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Bauer ME, Perez SL, Main EK, Norman GS, Fish LJ, Caldwell MA, Allen C, Hughes BL, Gibbs RS, Smith KL. Near-miss and maternal sepsis mortality: A qualitative study of survivors and support persons. Eur J Obstet Gynecol Reprod Biol 2024; 299:136-142. [PMID: 38865740 DOI: 10.1016/j.ejogrb.2024.05.038] [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: 03/13/2024] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Prior studies have shown that maternal deaths due to sepsis occur due to delays in recognition, treatment, and escalation of care through medical chart reviews. This study was conducted to obtain the patient perspective for near-miss and maternal mortality cases due to sepsis. OBJECTIVE To identify quality improvement opportunities for improving maternal sepsis through patient and support person experiences. STUDY DESIGN Twenty semi-structured interviews and three follow-up focus groups with patients who experienced critical illness from maternal sepsis in the United States and their support persons (when available) were conducted from May 23, 2022, through October 14, 2022. In this qualitative study, data were analyzed using inductive thematic analysis. RESULTS In this qualitative study of patients with maternal sepsis and their support persons, four main quality improvement themes were identified. The themes were the following: (1) participants reported a lack of awareness of pregnancy-related warning signs and symptoms of when to seek care, (2) many of the presenting symptoms participants experienced were not typical of expected warning signs of maternal sepsis, such as severe pain, overwhelming tiredness, and lack of fever (3) participant concerns were met with dismissal leading to delays in diagnosis, (4) participants experienced long-term sequelae but had difficulty receiving screening and referrals for treatment. CONCLUSIONS The findings of this study suggest that standardized patient education about the warning signs of maternal sepsis and provider education about the presentation of maternal sepsis, improved listening to patients, and follow-up for sequalae of sepsis are needed.
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Affiliation(s)
- Melissa E Bauer
- Department of Anesthesiology, Duke University, Durham, NC, United States.
| | - Susan L Perez
- Department of Public Health, California State University, Sacramento, CA, United States
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Stanford University, Palo Alto, CA, United States
| | - Gwendolyn S Norman
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, United States
| | - Laura J Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, United States
| | - Morgan A Caldwell
- Department of Anesthesiology, Duke University, Durham, NC, United States
| | - Christie Allen
- American College of Obstetrics and Gynecology, United States
| | - Brenna L Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States
| | - Ronald S Gibbs
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Stanford University, Palo Alto, CA, United States
| | - Kendra L Smith
- Smith Research & Consulting, LLC, Houston, TX, United States
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Teixeira C, Rosa RG. Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up. CRITICAL CARE SCIENCE 2024; 36:e20240265en. [PMID: 38896724 PMCID: PMC11152445 DOI: 10.62675/2965-2774.20240265-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 06/21/2024]
Abstract
A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.
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Affiliation(s)
- Cassiano Teixeira
- Department of Internal MedicineUniversidade Federal de Ciências da Saúde de Porto AlegrePorto AlegreRSBrazilDepartment of Internal Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brazil.
| | - Regis Goulart Rosa
- Department of Internal MedicineHospital Moinhos de VentoPorto AlegreRSBrazilDepartment of Internal Medicine, Hospital Moinhos de Vento - Porto Alegre (RS), Brazil.
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Lau J, Scott MM, Everett K, Gomes T, Tanuseputro P, Jennings S, Bagnarol R, Zimmermann C, Isenberg SR. Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada. CMAJ 2024; 196:E547-E557. [PMID: 38684285 PMCID: PMC11057880 DOI: 10.1503/cmaj.231419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND People with opioid use disorder (OUD) are at risk of premature death and can benefit from palliative care. We sought to compare palliative care provision for decedents with and without OUD. METHODS We conducted a cohort study using health administrative databases in Ontario, Canada, to identify people who died between July 1, 2015, and Dec. 31, 2021. The exposure was OUD, defined as having emergency department visits, hospital admissions, or pharmacologic treatments suggestive of OUD within 3 years of death. Our primary outcome was receipt of 1 or more palliative care services during the last 90 days before death. Secondary outcomes included setting, initiation, and intensity of palliative care. We conducted a secondary analysis excluding sudden deaths (e.g., opioid toxicity, injury). RESULTS Of 679 840 decedents, 11 200 (1.6%) had OUD. Compared with people without OUD, those with OUD died at a younger age and were more likely to live in neighbourhoods with high marginalization indices. We found people with OUD were less likely to receive palliative care at the end of their lives (adjusted relative risk [RR] 0.84, 95% confidence interval [CI] 0.82-0.86), but this difference did not exist after excluding people who died suddenly (adjusted RR 0.99, 95% CI 0.96-1.01). People with OUD were less likely to receive palliative care in clinics and their homes regardless of cause of death. INTERPRETATION Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death. Health care providers should receive training in palliative care and addiction medicine to support people with OUD.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont.
| | - Mary M Scott
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Karl Everett
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Tara Gomes
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sheila Jennings
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Rebecca Bagnarol
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Camilla Zimmermann
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
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Jouffroy R, Djossou F, Neviere R, Jaber S, Vivien B, Heming N, Gueye P. The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization. Ann Intensive Care 2024; 14:58. [PMID: 38625453 PMCID: PMC11019190 DOI: 10.1186/s13613-024-01282-6] [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: 10/06/2023] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France.
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM - Paris Saclay University, Paris, France.
- EA 7329 - Institut de Recherche Médicale et d'Épidémiologie du Sport - Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique - Hôpitaux de Paris, and Paris Saclay University, Saclay, France.
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Guyane and Laboratoire Ecosystèmes Amazoniens et Pathologie Tropicale EA 3593, Centre Hospitalier de Cayenne, Université de Guyane, Cayenne, France
| | - Rémi Neviere
- Service des Explorations Fonctionnelles Centre Hospitalier Universitaire de Martinique et UR5_3 PC2E Pathologie Cardiaque, toxicité Environnementale et Envenimations (ex EA7525, Université des Antilles, Antilles, France
| | - Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, INSERM U1046, Centre Hospitalier Universitaire Montpellier, Montpellier, 34295, France
| | - Benoît Vivien
- Service d'Anesthésie Réanimation, SAMU de Paris, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital, Laboratory of Infection & Inflammation - U1173, School of Medicine Simone Veil, FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), APHP University Versailles Saint Quentin - University Paris Saclay, University Versailles Saint Quentin - University Paris Saclay, INSERM, Garches, Garches, 92380, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, University of the Antilles, French West Indies, Antilles, France
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Kang J, Lee KM. Three-year mortality, readmission, and medical expenses in critical care survivors: A population-based cohort study. Aust Crit Care 2024; 37:251-257. [PMID: 37574386 DOI: 10.1016/j.aucc.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 07/10/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Due to the increasing number of critical care survivors, population-based studies on the long-term outcomes after discharge are necessary to inform local decision-making. OBJECTIVES This study aimed to investigate mortality and its risk factors, readmissions, and medical expenses of intensive care unit survivors for 3 years after hospital discharge. METHODS This retrospective study analysed data from the National Health Insurance Service-National Sample Cohort in Korea. Of the 195,702 patients who survived and were discharged from hospital in 2012, 2693 intensive care unit patients were assigned to the case group for the study, and the remaining 193,009 were assigned to the comparison group. The primary outcome was all-cause mortality for 3 years after discharge. Secondary outcomes were all-cause hospital readmission and medical expenses in 3 years. We analysed risk factors for mortality using the Cox proportional hazard regression. The differences in hospital readmission and medical expenses between the case and comparison groups were analysed by multivariate logistic regression and independent t-tests. RESULTS The 1-year, 2-year, and 3-year cumulative mortality rates in the case group were 15.9%, 20.5%, and 24.4%, respectively, and older age, disability, medical admission, and longer hospital stay increased mortality. Almost 40% of intensive care unit survivors were readmitted to hospital within 6 months of discharge, and their odds of being readmitted were significantly higher than those of the comparison group. Medical expenses were also significantly higher in the case group, with the highest paid within 6 months. CONCLUSIONS Mortality, hospital readmission, and medical expenses for intensive care unit survivors were the worst within 6 months of discharge. In light of the long-term recovery trajectory of critical illness, it is necessary to investigate what factors may have contributed to the negative outcome during this period. Further research is needed to determine which services primarily contributed to the increase in medical expenses.
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Affiliation(s)
- Jiyeon Kang
- College of Nursing, Dong-A University, Busan, South Korea.
| | - Kwang Min Lee
- Industry-Academy Cooperation, Dong-A University, Busan, South Korea
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Dias LM, da Cruz JA, Lopes AJ. Long-term assessment of functional capacity, muscle function, lung function, and quality of life in survivors of ventilator-associated pneumonia. Heliyon 2024; 10:e23431. [PMID: 38169824 PMCID: PMC10758824 DOI: 10.1016/j.heliyon.2023.e23431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Background and objective The many patients who develop ventilator-associated pneumonia (VAP) have generated numerous VAP survivors who are not followed up in the long term. This study aimed, primarily, to evaluate the long-term functional capacity, as measured using the Glittre-ADL test (TGlittre), of VAP survivors and, secondarily, to calculate the correlations of TGlittre with muscle and lung function. Methods This cross-sectional study evaluated 30 VAP survivors 10 months after discharge from the intensive care unit. The participants underwent the following assessments: TGlittre; respiratory muscle strength; handgrip strength (HGS); spirometry; Functional Assessment of Chronic Therapy (FACIT-F); and Short Form-36 (SF-36). Results The median TGlittre time was 95 (81-130)% of predicted, and 30 % of the participants performed poorly on TGlittre. One-third of the participants had abnormal spirometry results. TGlittre time was correlated with weight (rs = -0.412, P = 0.023), body index mass (BMI, rs = -0.400, P = 0.029), forced vital capacity (FVC, rs = -0.401, P = 0.030), HGS (rs = -0.571, P = 0.0009), FACIT-F score (rs = -0.405, P = 0.026), and different SF-36 domain scores. Participants who returned to work had a shorter TGlittre time than those who did not (89 (69-104) vs. 129 (102-183)% predicted). Multiple linear regression indicated that FVC and BMI explained 39 % of TGlittre variability. Conclusion VAP survivors had suboptimal functional capacity, low lung function, and general fatigue 10 months after discharge. The longer the TGlittre time was, the worse the lung function, muscle function, general fatigue, and quality of life were and the less likely the patient was to have returned to work.
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Affiliation(s)
- Larissa Mello Dias
- Rehabilitation Sciences Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
- Faculty Inspirar, Curitiba, Brazil
- Worker's Hospital Complex, Curitiba, Brazil
| | | | - Agnaldo José Lopes
- Rehabilitation Sciences Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
- Local Development Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
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Kim T, Kim H. Pathophysiology and Therapeutic Management of Bone Loss in Patients with Critical Illness. Pharmaceuticals (Basel) 2023; 16:1718. [PMID: 38139844 PMCID: PMC10747168 DOI: 10.3390/ph16121718] [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: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Patients with critical illnesses are at higher risk of comorbidities, which can include bone mineral density loss, bone turnover marker increase, and fragility fractures. Patients admitted to intensive care units (ICUs) have a higher risk of bone fractures. Since hypermetabolism is a characteristic of ICU patients, such patients are often rapidly affected by systemic deterioration, which often results in systemic wasting disease. Major risk factors for ICU-related bone loss include physical restraint, inflammation, neuroendocrine stress, malnutrition, and medications. A medical history of critical illness should be acknowledged as a risk factor for impaired bone metabolism. Bone loss associated with ICU admission should be recognized as a key component of post-intensive care syndrome, and further research that focuses on treatment protocols and prevention strategies is required. Studies aimed at maintaining gut integrity have emphasized protein administration and nutrition, while research is ongoing to evaluate the therapeutic benefits of anti-resorptive agents and physical therapy. This review examines both current and innovative clinical strategies that are used for identifying risk factors of bone loss. It provides an overview of perioperative outcomes and discusses the emerging novel treatment modalities. Furthermore, the review presents future directions in the treatment of ICU-related bone loss.
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Affiliation(s)
- Taejin Kim
- Department of Urology, CHA University Ilsan Medical Center, CHA University School of Medicine, Goyang-si 10414, Republic of Korea;
| | - Hyojin Kim
- Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si 14353, Republic of Korea
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Prescott HC, Ostermann M. What is new and different in the 2021 Surviving Sepsis Campaign guidelines. Med Klin Intensivmed Notfmed 2023; 118:75-79. [PMID: 37286842 PMCID: PMC10246868 DOI: 10.1007/s00063-023-01028-5] [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] [Received: 03/13/2023] [Revised: 03/23/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
The Surviving Sepsis Campaign (SSC) International Guidelines for the Management of Sepsis and Septic Shock provide recommendations on the care of hospitalized adult patients with (or at risk for) sepsis. This review discusses what is new or different in the 2021 SSC adult sepsis guidelines compared to 2016. The guidelines include new weak recommendations for use of balanced fluid over saline 0.9%, use of intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement, and peripheral initiation of intravenous vasopressors over delaying initiation in order to obtain central venous access. As before, there is a strong recommendation to initiate antimicrobials within 1 h of sepsis and septic shock, but there are now additional recommendations when the diagnosis is uncertain. The recommendation for initial fluid resuscitation in septic shock of 30 mL/kg crystalloid has been downgraded from strong to weak. Finally, there are 12 new recommendations addressing long-term outcomes from sepsis, including strong recommendations to screen for economic and social support and to make referrals for follow-up where available; use shared decision-making in post-intensive care unit (ICU) and hospital discharge planning; reconcile medications at both ICU and hospital discharge; provide information about sepsis and its sequelae in written and verbal hospital discharge summary; and to provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.
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Affiliation(s)
- Hallie C Prescott
- Department of Medicine, North Campus Research Center, University of Michigan, 48109-2800, Ann Arbor, MI, USA.
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.
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Lóser MK, Horowitz JK, England P, Esteitie R, Kaatz S, McLaughlin E, Munroe E, Heath M, Posa P, Flanders SA, Prescott HC. Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study. Crit Care Explor 2023; 5:e1004. [PMID: 37954901 PMCID: PMC10637402 DOI: 10.1097/cce.0000000000001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVES To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan. DESIGN Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review. SETTING Multicenter quality improvement consortium. SUBJECTS Fifty-one hospitals in Michigan. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded "we are good at this") and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services' Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics. CONCLUSIONS Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.
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Affiliation(s)
- Meghan K Lóser
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Peter England
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Rania Esteitie
- Division of Pulmonary & Critical Care Medicine, Covenant Healthcare, Saginaw, MI
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Elizabeth Munroe
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Megan Heath
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Pat Posa
- Quality and Patient Safety Program, University of Michigan, Ann Arbor, MI
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Hallie C Prescott
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
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10
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Rose L, Cox CE. Digital solutions and the future of recovery after critical illness. Curr Opin Crit Care 2023; 29:519-525. [PMID: 37598320 PMCID: PMC10487369 DOI: 10.1097/mcc.0000000000001075] [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: 08/21/2023]
Abstract
PURPOSE OF REVIEW Digital technologies may address known physical and psychological barriers to recovery experienced by intensive care survivors following hospital discharge and provide solutions to care fragmentation and unmet needs. The review highlights recent examples of digital technologies designed to support recovery of survivors of critically illness. RECENT FINDINGS Despite proliferation of digital technologies supporting health in the community, there are relatively few examples for intensive care survivors. Those we identified included web-based, app-based or telemedicine-informed recovery clinics or pathways offering services, including informational resources, care planning and navigation support, medication reconciliation, and recovery goal setting. Digital interventions supporting psychological recovery included apps providing adaptive coping skills training, mindfulness, and cognitive behavioural therapy. Efficacy data are limited, although feasibility and acceptability have been established for some. Challenges include difficulties identifying participants most likely to benefit and delivery in a format easily accessible to all, with digital exclusion a resultant risk. SUMMARY Digital interventions supporting recovery comprise web or app-based recovery clinics or pathways and digital delivery of psychological interventions. Understanding of efficacy is relatively nascent, although several studies demonstrate feasibility and acceptability. Future research is needed but should be mindful of the risk of digital exclusion.
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Affiliation(s)
- Louise Rose
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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11
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Taylor LJ, Jolley SE, Ramani C, Mayer KP, Etchill EW, Mart MF, Fakhri S, Peterson S, Colborn K, Sevin CM, Kadl A, Enfield K, Whitman GJR, Zwischenberger JB, Rove JY. Early posthospitalization recovery after extracorporeal membrane oxygenation in survivors of COVID-19. J Thorac Cardiovasc Surg 2023; 166:842-851.e1. [PMID: 35431034 PMCID: PMC8920082 DOI: 10.1016/j.jtcvs.2021.11.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/05/2021] [Accepted: 11/19/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We sought to determine the influence of venovenous extracorporeal membrane oxygenation (ECMO) on outcomes of mechanically ventilated patients with COVID-19 during the first 120 days after hospital discharge. METHODS Five academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 admitted during March through May 2020. Survivors had access to a multidisciplinary postintensive care recovery clinic. Physical, psychological, and cognitive deficits were measured using validated instruments and compared based on ECMO status. RESULTS Two hundred sixty two mechanically ventilated patients were compared with 46 patients cannulated for venovenous ECMO. Patients receiving ECMO were younger and traveled farther but there was no significant difference in gender, race, or body mass index. ECMO patients were mechanically ventilated for longer durations (median, 26 days [interquartile range, 19.5-41 days] vs 13 days [interquartile range, 7-20 days]) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes. Patients receiving ECMO experienced greater bleeding and clotting events (P < .01). However, survival at discharge was similar (69.6% vs 70.6%). Of the 217 survivors, 65.0% had documented follow-up within 120 days. Overall, 95.5% were residing at home, 25.7% had returned to work or usual activity, and 23.1% were still using supplemental oxygen; these rates did not differ significantly based on ECMO status. Rates of physical, psychological, and cognitive deficits were similar. CONCLUSIONS Our data suggest that COVID-19 survivors experience significant physical, psychological, and cognitive deficits following intensive care unit admission. Despite a more complex critical illness course, longer average duration of mechanical ventilation, and longer average length of stay, patients treated with venovenous ECMO had similar survival at discharge and outcomes within 120 days of discharge.
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Affiliation(s)
- Lauren J Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Chintan Ramani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Va
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Ky
| | - Eric W Etchill
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Shoaib Fakhri
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Skyler Peterson
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Kathryn Colborn
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Carla M Sevin
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Alexandra Kadl
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Va
| | - Kyle Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Va
| | - Glenn J R Whitman
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Joseph B Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, College of Medicine, University of Kentucky, Lexington, Ky
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo.
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12
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Hechtman RK, Cano J, Whittington T, Hogan CK, Seelye SM, Sussman JB, Prescott HC. A Multi-Hospital Survey of Current Practices for Supporting Recovery From Sepsis. Crit Care Explor 2023; 5:e0926. [PMID: 37637354 PMCID: PMC10456977 DOI: 10.1097/cce.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Sepsis survivors are at increased risk for morbidity and functional impairment. There are recommended practices to support recovery after sepsis, but it is unclear how often they are implemented. We sought to assess the current use of recovery-based practices across hospitals. DESIGN Electronic survey assessing the use of best practices for recovery from COVID-related and non-COVID-related sepsis. Questions included four-point Likert responses of "never" to "always/nearly always." SETTING Twenty-six veterans affairs hospitals with the highest (n = 13) and lowest (n = 13) risk-adjusted 90-day sepsis survival. SUBJECTS Inpatient and outpatient clinician leaders. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For each domain, we calculated the proportion of "always/nearly always" responses and mean Likert scores. We assessed for differences by hospital survival, COVID versus non-COVID sepsis, and sepsis case volume. Across eight domains of care, the proportion "always/nearly always" responses ranged from: 80.7% (social support) and 69.8% (medication management) to 22.5% (physical recovery and adaptation) and 0.0% (emotional support). Higher-survival hospitals more often performed screening for new symptoms/limitations (49.2% vs 35.1% "always/nearly always," p = 0.02) compared with lower-survival hospitals. There was no difference in "always/nearly always" responses for COVID-related versus non-COVID-related sepsis, but small differences in mean Likert score in four domains: care coordination (3.34 vs 3.48, p = 0.01), medication management (3.59 vs 3.65, p = 0.04), screening for new symptoms/limitations (3.13 vs 3.20, p = 0.02), and anticipatory guidance and education (2.97 vs 2.84, p < 0.001). Lower case volume hospitals more often performed care coordination (72.7% vs 43.8% "always/nearly always," p = 0.02), screening for new symptoms/limitations (60.6% vs 35.8%, p < 0.001), and social support (100% vs 74.2%, p = 0.01). CONCLUSIONS Our findings show variable adoption of practices for sepsis recovery. Future work is needed to understand why some practice domains are employed more frequently than others, and how to facilitate practice implementation, particularly within rarely adopted domains such as emotional support.
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Affiliation(s)
| | - Jennifer Cano
- VA Center for Clinical Management Research, Ann Arbor, MI
| | | | | | - Sarah M Seelye
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Jeremy B Sussman
- Department of Medicine, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Hallie C Prescott
- Department of Medicine, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor, MI
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13
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Alabsi H, Emerson K, Lin DJ. Neurorecovery after Critical COVID-19 Illness. Semin Neurol 2023. [PMID: 37168008 DOI: 10.1055/s-0043-1768714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.
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Affiliation(s)
- Haitham Alabsi
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristi Emerson
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Lin
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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14
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Bose S, Groat D, Dinglas VD, Akhlaghi N, Banner-Goodspeed V, Beesley SJ, Greene T, Hopkins RO, Mir-Kasimov M, Sevin CM, Turnbull AE, Jackson JC, Needham DM, Brown SM. Association Between Unmet Nonmedication Needs After Hospital Discharge and Readmission or Death Among Acute Respiratory Failure Survivors: A Multicenter Prospective Cohort Study. Crit Care Med 2023; 51:212-221. [PMID: 36661449 DOI: 10.1097/ccm.0000000000005709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To characterize early unmet nonmedication discharge needs (UDNs), classified as durable medical equipment (DME), home health services (HHS), and follow-up medical appointments (FUAs) and explore their association with 90-day readmission and mortality among survivors of acute respiratory failure (ARF) who were discharged home. DESIGN Prospective multicenter cohort study. SETTING Six academic medical centers across United States. PARTICIPANTS Adult survivors of ARF who required an ICU stay and were discharged home from hospital. INTERVENTIONS None. Exposure of interest was the proportion of UDN for the following categories: DME, HHS, and FUA ascertained within 7-28 days after hospital discharge. MEASUREMENTS AND MAIN RESULTS Two hundred eligible patients were recruited between January 2019 and August 2020. One-hundred ninety-five patients were included in the analytic cohort: 118 were prescribed DME, 134 were prescribed HHS, and 189 needed at least one FUA according to discharge plans. 98.4% (192/195) had at least one identified nonmedication need at hospital discharge. Median (interquartile range) proportion of unmet needs across three categories were 0 (0-15%) for DME, 0 (0-50%) for HHS, and 0 (0-25%) for FUA, and overall was 0 (0-20%). Fifty-six patients (29%) had 90-day death or readmission. After adjusting for prespecified covariates, having greater than the median level of unmet needs was not associated with an increased risk of readmission or death within 90 days of discharge (risk ratio, 0.89; 0.51-1.57; p = 0.690). Age, hospital length of stay, Acute Physiology and Chronic Health Evaluation II severity of illness score, and Multidimensional Scale Perceived Social Support score were associated with UDN. CONCLUSIONS UDN were common among survivors of ARF but not significantly associated a composite outcome of 90-day readmission or death. Our results highlight the substantial magnitude of UDN and identifies areas especially vulnerable to lapses in healthcare coordination.
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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
- Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Danielle Groat
- Department of Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - 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
| | - Narjes Akhlaghi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah J Beesley
- Department of Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT
| | - Tom Greene
- Department of Biostatistics and Epidemiology, University of Utah, Salt Lake City, UT
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
| | - Mustafa Mir-Kasimov
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT
- Section of Pulmonary and Critical Care Medicine, George E Wahlen VA Medical Center, Salt Lake City, UT
| | - Carla M Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - 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
| | - Samuel M Brown
- Department of Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT
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15
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Jentzer JC, Lawler PR, Van Houten HK, Yao X, Kashani KB, Dunlay SM. Cardiovascular Events Among Survivors of Sepsis Hospitalization: A Retrospective Cohort Analysis. J Am Heart Assoc 2023; 12:e027813. [PMID: 36722388 PMCID: PMC9973620 DOI: 10.1161/jaha.122.027813] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Sepsis is associated with an elevated risk of late cardiovascular events among hospital survivors. Methods and Results We included OptumLabs Data Warehouse patients from 2009 to 2019 who survived a medical/nonsurgical hospitalization lasting at least 2 nights. The association between sepsis during hospitalization, based on explicit and implicit discharge International Classification of Diseases, Ninth Revision (ICD-9)/Tenth Revision (ICD-10) diagnosis codes, with subsequent death and rehospitalization was analyzed using Kaplan-Meier survival analysis and multivariable Cox proportional-hazards models. The study population included 2 258 464 survivors of nonsurgical hospitalization (5 396 051 total patient-years of follow-up). A total of 808 673 (35.8%) patients had a sepsis hospitalization, including implicit sepsis only in 448 644, explicit sepsis only in 124 841, and both in 235 188. Patients with sepsis during hospitalization had an elevated risk of all-cause mortality (adjusted hazard ratio [HR], 1.27 [95% CI, 1.25-1.28]; P<0.001), all-cause rehospitalization (adjusted HR, 1.38 [95% CI, 1.37-1.39]; P<0.001), and cardiovascular hospitalization (adjusted HR, 1.43 [95% CI, 1.41-1.44]; P<0.001), especially heart failure hospitalization (adjusted HR, 1.51 [95% CI, 1.49-1.53]). Patients with implicit sepsis had higher risk than those with explicit sepsis. A sensitivity analysis using the first hospitalization yielded concordant results for cardiovascular hospitalization (adjusted HR, 1.78 [95% CI, 1.76-1.78]; P<0.001), as did a propensity-weighted analysis (adjusted HR, 1.52 [95% CI, 1.50-1.54]; P<0.001). Conclusions Survivors of sepsis hospitalization are at elevated risk of early and late post-discharge death as well as cardiovascular and non-cardiovascular rehospitalization. This hazard spans the spectrum of cardiovascular events and may suggest that sepsis is an important cardiovascular risk factor.
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Affiliation(s)
- Jacob C. Jentzer
- Department of Cardiovascular MedicineMayo ClinicRochesterMN,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochesterMN
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre, University Health NetworkTorontoOntarioCanada,Interdepartmental Division of Critical Care Medicine and Division of CardiologyUniversity of TorontoTorontoOntarioCanada
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochesterMN
| | - Xiaoxi Yao
- Department of Cardiovascular MedicineMayo ClinicRochesterMN,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochesterMN
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterMN,Division of Nephrology and HypertensionMayo ClinicRochesterMN
| | - Shannon M. Dunlay
- Department of Cardiovascular MedicineMayo ClinicRochesterMN,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochesterMN
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16
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Born S, Matthäus-Krämer C, Bichmann A, Boltz HS, Esch M, Heydt L, Sell S, Streich K, Scherag A, Reinhart K, Hartog CS, Fleischmann-Struzek C. Sepsis survivors and caregivers perspectives on post-acute rehabilitation and aftercare in the first year after sepsis in Germany. Front Med (Lausanne) 2023; 10:1137027. [PMID: 37113609 PMCID: PMC10126403 DOI: 10.3389/fmed.2023.1137027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/15/2023] [Indexed: 04/29/2023] Open
Abstract
Background Sepsis survivors often suffer from new morbidities. Current rehabilitation therapies are not tailored to their specific needs. The perspective of sepsis survivors and their caregivers on rehabilitation and aftercare is insufficiently understood. We aimed to assess how sepsis survivors in Germany rated the suitability, extent and satisfaction with rehabilitation therapies that they underwent in the year following the acute sepsis episode. Methods Prospective mixed-methods, multicenter study among a cohort of adult ICU-treated sepsis survivors and their caregivers. Interviews were conducted 6 and 12 months after ICU discharge by telephone and comprised closed as well as open-ended questions. Primary outcomes were the utilization and patient satisfaction with inpatient and outpatient rehabilitation and post-sepsis aftercare in general. Open-ended questions were analyzed according to the principles of content analysis. Results Foun hundred interviews were performed with 287 patients and/or relatives. At 6 months after sepsis, 85.0% of survivors had applied for and 70.0% had undergone rehabilitation. Among these, 97% received physical therapy, but only a minority reported therapies for specific ailments including pain, weaning from mechanical ventilation, cognitive deficits of fatigue. Survivors were moderately satisfied with the suitability, extent, and overall results of received therapies and perceived deficits in the timeliness, accessibility, and specificity of therapies as well as deficits in the structural support frameworks and patient education. Conclusion From the perspective of survivors who undergo rehabilitation, therapies should already begin in hospital, be more appropriate for their specific ailments and include better patient and caregiver education. The general aftercare and structural support framework should be improved.
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Affiliation(s)
- Sebastian Born
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Claudia Matthäus-Krämer
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Anna Bichmann
- Department of Anesthesiology and Operative Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hannah-Sophia Boltz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Marlene Esch
- Department of Anesthesiology and Operative Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Luisa Heydt
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Stefan Sell
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Kathleen Streich
- Department of Anesthesiology and Operative Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - André Scherag
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christiane S. Hartog
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Klinik Bavaria, Kreischa, Germany
| | - Carolin Fleischmann-Struzek
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- *Correspondence: Carolin Fleischmann-Struzek,
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17
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Hope AA, McPeake J. Healthcare delivery and recovery after critical illness. Curr Opin Crit Care 2022; 28:566-571. [PMID: 35975964 DOI: 10.1097/mcc.0000000000000984] [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] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Aluko A Hope
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - Joanne McPeake
- The Institute of Healthcare Improvement Studies, University of Cambridge, Cambridge
- The Improvement Hub, Healthcare Improvement Scotland, Glasgow, UK
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18
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Jain S, Hauschildt K, Scheunemann LP. Social determinants of recovery. Curr Opin Crit Care 2022; 28:557-565. [PMID: 35993295 DOI: 10.1097/mcc.0000000000000982] [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] [Indexed: 11/25/2022]
Abstract
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.
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19
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Receipt of Recovery-Oriented Care Practices During Hospitalization for Sepsis. Crit Care Explor 2022; 4:e0766. [DOI: 10.1097/cce.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Toward Tailored Care for Sepsis Survivors. Ann Am Thorac Soc 2022; 19:1271-1272. [PMID: 35913466 PMCID: PMC9353950 DOI: 10.1513/annalsats.202203-240ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Amrollahi F, Shashikumar SP, Meier A, Ohno-Machado L, Nemati S, Wardi G. Inclusion of social determinants of health improves sepsis readmission prediction models. J Am Med Inform Assoc 2022; 29:1263-1270. [PMID: 35511233 PMCID: PMC9196687 DOI: 10.1093/jamia/ocac060] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/22/2022] [Accepted: 04/12/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Sepsis has a high rate of 30-day unplanned readmissions. Predictive modeling has been suggested as a tool to identify high-risk patients. However, existing sepsis readmission models have low predictive value and most predictive factors in such models are not actionable. MATERIALS AND METHODS Data from patients enrolled in the AllofUs Research Program cohort from 35 hospitals were used to develop a multicenter validated sepsis-related unplanned readmission model that incorporates clinical and social determinants of health (SDH) to predict 30-day unplanned readmissions. Sepsis cases were identified using concepts represented in the Observational Medical Outcomes Partnership. The dataset included over 60 clinical/laboratory features and over 100 SDH features. RESULTS Incorporation of SDH factors into our model of clinical and demographic features improves model area under the receiver operating characteristic curve (AUC) significantly (from 0.75 to 0.80; P < .001). Model-agnostic interpretability techniques revealed demographics, economic stability, and delay in getting medical care as important SDH predictive features of unplanned hospital readmissions. DISCUSSION This work represents one of the largest studies of sepsis readmissions using objective clinical data to date (8935 septic index encounters). SDH are important to determine which sepsis patients are more likely to have an unplanned 30-day readmission. The AllofUS dataset provides granular data from a diverse set of individuals, making this model potentially more generalizable than prior models. CONCLUSION Use of SDH improves predictive performance of a model to identify which sepsis patients are at high risk of an unplanned 30-day readmission.
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Affiliation(s)
- Fatemeh Amrollahi
- Division of Biomedical Informatics, University of California San Diego, San Diego, California, USA
| | - Supreeth P Shashikumar
- Division of Biomedical Informatics, University of California San Diego, San Diego, California, USA
| | - Angela Meier
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California, USA
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, University of California San Diego, San Diego, California, USA
| | - Shamim Nemati
- Division of Biomedical Informatics, University of California San Diego, San Diego, California, USA
| | - Gabriel Wardi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California, USA.,Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
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22
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Fleischmann-Struzek C, Rose N, Born S, Freytag A, Ditscheid B, Storch J, Schettler A, Schlattmann P, Wedekind L, Pletz MW, Sänger S, Brunsmann F, Oehmichen F, Apfelbacher C, Drewitz KP, Piedmont S, Denke C, Vollmar HC, Schmidt K, Landgraf I, Bodechtel U, Trumann A, Hecker R, Reinhart K, Hartog CS. [White Paper - Improving the care of patients with impairments following sepsis and infections]. Dtsch Med Wochenschr 2022; 147:485-491. [PMID: 35405753 DOI: 10.1055/a-1741-3013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hundreds of thousands of individuals who experience lasting sequelae after sepsis and infections in Germany do not receive optimal care. In this White Paper we present measures for improvement, which were developed by a multidisciplinary expect panel as part of the SEPFROK project. Improved care rests on four pillars: 1. cross-sectoral assessment of sequelae and a structured discharge and transition management, 2. interdisciplinary rehabilitation and aftercare with structural support, 3. strengthening the specific health literacy of patients and families, and 4. increased research into causes, prevention and treatment of sequelae. To achieve this, appropriate cross-sectoral care structures and legal frameworks must be created.
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Affiliation(s)
- Carolin Fleischmann-Struzek
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena.,IFB Sepsis und Sepsisfolgen, Universitätsklinikum Jena
| | - Norman Rose
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena.,IFB Sepsis und Sepsisfolgen, Universitätsklinikum Jena
| | - Sebastian Born
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena.,IFB Sepsis und Sepsisfolgen, Universitätsklinikum Jena
| | - Antje Freytag
- Institut für Allgemeinmedizin, Universitätsklinikum Jena
| | | | | | - Anna Schettler
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena.,Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena
| | - Peter Schlattmann
- Institut für Medizinische Statistik, Informatik und Datenwissenschaften, Universitätsklinikum Jena
| | - Lisa Wedekind
- Institut für Medizinische Statistik, Informatik und Datenwissenschaften, Universitätsklinikum Jena
| | - Mathias W Pletz
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena
| | | | - Frank Brunsmann
- Co-Sprecher der Patientenvertretung im UA Qualitätssicherung des Gemeinsamen Bundesausschusses, Berlin
| | | | - Christian Apfelbacher
- Institut für Sozialmedizin und Gesundheitssystemforschung, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg
| | - Karl-Philipp Drewitz
- Institut für Sozialmedizin und Gesundheitssystemforschung, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg
| | - Silke Piedmont
- Institut für Sozialmedizin und Gesundheitssystemforschung, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg
| | - Claudia Denke
- Klinik für Anästhesie mit Schwerpunkt Operative Intensivmedizin, Charité -Universitätsmedizin Berlin
| | - Horst C Vollmar
- Abteilung für Allgemeinmedizin (AM RUB), Medizinische Fakultät, Ruhr-Universität Bochum (RUB)
| | - Konrad Schmidt
- Institut für Allgemeinmedizin, Universitätsklinikum Jena.,Institut für Allgemeinmedizin, Charité - Universitätsmedizin Berlin
| | | | | | | | | | - Konrad Reinhart
- Klinik für Anästhesie mit Schwerpunkt Operative Intensivmedizin, Charité -Universitätsmedizin Berlin
| | - Christiane S Hartog
- Klinik Bavaria Kreischa.,Klinik für Anästhesie mit Schwerpunkt Operative Intensivmedizin, Charité -Universitätsmedizin Berlin
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23
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Kim SM, Ryoo SM, Shin TG, Park YS, Jo YH, Lim TH, Chung SP, Choi SH, Suh GJ, Kim WY. Prognostic factors for late death in septic shock survivors: a multi-center, prospective, registry-based observational study. Intern Emerg Med 2022; 17:865-871. [PMID: 34604939 DOI: 10.1007/s11739-021-02847-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023]
Abstract
Septic shock patients who survive past the acute period are associated with an increased risk of long-term mortality. However, factors for predicting late death remain unclear. We aimed to investigate the prognostic factors associated with late mortality in septic shock patients with 28-day survival after admission. This retrospective observational study used a prospective, multi-center registry of septic shock patients between October 2015 and December 2019 involving 12 emergency departments (EDs) from the Korean Shock Society. Adult septic shock patients visiting the ED with 28-day survival after admission were included. Among 4624 septic shock patients, 3588 (77.6%) who survived past day 28 were analyzed. The 90-day mortality rate was 14.2%. Non-survivors were older (66.8 vs. 68.9 years; p = 0.032) and had higher lactate levels (3.7 vs. 4.0 mmol/L; p = 0.028) than survivors. Pulmonary and hepatobiliary infections and a history of malignancy (27.7 vs. 57.5%; p < 0.001) were more frequent in the non-survivor group than in the survivor group. Independent risk factors for late death on multivariate regression analysis were age; malignancy; and hemoglobin, blood urea nitrogen, and albumin levels. The length of intensive care unit stay and Sequential Organ Failure Assessment score were independently associated with late death. Approximately, one-seventh of septic shock patients who survived past day 28 of admission died by day 90. Physicians must pay attention to survivors with these risk factors during the post-acute period as they have an increased mortality risk.
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Affiliation(s)
- Sang-Min Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
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24
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Bourne RS, Jennings JK, Panagioti M, Hodkinson A, Sutton A, Ashcroft DM. Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. BMJ Qual Saf 2022; 31:609-622. [PMID: 35042765 PMCID: PMC9304084 DOI: 10.1136/bmjqs-2021-013760] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/14/2021] [Indexed: 12/26/2022]
Abstract
BackgroundPatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.MethodsThe systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations.ResultsSeventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I2=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I2=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I2=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I2=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process.ConclusionsMulticomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.
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Affiliation(s)
- Richard S Bourne
- Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jennifer K Jennings
- Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Maria Panagioti
- National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (PSTRC), School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Alexander Hodkinson
- National Institute for Health Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Anthea Sutton
- School of Health and Related Sciences (ScHARR), The University of Sheffield, Sheffield, Sheffield, UK
| | - Darren M Ashcroft
- National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (PSTRC), School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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25
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Brown SM, Dinglas VD, Akhlaghi N, Bose S, Banner-Goodspeed V, Beesley S, Groat D, Greene T, Hopkins RO, Mir-Kasimov M, Sevin CM, Turnbull AE, Jackson JC, Needham DM. Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study. Crit Care 2022; 26:6. [PMID: 34991660 PMCID: PMC8738999 DOI: 10.1186/s13054-021-03848-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Survivors of acute respiratory failure (ARF) commonly experience long-lasting physical, cognitive, and/or mental health impairments. Unmet medication needs occurring immediately after hospital discharge may have an important effect on subsequent recovery. Methods and analysis In this multicenter prospective cohort study, we enrolled ARF survivors who were discharged directly home from their acute care hospitalization. The primary exposure was unmet medication needs. The primary outcome was hospital readmission or death within 3 months after discharge. We performed a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the exposure–outcome association, with an a priori sample size of 200 ARF survivors. Results We enrolled 200 ARF survivors, of whom 107 (53%) were female and 77 (39%) were people of color. Median (IQR) age was 55 (43–66) years, APACHE II score 20 (15–26) points, and hospital length of stay 14 (9–21) days. Of the 200 participants, 195 (98%) were in the analytic cohort. One hundred fourteen (57%) patients had at least one unmet medication need; the proportion of medication needs that were unmet was 6% (0–15%). Fifty-six (29%) patients were readmitted or died by 3 months; 10 (5%) died within 3 months. Unmet needs were not associated (risk ratio 1.25; 95% CI 0.75–2.1) with hospital readmission or death, although a higher proportion of unmet needs may have been associated with increased hospital readmission (risk ratio 1.7; 95% CI 0.96–3.1) and decreased mortality (risk ratio 0.13; 95% CI 0.02–0.99). Discussion Unmet medication needs are common among survivors of acute respiratory failure shortly after discharge home. The association of unmet medication needs with 3-month readmission and mortality is complex and requires additional investigation to inform clinical trials of interventions to reduce unmet medication needs. Study registration number: NCT03738774. The study was prospectively registered before enrollment of the first patient. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03848-3.
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Affiliation(s)
- Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA. .,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA. .,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA. .,Shock Trauma ICU, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, 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
| | - Narjes Akhlaghi
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Somnath Bose
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sarah Beesley
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Danielle Groat
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Tom Greene
- Biostatistics and Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA.,Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Mustafa Mir-Kasimov
- Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.,Salt Lake City Veterans Administration, Salt Lake City, UT, USA
| | - Carla M Sevin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 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
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26
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 852] [Impact Index Per Article: 284.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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27
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1400] [Impact Index Per Article: 466.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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28
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Khemani RG, Lee JT, Wu D, Schenck EJ, Hayes MM, Kritek PA, Mutlu GM, Gershengorn HB, Coudroy R. Update in Critical Care 2020. Am J Respir Crit Care Med 2021; 203:1088-1098. [PMID: 33734938 DOI: 10.1164/rccm.202102-0336up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jessica T Lee
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Wu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patricia A Kritek
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Washington Seattle, Washington
| | - Gökhan M Mutlu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rémi Coudroy
- Institut National de la Santé et de la Recherche Médicale, Poitiers, France; and.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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29
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Kowalkowski M, Eaton T, McWilliams A, Tapp H, Rios A, Murphy S, Burns R, Gutnik B, O'Hare K, McCurdy L, Dulin M, Blanchette C, Chou SH, Halpern S, Angus DC, Taylor SP. Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS). BMC Health Serv Res 2021; 21:544. [PMID: 34078374 PMCID: PMC8170654 DOI: 10.1186/s12913-021-06521-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation. METHODS This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation. DISCUSSION This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems. TRIAL REGISTRATION NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.
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Affiliation(s)
- Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.
| | - Tara Eaton
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.,Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, USA
| | - Aleta Rios
- Ambulatory Care Management, Atrium Health, Charlotte, USA
| | | | - Ryan Burns
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Bella Gutnik
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | | | - Lewis McCurdy
- Division of Infectious Disease, Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte & Mecklenburg County Public Health Department, Charlotte, USA.,Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
| | - Christopher Blanchette
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA.,Health Economics and Outcomes Research Strategy, Novo Nordisk, Plainsboro Township, USA
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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Rousseau AF, Prescott HC, Brett SJ, Weiss B, Azoulay E, Creteur J, Latronico N, Hough CL, Weber-Carstens S, Vincent JL, Preiser JC. Long-term outcomes after critical illness: recent insights. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:108. [PMID: 33731201 PMCID: PMC7968190 DOI: 10.1186/s13054-021-03535-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/05/2021] [Indexed: 02/08/2023]
Abstract
Intensive care survivors often experience post-intensive care sequelae, which are frequently gathered together under the term “post-intensive care syndrome” (PICS). The consequences of PICS on quality of life, health-related costs and hospital readmissions are real public health problems. In the present Viewpoint, we summarize current knowledge and gaps in our understanding of PICS and approaches to management.
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Affiliation(s)
- Anne-Françoise Rousseau
- Department of Intensive Care and Burn Center, University Hospital, University of Liège, Liège, Belgium
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Stephen J Brett
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Elie Azoulay
- Réanimation Médicale, Hôpital St Louis, Paris, France
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicola Latronico
- Department of Anesthesiology, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.,Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. .,Erasme University Hospital, Route de Lennik 808, Brussels, Belgium.
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31
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Akhlaghi N, Needham DM, Bose S, Banner-Goodspeed VM, Beesley SJ, Dinglas VD, Groat D, Greene T, Hopkins RO, Jackson J, Mir-Kasimov M, Sevin CM, Wilson E, Brown SM. Evaluating the association between unmet healthcare needs and subsequent clinical outcomes: protocol for the Addressing Post-Intensive Care Syndrome-01 (APICS-01) multicentre cohort study. BMJ Open 2020; 10:e040830. [PMID: 33099499 PMCID: PMC7590359 DOI: 10.1136/bmjopen-2020-040830] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION As short-term mortality declines for critically ill patients, a growing number of survivors face long-term physical, cognitive and/or mental health impairments. After hospital discharge, many critical illness survivors require an in-depth plan to address their healthcare needs. Early after hospital discharge, numerous survivors experience inadequate care or a mismatch between their healthcare needs and what is provided. Many patients are readmitted to the hospital, have substantial healthcare resource use and experience long-lasting morbidity. The objective of this study is to investigate the gap in healthcare needs occurring immediately after hospital discharge and its association with hospital readmissions or death for survivors of acute respiratory failure (ARF). METHODS AND ANALYSIS In this multicentre prospective cohort study, we will enrol 200 survivors of ARF in the intensive care unit (ICU) who are discharged directly home from their acute care hospital stay. Unmet healthcare needs, the primary exposure of interest, will be evaluated as soon as possible within 1 to 4 weeks after hospital discharge, via a standardised telephone assessment. The primary outcome, death or hospital readmission, will be measured at 3 months after discharge. Secondary outcomes (eg, quality of life, cognitive impairment, depression, anxiety and post-traumatic stress disorder) will be measured as part of 3-month and 6-month telephone-based follow-up assessments. Descriptive statistics will be reported for the exposure and outcome variables along with a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the relationship between the primary exposure and outcome. ETHICS AND DISSEMINATION The study received ethics approval from Vanderbilt University Medical Center Institutional Review Board (IRB) and the University of Utah IRB (for the Veterans Affairs site). These results will inform both clinical practice and future interventional trials in the field. We plan to disseminate the results in peer-reviewed journals, and via national and international conferences. TRIAL REGISTRATION DETAILS ClinicalTrials.gov (NCT03738774). Registered before enrollment of the first patient.
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Affiliation(s)
- Narjes Akhlaghi
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Somnath Bose
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Valerie M Banner-Goodspeed
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Sarah J Beesley
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Danielle Groat
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Tom Greene
- Division of Epidemiology Biostatistics, University of Utah, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
- Psychology and Neuroscience, Brigham Young University, Provo, UT, USA
| | - James Jackson
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mustafa Mir-Kasimov
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Carla M Sevin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emily Wilson
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Samuel M Brown
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Abstract
PURPOSE OF REVIEW Critical illness survivorship is associated with new and worsening physical, cognitive, and emotional status. Survivors are vulnerable to further health set-backs, most commonly because of infection and exacerbation of chronic medical conditions. Awareness of survivors' challenges are important given the anticipated rise in critical illness survivors because of SARS-CoV-2 viral sepsis. RECENT FINDINGS Studies continue to document challenges of critical illness survivorship. Beyond the cognitive, physical, and mental health sequelae encompassed by postintensive case syndrome, patients commonly experience persistent immunosuppression, re-hospitalization, inability to resume prior employment, and reduced quality of life. Although recommended practices for enhancing recovery from sepsis are associated with better outcomes, only a minority of patients receive all recommended practices. ICU follow-up programs or peer support groups remain important interventions to learn about and address the multifaceted challenges of critical illness survivorship, but there is little evidence of benefit to date. SUMMARY Survivors of sepsis and critical illness commonly experience impaired health status, reduced quality of life, and inability to return to prior employment. Although the challenges of critical illness survivorship are increasingly well documented, there are relatively few studies on enhancing recovery. Future studies must focus on identifying best practices for optimizing recovery and strategies to promote their implementation.
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Affiliation(s)
- Hallie C Prescott
- Department of Internal Medicine, University of Michigan.,VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Jeremy B Sussman
- Department of Internal Medicine, University of Michigan.,VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - W Joost Wiersinga
- Department of Medicine, Division of Infectious Diseases.,Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Shankar-Hari M, Rubenfeld GD, Ferrando-Vivas P, Harrison DA, Rowan K. Development, Validation, and Clinical Utility Assessment of a Prognostic Score for 1-Year Unplanned Rehospitalization or Death of Adult Sepsis Survivors. JAMA Netw Open 2020; 3:e2013580. [PMID: 32926114 PMCID: PMC7490647 DOI: 10.1001/jamanetworkopen.2020.13580] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE The longer-term risk of rehospitalizations and death of adult sepsis survivors is associated with index sepsis illness characteristics. OBJECTIVE To derive and validate a parsimonious prognostic score for unplanned rehospitalizations or death in the first year after hospital discharge of adult sepsis survivors. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Intensive Care National Audit & Research Centre Case Mix Programme database on adult sepsis survivors identified from consecutive critical care admissions to 192 adult general critical care units in England, United Kingdom, between April 1, 2009, and March 31, 2014 (94 748 patients in the derivation cohort), and between April 1, 2014, and March 31, 2015 (24 669 patients in the validation cohort). Statistical analysis was performed from July 5 to October 31, 2019. Generic characteristics (age, sex, race/ethnicity, 2015 Index of Multiple Deprivation [IMD2015] in England quintiles, preadmission dependence, previous hospitalizations in the year preceding index sepsis admission, comorbidity, admission type, Acute Physiology and Chronic Health Evaluation II physiology score, hospital length of stay, worst blood lactate and blood hemoglobin concentrations, and type of hospital) and sepsis-specific characteristics (site of infection, numbers of organ dysfunctions, and organ support) at the index sepsis admission were used as predictors. MAIN OUTCOMES AND MEASURES Prognostic score derived and validated using multivariable logistic regression for the outcome of unplanned rehospitalization or death in the first year after hospital discharge of adult sepsis survivors, as well as clinical usefulness assessed using decision curve analysis. Prognostic score validation was performed for internal validation with bootstrapping and temporal cohort external validation. RESULTS This cohort study included 94 748 patients (51 164 men [54.0%]; mean [SD] age, 61.3 [17.0] years) in the derivation cohort and 24 669 patients (13 255 men [53.7%]; mean [SD] age, 62.1 [16.8%]) in the validation cohort. Unplanned rehospitalization or death in the first year after hospital discharge occurred for 48 594 patients (51.3%) in the derivation cohort and 13 129 patients (53.2%) in the validation cohort. Eight independent predictors were identified and weighted to generate a prognostic score for every patient: previous hospitalizations, age in 10-year increments, IMD2015 in England quintiles, preadmission dependence, comorbidities, admission type, blood hemoglobin level, and site of infection. The total prognostic score ranged from 0 to 22 points, with lower scores indicating a lower risk of the outcome. The derivation and validation cohorts had similar rates of prognostic scores of 0 to 4 points (5088 of 16 684 patients [30.5%] and 471 of 1725 patients [27.3%]) and prognostic scores of 11 points or more (15 732 of 21 641 patients [72.7%] and 5753 of 7952 patients [72.3%]). The area under the receiver operating characteristic curve for the prognostic score was 0.675 (95% CI, 0.672-0.679). The decision curve analysis highlighted an optimal score cutoff of 7 points or more. CONCLUSIONS AND RELEVANCE The prognostic score reported in this study uses 8 internationally feasible predictors measured during the index sepsis admission and provides clinically useful information on sepsis survivors' risk of unplanned rehospitalization or death in the first year after hospital discharge.
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Affiliation(s)
- Manu Shankar-Hari
- Guy’s and St Thomas’ NHS Foundation Trust, ICU Support Offices, St Thomas’ Hospital, London, United Kingdom
- School of Immunology & Microbial Sciences, King’s College London, London, United Kingdom
| | - Gordon D. Rubenfeld
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Associate Editor, JAMA Network Open
| | - Paloma Ferrando-Vivas
- Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom
| | - David A. Harrison
- Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom
| | - Kathryn Rowan
- Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom
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Affiliation(s)
- Hallie C Prescott
- Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Medication-related Problems in Intensive Care Unit Survivors: Learning from a Multicenter Program. Ann Am Thorac Soc 2020; 17:1326-1329. [PMID: 32716636 PMCID: PMC7640628 DOI: 10.1513/annalsats.202005-444rl] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Introduction: Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury common in critically ill patients and characterized by significant morbidity and mortality. It frequently manifests long-lasting effects beyond hospitalization, from cognitive impairment to physical weakness.Areas covered: Several complications of ARDS have been identified in patients after hospital discharge. The authors conducted literature searches to identify observational studies, randomized clinical trials, systematic reviews, and guidelines. A summary of is presented here to outline the sequelae of ARDS and their risk factors with a focus on the limited but growing research into possible therapies. Long term sequelae of ARDS commonly identified in the literature include long-term cognitive impairment, psychological morbidities, neuromuscular weakness, pulmonary dysfunction, and ongoing healthcare utilization with reduced quality of life.Expert opinion: Given the public health significance of long-term complications following ARDS, the development of new therapies for prevention and treatment is of vital importance. Furthering knowledge of the pathophysiology of these impairments will provide a framework to develop new therapeutic targets to fuel future clinical trials in this area of critical care medicine.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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