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

Clinician- and Patient-Identified Solutions to Reduce the Fragmentation of Post-ICU Care in Australia

BACKGROUND

Critical care survivors experience multiple care transitions, with no formal follow-up care pathway.

RESEARCH QUESTION

What are the potential solutions to improve the communication between treating teams and integration of care following an ICU admission, from the perspective of patients, their caregivers, intensivists, and general practitioners (GPs) from diverse socioeconomic areas?

STUDY DESIGN AND METHODS

This study included a qualitative design using semi-structured interviews with intensivists, GPs, and patients and caregivers. Framework analysis was used to analyze data and to identify solutions to improve the integration of care following hospital discharge. Patients were previously mechanically ventilated for > 24 h in the ICU and had access to a video-enabled device. Clinicians were recruited from hospital networks and a state-wide GP network.

RESULTS

Forty-six interviews with clinicians, patients, and caregivers were completed (15 intensivists, eight GPs, 15 patients, and eight caregivers). Three higher level feedback loops were identified that comprised 10 themes. Feedback loop 1 was an ICU and primary care collaboration. It included the following: (1) developing collaborative relationships between the ICU and primary care; (2) providing interprofessional education and resources to support primary care; and (3) improving role clarity for patient follow-up care. Feedback loop 2 was developing mechanisms for improved communication across the care continuum. It included: (4) timely, concise information-sharing with primary care on post-ICU recovery; (5) survivorship-focused information-sharing across the continuum of care; (6) empowering patients and caregivers in self-management; and (7) creation of a care coordinator role for survivors. Feedback loop 3 was learning from post-ICU outcomes to improve future care. It included: (8) developing comprehensive post-ICU care pathways; (9) enhancing support for patients following a hospital stay; and (10) integration of post-ICU outcomes within the ICU to improve clinician morale and understanding.

INTERPRETATION

Practical solutions to enhance the quality of survivorship for critical care survivors and their caregivers were identified. These themes are mapped to a novel conceptual model that includes key feedback loops for health system improvements and foci for future interventional trials to improve ICU survivorship outcomes.

Anxiety and depression following critical illness: A comparison of the recovery trajectories of patients and caregivers

BACKGROUND

Following critical illness, family members are often required to adopt caregiving responsibilities. Anxiety and depression are common long term problems for both patients and caregivers. However, at present, it is not known how the trajectories of these symptoms compare between patients and caregivers.

OBJECTIVES

The aim of this study was to investigate and compare the trajectories of anxiety and depression in patients and caregivers in the first year following critical illness.

METHODS

This study analyses data from a prospective multicentre cohort study of patients and caregivers who underwent a complex recovery intervention following critical illness. Paired patients and caregivers were recruited. The Hospital Anxiety and Depression Scale was used to evaluate symptoms of anxiety and depression at three timepoints: baseline; 3 months; and 12 months in both patient and caregivers. A linear mixed-effects regression model was used to evaluate the trajectories of these symptoms over the first year following critical illness.

RESULTS

115 paired patients and caregivers, who received the complex recovery intervention, were recruited. There was no significant difference in the relative trajectory of depressive symptoms between patients and caregivers in the first 12 months following critical illness (p = 0.08). There was, however, a significant difference in the trajectory of anxiety symptoms between patients and caregivers during this time period (p = 0.04), with caregivers seeing reduced resolution of symptoms in comparison to patients.

CONCLUSIONS

Following critical illness, symptoms of anxiety and depression are common in both patients and caregivers. The trajectory of symptoms of depression was similar between caregivers and patients; however, there was a significantly different recovery trajectory in symptoms of anxiety. Further research is required to understand the recovery pathway of caregivers in order to design effective interventions.

Characterizing Program Delivery for an Effective Multicomponent Sepsis Recovery Intervention

Rationale: A recent randomized controlled trial revealed that a multicomponent sepsis transition and recovery (STAR) program delivered through specialized nurse navigators was effective in reducing a composite of 30-day readmission and mortality. Better understanding of patterns of care provided by the STAR program is needed to promote implementation and dissemination of this effective program.Objectives: This study characterizes individual care activities and distinct "packages" of care delivered by the STAR program.Methods: We performed a secondary analysis of data from the intervention arm of the IMPACTS (Improving Morbidity during Post-Acute Care Transitions for Sepsis) randomized controlled trial, conducted at three urban hospitals in the southeastern United States from January 2019 to March 2020. We used a structured data collection process to identify STAR nurse navigator care activities from electronic health record documentation. We then used latent class analysis to identify groups of patients receiving distinct combinations of intervention components. We evaluated differences in patient characteristics and outcomes between groups receiving distinct intervention packages.Results: The 317 sepsis survivors enrolled into the intervention arm of the IMPACTS trial received one or more of nine unique care activities delivered by STAR nurse navigators (care coordination, health promotion counseling, emotional listening, symptom management, medication management, chronic disease management, addressing social determinants of health, care setting advice and guidance, and primary palliative care). Patients received a median of three individual care activities (interquartile range, 2-5). Latent class analysis revealed four distinct packages of care activities delivered to patients with different observable characteristics and different frequency of 30-day readmission and mortality.Conclusions: We identified nine care activities delivered by an effective STAR program and four distinct latent classes or packages of intervention delivery. These results can be leveraged to increase widespread implementation and provide targets to augment future program delivery.

Could an integrated model of health and social care after critical illness reduce socioeconomic disparities in outcomes? A Bayesian analysis

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.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Barriers to and Facilitators of Family Caregiving of Patients With COVID-19 Early in the Pandemic

BACKGROUND

In 2020, many family members were thrust into the role of caregiving for a relative with COVID-19 with little preparation, training, or understanding of the disease and its symptoms.

OBJECTIVES

To explore the barriers to and facilitators of caregiving experienced by family caregivers of patients with COVID-19 who had been in intensive care in the pandemic's earliest months.

METHODS

In-depth qualitative interviews were conducted by web conference with 16 adults recovering at home after intubation for COVID-19 in an intensive care unit at a major academic medical center and their primary caregivers from March to August 2020 (N = 32). Thematic qualitative analysis was done using Watkins' rigorous and accelerated data reduction technique with MAXQDA software.

RESULTS

Seven themes emerged regarding factors that facilitated or posed barriers to care: other health conditions that increased complexity of care, interactions and experiences in the health care system, COVID-19's proliferation into other areas of life, the psychological well-being of the patient-caregiver dyad, experience of support from the dyad's network, the role of caregiving in the dyad, and contextual circumstances of the dyad. The themes often included both barriers and facilitators, depending on the experience of the dyad (eg, feeling encouraged vs fatigued by their support network).

CONCLUSIONS

Understanding how patients with COVID-19 and their caregivers experience illness management across the recovery journey can help clarify the COVID-19 care-giving process and identify intervention targets to improve overall health and well-being of the care dyad.

Mental Health in Women

Mental health illness has been increasing worldwide. The prevalence of mental illness and is higher among females than among males. It is estimated that one in 5 women experience a common mental health disorder. This article highlights gender disparities in the risk, prevalence, and presentation of different mental health disorders. Nearly all survivors of critical illness experience 1 or more domains of the post-intensive care syndrome. We review different mental health disorders including anxiety disorders, mood disorders, psychotic disorders, and post-intensive care syndrome, and medications used to manage these disorders. Delirium in the intensive care unit can be misdiagnosed as a primary psychiatric disorder and is important to distinguish from each other. We also highlight the inadequacy of surveillance and recognition of mental health disorders in the intensive care unit, leading to missed opportunities to properly manage these important psychiatric conditions.

Post-hospital recovery trajectories of family members of critically ill COVID-19 survivors: an international qualitative investigation

PURPOSE

The immediate impact of coronavirus disease 2019 (COVID-19) visiting restrictions for family members has been well-documented. However, the longer-term trajectory, including mechanisms for support, is less well-known. To address this knowledge gap, we aimed to explore the post-hospital recovery trajectory of family members of patients hospitalised with a critical care COVID-19 admission. We also sought to understand any differences across international contexts.

METHODS

We undertook semi-structured interviews with family members of patients who had survived a COVID-19 critical care admission. Family members were recruited from Spain and the United Kingdom (UK) and telephone interviews were undertaken. Interviews were analysed using a thematic content analysis.

RESULTS

Across the international sites, 19 family members were interviewed. Four themes were identified: changing relationships and carer burden; family health and trauma; social support and networks and differences in lived experience. We found differences in the social support and networks theme across international contexts, with Spanish participants more frequently discussing religion as a form of support.

CONCLUSIONS

This international qualitative investigation has demonstrated the challenges which family members of patients hospitalised with a critical care COVID-19 admission experience following hospital discharge. Specific support mechanisms which could include peer support networks, should be implemented for family members to ensure ongoing needs are met.

Evaluating pain in survivors of critical illness: the correlation between the EQ-5D-5L and the Brief Pain Inventory

INTRODUCTION

Pain is a common and debilitating symptom in survivors of critical illness. The 'Core Outcome Set for Survivors of Acute Respiratory Failure' proposes that the pain and discomfort question of the EuroQol 5 Dimension 5 Level (EQ-5D-5L) could be used to assess pain in this group, however, it was recognised that further research is required to evaluate how this single question compares to other more detailed pain tools. This study aims to evaluate the relationship between the pain and discomfort question of the EQ-5D-5L and the Brief Pain Inventory (BPI) in survivors of critical illness.

METHODS

This study retrospectively analysed paired EQ-5D-5L and BPI data extracted from a prospective, multicentre study evaluating the impact of a critical care recovery programme. 172 patients who received a complex recovery intervention and 108 patients who did not receive this intervention were included. Data were available for the intervention cohort at multiple time points, namely, baseline, 3 months and 12 months. While, data were available for the usual care cohort at a single time point (12 months). We assessed the correlation between the pain and discomfort question of the EQ-5D-5L and two separate components of the BPI: severity of pain and pain interference.

RESULTS

Correlation coefficients comparing the pain and discomfort question of the EQ-5D-5L and the BPI pain severity score ranged between 0.73 (95% CI 0.63 to 0.80) and 0.80 (95% CI 0.72 to 0.86). Correlation coefficients comparing the pain and discomfort question of the EQ-5D-5L and the BPI pain interference score ranged between 0.71 (95% CI 0.62 to 0.79) and 0.83 (95% CI 0.76 to 0.88) across the various time points.

CONCLUSIONS

The pain and discomfort question of the EQ-5D-5L correlates moderately well with a more detailed pain tool and may help to streamline assessments in survivorship studies. More in-depth tools may be of use where pain is the primary study outcome or a patient-reported concern.

Identification of risk factors for post-intensive care syndrome in family members (PICS-F) among adult patients: a systematic review

INTRODUCTION

Relatives of critically ill patients who either die or survive the intensive care unit (ICU) may develop substantial mental health problems that are collectively defined as post-intensive care syndrome in family (PICS-F).

MATERIAL AND METHODS

By using a systematised search strategy we included studies that focused on PICS-F in relatives of adult ICU patients and reported the risk factors associated with its development. The search was conducted within PubMed, Embase, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 23 August 2022. PRISMA 2020 guidelines were implemented for appropriate reporting. The objective was to document all possible risk factors associated with the development of PICS-F.

RESULTS

We included 51 papers covering 9302 relatives. The frequency of PICS-F varied between 2.5 and 69%. We identified 51 different risk factors of PICS-F, among which we distinguished patient-related ( n = 16), relative-related ( n = 27), and medical staff-related ( n = 8) risk factors. Among 21 studies of the highest quality, we identified the 33 variables associated with the development of PICS-F, of which younger age of a patient, death of a patient, depression in relatives during the ICU stay, history of mental disorders in relatives, being a female relative, being a spouse, and having low satisfaction with communication and care in the ICU were the most commonly reported risk factors.

CONCLUSIONS

PICS-F is a highly frequent phenomenon that can be exacerbated by several risk factors. Special attention should be paid to relatives of younger patients with worse prognosis and with the following relative-related risk factors: female sex, being a spouse, and history of mental health disorders. Finally, the medical staff play a role in preventing the PICS-F development, not only by maintenance of proper communication, but also by early identification of relatives prone to PICS-F.

Healthcare delivery and recovery after critical illness

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Social determinants of recovery

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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