of Tsukuba Hospital, Ibaraki, Japan
| | - Haruka Shida
- Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Motohiro Shimizu
- Department of Emergency Medicine, Intensive Care Unit, Ryokusen-kai Yonemori Hospital, Kagoshima, Japan
| | - Yoshihisa Fujinami
- Department of Emergency Medicine, Kakogawa Central City Hospital, Hyogo, Japan
| | - Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Saga University, Saga, Japan
| | - Shinichi Watanabe
- Department of Physical Therapy, Gifu University of Health Science, Gifu, Japan
| | - Shunsuke Taito
- Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University, Hyogo, Japan
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Edelstein J, Messenger L, Kinney AR, Graham JE, Malcolm MP. Predicting Receipt and Types of Occupational Therapy Services for Patients with Arousal Deficits in the Neuro Critical Care Unit. Occup Ther Health Care 2023; 37:445-460. [PMID: 35200095 DOI: 10.1080/07380577.2022.2041781] [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: 10/04/2021] [Accepted: 02/08/2022] [Indexed: 10/19/2022]
Abstract
Occupational therapy has been identified as a required service in the neuro critical care unit (NCCU), however who receives occupational therapy services and what services they receive are not well understood. We sought to determine if arousal deficits impacted patients' likelihood to receive an occupational therapy evaluation or specific types of occupational therapy interventions in the NCCU. When compared to patients without arousal deficits, patients who were experiencing agitation or light sedation, but not deep sedation, were more likely to receive occupational therapy interventions in the therapeutic activities category. Arousal deficits were not associated with receipt of occupational therapy services or occupational therapy interventions in the self-care or therapeutic exercise categories. Determining predictors of occupational therapy services will help ensure the timely delivery of services by improving the allocation of resources and identifying potential gaps in care.
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Affiliation(s)
- Jessica Edelstein
- Department of Occupational Therapy, Colorado State University, CO, USA
| | - Lindsey Messenger
- Department of Occupational Therapy, Colorado State University, CO, USA
| | - Adam R Kinney
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Department of Veterans Affairs, Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - James E Graham
- Department of Occupational Therapy, Colorado State University, CO, USA
| | - Matt P Malcolm
- Department of Occupational Therapy, Colorado State University, CO, USA
- Colorado School of Public Health, Colorado State, CO, USA
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Rai S, Brace C, Ross P, Darvall J, Haines K, Mitchell I, van Haren F, Pilcher D. Characteristics and Outcomes of Very Elderly Patients Admitted to Intensive Care: A Retrospective Multicenter Cohort Analysis. Crit Care Med 2023; 51:1328-1338. [PMID: 37219961 PMCID: PMC10497207 DOI: 10.1097/ccm.0000000000005943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To characterize and compare trends in ICU admission, hospital outcomes, and resource utilization for critically ill very elderly patients (≥ 80 yr old) compared with the younger cohort (16-79 yr old). DESIGN A retrospective multicenter cohort study. SETTING One-hundred ninety-four ICUs contributing data to the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database between January 2006 and December 2018. PATIENTS Adult (≥ 16 yr) patients admitted to Australian and New Zealand ICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Very elderly patients with a mean ± sd age of 84.8 ± 3.7 years accounted for 14.8% (232,582/1,568,959) of all adult ICU admissions. They had higher comorbid disease burden and illness severity scores compared with the younger cohort. Hospital (15.4% vs 7.8%, p < 0.001) and ICU mortality (8.5% vs 5.2%, p < 0.001) were higher in the very elderly. They stayed fewer days in ICU, but longer in hospital and had more ICU readmissions. Among survivors, a lower proportion of very elderly was discharged home (65.2% vs 82.4%, p < 0.001), and a higher proportion was discharged to chronic care/nursing home facilities (20.1% vs 7.8%, p < 0.001). Although there was no change in the proportion of very elderly ICU admissions over the study period, they showed a greater decline in risk-adjusted mortality (6.3% [95% CI, 5.9%-6.7%] vs 4.0% [95% CI, 3.7%-4.2%] relative reduction per year, p < 0.001) compared with the younger cohort. The mortality of very elderly unplanned ICU admissions improved faster than the younger cohort ( p < 0.001), whereas improvements in mortality among elective surgical ICU admissions were similar in both groups ( p = 0.45). CONCLUSIONS The proportion of ICU admissions greater than or equal to 80 years old did not change over the 13-year study period. Although their mortality was higher, they showed improved survivorship over time, especially in the unplanned ICU admission subgroup. A higher proportion of survivors were discharged to chronic care facilities.
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Affiliation(s)
- Sumeet Rai
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, Canberra Health Services, Garran, Canberra, Australia
| | - Charlotte Brace
- Department of Anaesthesia, Auckland City District Health Board, Auckland, New Zealand
| | - Paul Ross
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, St. Kilda Rd, Prahran, Melbourne, Australia
| | - Jai Darvall
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Kimberley Haines
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Physiotherapy, Western Health, Melbourne, Australia
| | - Imogen Mitchell
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, Canberra Health Services, Garran, Canberra, Australia
| | - Frank van Haren
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - David Pilcher
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, St. Kilda Rd, Prahran, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Camberwell, Melbourne, Australia
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Hallek M, Kochanek M. [New developments in internistic intensive care medicine]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:911-912. [PMID: 37747520 DOI: 10.1007/s00108-023-01595-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Michael Hallek
- Medizinische Fakultät und Universitätsklinikum Köln, Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO), Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Matthias Kochanek
- Medizinische Fakultät und Universitätsklinikum Köln, Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO), Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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Caruso PF, Greco M, Ebm C, Angelotti G, Cecconi M. Implementing Artificial Intelligence: Assessing the Cost and Benefits of Algorithmic Decision-Making in Critical Care. Crit Care Clin 2023; 39:783-793. [PMID: 37704340 DOI: 10.1016/j.ccc.2023.03.007] [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: 09/15/2023]
Abstract
This article provides an overview of the most useful artificial intelligence algorithms developed in critical care, followed by a comprehensive outline of the benefits and limitations. We begin by describing how nurses and physicians might be aided by these new technologies. We then move to the possible changes in clinical guidelines with personalized medicine that will allow tailored therapies and probably will increase the quality of the care provided to patients. Finally, we describe how artificial intelligence models can unleash researchers' minds by proposing new strategies, by increasing the quality of clinical practice, and by questioning current knowledge and understanding.
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Affiliation(s)
- Pier Francesco Caruso
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan 20072, Italy; Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan 20072, Italy; Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy.
| | - Claudia Ebm
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan 20072, Italy
| | - Giovanni Angelotti
- Artificial Intelligence Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan 20072, Italy; Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
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Herbst N, Javidfar J. The Burden of Survivorship After Venoarterial Extracorporeal Membrane Oxygenation: A Black Box. Crit Care Med 2023; 51:1278-1280. [PMID: 37589522 DOI: 10.1097/ccm.0000000000005948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Nicole Herbst
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Jeffrey Javidfar
- Division of Cardiothoracic Surgery, Department of Surgery, Emory School of Medicine, Atlanta, GA
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Binette E, Elwell J, Parekh de Campos A, Anderson RV. Show and Tell: Photography and Storytelling to Better Understand the End-of-Life Experience of Families in the Intensive Care Unit. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231190957. [PMID: 37496111 DOI: 10.1177/00302228231190957] [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: 07/28/2023]
Abstract
End-of-life in the Intensive Care Unit (ICU) is common, costly, and can contribute to negative health outcomes for bereaved family members. Insufficient understanding of the family experience results in poor quality, highly variable care riddled with deficiencies including effective identification and application of evidence-based clinical interventions. Successfully managing the multitude of transitions, for example changes in family role or personal identity requires creative practice guided by theory. This project supports the feasibility of using peri-mortem photographs captured by family members with story-telling and a standardized measurement of grief to explore the family experience of end-of-life in the ICU. Project findings reveal shared experiential themes and emphasize the value of photography and storytelling as meaning-making interventions for families. Further study to generalize findings and develop additional preventative and therapeutic interventions at and beyond end-of-life in the ICU is needed to better meet family needs and improve their health outcomes.
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Affiliation(s)
| | - Joy Elwell
- University of Connecticut, Storrs, CT, USA
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Hurley JC. Trends in ICU mortality and underlying risk over three decades among mechanically ventilated patients. A group level analysis of cohorts from infection prevention studies. Ann Intensive Care 2023; 13:62. [PMID: 37432605 DOI: 10.1186/s13613-023-01159-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Has either the underlying risk or the mortality incidence among ICU patients receiving mechanical ventilation (MV) in the literature changed in recent decades? Interpreting ICU mortality trends requires an adjusted analysis accounting for changes in underlying patient risk. METHODS Control and intervention groups from 147 randomized concurrent control trials (RCCT) of various VAP prevention interventions, as listed primarily within 13 Cochrane reviews and 63 observational studies listed primarily within four systematic reviews. Eligible studies were those including ICU patients with > 50% of patients receiving > 24 h of MV with mortality data available. ICU mortality (censored day 21 or before) or late (after day 21) mortality together with group-mean age, and group-mean APACHE II scores were extracted from all groups. These incidences were summarized in five meta-regression models versus publication year being variously adjusted for age, APACHE II scores, type of study intervention and other group level parameters. RESULTS Among 210 studies published between 1985 and 2021, 169 being found in systematic reviews, the increase per decade in mean mortality incidence, group-mean APACHE II scores, and group-mean age, were < 1 percentage point (p = 0.43), 1.83 (95% CI; 0.51-3.15) points, and 3.9 (95% CI; 1.1-6.7) years, respectively. Only in the model with risk adjustment for both group-mean age and group-mean APACHE II score was a significant decline in mortality apparent. In all models, the mortality incidence among concurrent control groups of decontamination studies was paradoxically five percentage points higher than benchmark and showed greater dispersion. CONCLUSION Mortality incidence has changed little over 35 years among ICU infection prevention studies whilst the patient age and underlying disease severity, measured as APACHE II, have both increased. The paradoxically high mortality among concurrent control groups within studies of decontamination methods of infection prevention remains unaccounted for.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Division of Internal Medicine, Grampians Health, Ballarat, VIC, Australia.
- Internal Medicine Service, Ballarat Health Services, PO Box 577, Ballarat, 3353, Australia.
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Sticht F, Malfertheiner M. [Aftercare of ICU patients: A task for pneumology?]. Pneumologie 2023; 77:415-425. [PMID: 37442144 DOI: 10.1055/a-2051-7562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
As the number of patients treated in intensive care medicine increases, so does the number of those who suffer from the long-term consequences of critical illness and the consequences of a stay in an intensive care unit. For this group of patients with a post-intensive care syndrome (PICS), there are currently no specialized outpatient care structures that follow the hospital stay and possible follow-up treatment. A number of studies are researching the effectiveness of intensive care outpatient clinics nationally and internationally.After presenting the PICS and the associated complex need for care, this review article presents various model projects for outpatient follow-up care of critically ill patients. We discuss whether the field of pneumology is particularly suitable for the study of therapy control of complex clinical pictures since it has vast experience in the treatment of intensive care patients and the outpatient care of chronically ill patients.
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Affiliation(s)
- Florian Sticht
- Klinik und Poliklinik für Innere Medizin II, Abteilung für Pneumologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Stevens TJ, Lee DB. Postintensive Care Syndrome: Feasibly Bridging Care at a Tertiary Trauma Center. J Trauma Nurs 2023; 30:242-248. [PMID: 37417676 DOI: 10.1097/jtn.0000000000000735] [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: 07/08/2023]
Abstract
BACKGROUND Advancements in critical care management have improved mortality rates of trauma patients; however, research has identified physical and psychological impairments that remain with patients for an extended time. Cognitive impairments, anxiety, stress, depression, and weakness in the postintensive care phase are an impetus for trauma centers to examine their ability to improve patient outcomes. OBJECTIVE This article describes one center's efforts to intervene to address postintensive care syndrome in trauma patients. METHODS This article describes implementing aspects of the Society of Critical Care Medicine's liberation bundle to address postintensive care syndrome in trauma patients. RESULTS The implementation of the liberation bundle initiatives was successful and well received by trauma staff, patients, and families. It requires strong multidisciplinary commitment and adequate staffing. Continued focus and retraining are requirements in the face of staff turnover and shortages, which are real-world barriers. CONCLUSIONS Implementation of the liberation bundle was feasible. Although the initiatives were positively received by trauma patients and their families, we identified a gap in the availability of long-term outpatient services for trauma patients after discharge from the hospital.
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Rengel KF, Mart MF, Wilson JE, Ely EW. Thinking Clearly: The History of Brain Dysfunction in Critical Illness. Crit Care Clin 2023; 39:465-477. [PMID: 37230551 DOI: 10.1016/j.ccc.2023.01.004] [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: 05/27/2023]
Abstract
Brain dysfunction during critical illness (ie, delirium and coma) is extremely common, and its lasting effect has only become increasingly understood in the last two decades. Brain dysfunction in the intensive care unit (ICU) is an independent predictor of both increased mortality and long-term impairments in cognition among survivors. As critical care medicine has grown, important insights regarding brain dysfunction in the ICU have shaped our practice including the importance of light sedation and the avoidance of deliriogenic drugs such as benzodiazepines. Best practices are now strategically incorporated in targeted bundles of care like the ICU Liberation Campaign's ABCDEF Bundle.
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Affiliation(s)
- Kimberly F Rengel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37213, USA.
| | - Matthew F Mart
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, Nashville, TN 37212, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA
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Flaws D, Allen C, Baker S, Barnett A, Metcalf O, Pollock H, Ramanan M, Tabah A, Varker T. A protocol for a pilot randomised controlled trial of an Early Psychiatric Assessment, Referral, and Intervention Study (EPARIS) for intensive care patients. PLoS One 2023; 18:e0287470. [PMID: 37384627 PMCID: PMC10309621 DOI: 10.1371/journal.pone.0287470] [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: 09/21/2022] [Accepted: 06/02/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Up to 80% of Intensive Care Unit patients experience physical, cognitive, and/or psychological complications post-discharge, known as 'Post Intensive Care Syndrome' (PICS). Early diagnosis and intervention are a priority, but while current post-intensive care follow-up processes endorse a multidisciplinary model, incorporating a psychiatric consultation has not been studied. METHODS A pilot, open-label randomised controlled trial was developed by a multidisciplinary team to evaluate the feasibility and acceptability of incorporating a psychiatric review into an existing post-ICU clinic. The study will run for 12 months and aim to recruit 30 participants. Inclusion criteria for participants: a) ICU admission greater than 48 hours, b) no cognitive impairment that prevents participation, c) ≥ 18 years old, d) residing in Australia, e) fluent in English, f) able to provide GP information, and g) likely to be contactable in 6 months. Patient recruitment will be at Redcliffe Hospital, Queensland, Australia, and will involve patients attending the Redcliffe post intensive care clinic. Participants will be allocated to intervention or control using block randomisation and allocation concealment. Participants allocated to the control arm will receive the standard cares provided by the clinic, which involves an unstructured interview about their ICU experience and a battery of surveys about their psychological, cognitive, and physical function. Those allocated to the intervention arm will receive these same cares as well as an appointment with a psychiatrist for a single session intervention. The psychiatric intervention will involve a comprehensive review, including comorbid disorders, substance use, suicidal ideation, psychosocial stressors, social/emotional supports. Psychoeducation and initial treatment will be provided as indicated and recommendations given to the patient and their GP about how to access ongoing care. In addition to surveys conducted as part of standard clinic cares, all participants will complete additional questionnaires about their history, hospital experience, mental and physical health as well as employment circumstances. All participants will be followed up 6 months after their appointment and will be invited to complete follow-up questionnaires about their mental and physical health, as well as health service use and employment circumstances. The trial has been registered with ANZCTR (ACTRN12622000894796). RESULTS To evaluate the feasibility and acceptability of the intervention to the patient population. Differences between groups will be assessed using an independent samples t-test. Resource requirements to administer the intervention will be evaluated by reporting the mean duration of the EPARIS assessment and approximate cost per patient to provide this service. To estimate the effect size of any treatment effects, changes in secondary outcome measures between baseline and 6 months will be compared between intervention and control groups using Analysis of Covariance regression. As this is a pilot, we will not use p-values or test a null hypothesis, but will give confidence intervals. CONCLUSIONS This protocol provides a pragmatic evaluation of the acceptability of introducing early psychiatric assessment into an existing post-ICU follow-up process, and if considered acceptable will inform future research into the efficacy and generalisability of the intervention. The strengths of EPARIS are the prospective, longitudinal design with a control population, and its use of validated post-ICU outcome measures.
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Affiliation(s)
- Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
- School of Clinical Sciences, Queensland University of Technology, Queensland, Australia
- Metro North Mental Health, Caboolture Hospital, Queensland, Australia
- Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Chelsea Allen
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Queensland, Australia
| | - Stuart Baker
- Department of Intensive Care, Redcliffe Hospital, Queensland, Australia
| | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Queensland, Australia
| | - Olivia Metcalf
- Phoenix Australia, Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Victoria, Australia
| | - Hamish Pollock
- Department of Intensive Care, Redcliffe Hospital, Queensland, Australia
| | - Mahesh Ramanan
- Department of Intensive Care, Caboolture Hospital, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia
- Mayne Academy of Critical Care, University of Queensland, Queensland, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Alexis Tabah
- School of Clinical Sciences, Queensland University of Technology, Queensland, Australia
- Faculty of Medicine, University of Queensland, Queensland, Australia
- Department of Intensive Care, Redcliffe Hospital, Queensland, Australia
| | - Tracey Varker
- Phoenix Australia, Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Victoria, Australia
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Choi J, Park E, Choi AY, Son MH, Cho J. Incidence and Mortality Trends in Critically Ill Children: A Korean Population-Based Study. J Korean Med Sci 2023; 38:e178. [PMID: 37309697 DOI: 10.3346/jkms.2023.38.e178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/24/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Monitoring mortality trends can help design ways to improve survival, but observation of national mortality trends in critically ill children is lacking for the Korean population. METHODS We analyzed the incidence and mortality trends of children younger than 18 years admitted to an intensive care unit (ICU) from 2012 to 2018 using the Korean National Health Insurance database. Neonates and neonatal ICU admissions were excluded. Multivariable logistic regression analyses were performed to estimate the odds ratio of in-hospital mortality according to admission year. Trends in incidence and in-hospital mortality of subgroups according to admission department, age, presence of intensivists, admissions to pediatric ICU, mechanical ventilation, and use of vasopressors were evaluated. RESULTS The overall mortality of critically ill children was 4.4%. There was a significant decrease in mortality from 5.5% in 2012 to 4.1% in 2018 (P for trend < 0.001). The incidence of ICU admission in children remained around 8.5/10,000 population years (P for trend = 0.069). In-hospital mortality decreased by 9.2% yearly in adjusted analysis (P < 0.001). The presence of dedicated intensivists (P for trend < 0.001, mortality decrease from 5.7% to 4.0%) and admission to pediatric ICU (P for trend < 0.001, mortality decrease from 5.0% to 3.2%) were associated with significant decreasing trends in mortality. CONCLUSION Mortality among critically ill children improved during the study period, and the improving trend was prominent in children with high treatment requirements. Varying mortality trends, according to ICU organizations, highlight that advances in medical knowledge should be supported structurally.
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Affiliation(s)
- Jaeyoung Choi
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Esther Park
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Korea
| | - Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Meong Hi Son
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Kirk LE, Mitchell I. Has the COVID-19 pandemic unmasked the fragility of the Australian health care system? Med J Aust 2023. [PMID: 37161524 DOI: 10.5694/mja2.51946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/17/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Lucy E Kirk
- Hunter New England Local Health District, NSW Health, Newcastle, NSW
| | - Imogen Mitchell
- Canberra Health Services, Canberra, ACT
- Australian National University, Canberra, ACT
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Davison BA, Edwards C, Cotter G, Kimmoun A, Gayat É, Latosinska A, Mischak H, Takagi K, Deniau B, Picod A, Mebazaa A. Plasma and Urinary Biomarkers Improve Prediction of Mortality through 1 Year in Intensive Care Patients: An Analysis from FROG-ICU. J Clin Med 2023; 12:jcm12093311. [PMID: 37176751 PMCID: PMC10179283 DOI: 10.3390/jcm12093311] [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: 04/14/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND This study aimed to assess the value of blood and urine biomarkers in addition to routine clinical variables in risk stratification of patients admitted to ICU. METHODS Multivariable prognostic models were developed in this post hoc analysis of the French and EuRopean Outcome ReGistry in Intensive Care Units study, a prospective observational study of patients admitted to ICUs. The study included 2087 patients consecutively admitted to the ICU who required invasive mechanical ventilation or a vasoactive agent for more than 24 h. The main outcome measures were in-ICU, in-hospital, and 1 year mortality. RESULTS Models including only SAPS II or APACHE II scores had c-indexes for in-hospital and 1 year mortality of 0.64 and 0.65, and 0.63 and 0.61, respectively. The c-indexes for a model including age and estimated glomerular filtration rate were higher at 0.69 and 0.67, respectively. Models utilizing available clinical variables increased the c-index for in-hospital and 1 year mortality to 0.80 and 0.76, respectively. The addition of biomarkers and urine proteomic markers increased c-indexes to 0.83 and 0.78. CONCLUSIONS The commonly used scores for risk stratification in ICU patients did not perform well in this study. Models including clinical variables and biomarkers had significantly higher predictive values.
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Affiliation(s)
- Beth A Davison
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, 75010 Paris, France
- Momentum Research, Inc., Durham, NC 27713, USA
| | | | - Gad Cotter
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, 75010 Paris, France
- Momentum Research, Inc., Durham, NC 27713, USA
| | - Antoine Kimmoun
- Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Université de Lorraine, 54511 Nancy, France
- Inserm U1116, F-CRIN INI-CRCT, 54500 Nancy, France
| | - Étienne Gayat
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, 75010 Paris, France
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 75010 Paris, France
- Université Paris Cité, 75006 Paris, France
| | | | | | - Koji Takagi
- Momentum Research, Inc., Durham, NC 27713, USA
| | - Benjamin Deniau
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, 75010 Paris, France
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 75010 Paris, France
- Université Paris Cité, 75006 Paris, France
| | - Adrien Picod
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, 75010 Paris, France
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 75010 Paris, France
| | - Alexandre Mebazaa
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, 75010 Paris, France
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 75010 Paris, France
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Barreto SG, Kaambwa B, Venkatesh K, Sasson SC, Andersen C, Delaney A, Bihari S, Pilcher D. Mortality and costs related to severe acute pancreatitis in the intensive care units of Australia and New Zealand (ANZ), 2003-2020. Pancreatology 2023:S1424-3903(23)00100-X. [PMID: 37121877 DOI: 10.1016/j.pan.2023.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP. METHODS We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020. RESULTS 12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods. CONCLUSIONS In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, South Australia, Australia.
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Karthik Venkatesh
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; The Kirby Institute, UNSW, Sydney, Australia
| | - Sarah C Sasson
- The Kirby Institute, UNSW, Sydney, Australia; NSW Health Pathology I.C.P.M.R, Westmead Hospital, Sydney, Australia
| | - Christopher Andersen
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; The Kirby Institute, UNSW, Sydney, Australia; Northern Clinical School, University of Sydney, Sydney, NSW, Australia; The George Institute for Global Health, King Street, Newtown, NSW, 2042, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Shailesh Bihari
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Department of ICCU, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, 3004, Australia; The Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia; The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resource Evaluation (CORE), 277 Camberwell Road, Camberwell, Victoria, 3124, Australia
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Shankar DA, Walkey AJ, Hawkins FJ, Bosch NA, Peterson D, Law AC. Hospital-level variation in practices and outcomes for patients with severe acute exacerbations of idiopathic pulmonary fibrosis: a retrospective multicentre cohort study. BMJ Open Respir Res 2023; 10:e001593. [PMID: 37076251 PMCID: PMC10124258 DOI: 10.1136/bmjresp-2022-001593] [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: 12/19/2022] [Accepted: 03/17/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND In the absence of evidence-based strategies to improve patient outcomes, the management of patients with severe idiopathic pulmonary fibrosis (IPF) exacerbations may vary widely across centres. We assessed between-hospital variation in practices and mortality for patients with severe IPF exacerbations. METHODS Using the Premier Healthcare Database from 1 October 2015 to 31 December 2020, we identified patients admitted to intensive care unit (ICU) or intermediate care unit with an IPF exacerbation. We assessed idiosyncratic, between-hospital variation in ICU practices (invasive mechanical ventilation (IMV), non-invasive mechanical ventilation (NIMV), corticosteroid use, and immunosuppressive and/or antioxidant use) and hospital mortality by determining median risk-adjusted hospital rates and intraclass correlation coefficients (ICCs) from hierarchical multivariable regression models. A priori, an ICC>15% was deemed 'high variation'. RESULTS We identified 5256 critically ill patients with a severe IPF exacerbation at 385 US hospitals. Hospital median risk-adjusted rates of practices were: IMV (14% (IQR: 8.3%-26%)), NIMV (42% (31%-54%)), corticosteroid use (89% (84%-93%)), and immunosuppressive and/or antioxidant use (3.3% (1.9%-5.8%)). Model ICCs were: IMV (19% (95% CI: 18% to 21%)), NIMV (15% (13% to 16%)), corticosteroid use (9.8% (8.3% to 11%)), and immunosuppressive and/or antioxidant use (8.5% (7.1% to 9.9%)). The median risk-adjusted hospital mortality was 16% (IQR: 11%-24%) with an ICC of 7.5% (95% CI: 6.2% to 8.9%). INTERPRETATION We observed high variation in the use of IMV and NIMV, and less variation in corticosteroid and immunosuppressant and/or antioxidant use among patients hospitalised with severe IPF exacerbations. Further research is needed to guide the decisions surrounding initiation of IMV and role of NIMV and to understand the effectiveness of corticosteroids among patients with severe IPF exacerbations.
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Affiliation(s)
- Divya A Shankar
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Allan J Walkey
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Finn J Hawkins
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nicholas A Bosch
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel Peterson
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Anica C Law
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
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