Critical Care Survivors Research Articles

Conceptualizing and measuring health-related quality of life in critical care

IntroductionWhen assessing health-related quality of life (HRQL), critical care outcomes research generally uses generic measures in the absence of a suitable critical care–specific measure. Our aims were to construct a conceptual framework of survivors' HRQL and assess the extent to which the 2 most commonly used generic measures (the Short Form 36 Health Survey and EuroQol-5D) covered the framework. MethodsA preliminary framework for survivors' HRQL was constructed based on a systematic literature review and on a secondary analysis of 40 existing in-depth interviews with adult, critical care survivors. Its adequacy was then tested using new in-depth interviews with a maximum variation sample of critical care survivors. The extent of coverage of the final framework by the 2 generic HRQL instruments was then evaluated in 2 ways: by comparison with critical care survivors' accounts from the new in-depth interviews and by eliciting survivors' views on the adequacy of the 2 generic HRQL instruments using cognitive debriefing. ResultsThe final framework recognized 3 aspects of health status that affected 9 areas of life. The 2 most commonly used generic measures had substantial gaps in their coverage of the framework of survivors' HRQL. ConclusionsThe findings argue strongly for a new critical care–specific HRQL measure.

Risk of a Diagnosis of Dementia for Elderly Medicare Beneficiaries after Intensive Care.

Critical illness is likely associated with an increased risk of dementia, but the magnitude remains uncertain. The cohort was a random 2.5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge. Patients were matched with general population controls (age, sex, and race) with 3 yr of follow-up. The authors used an extended Cox model to assess the risk of a diagnosis of dementia, adjusting for the known risk factors for dementia, and the competing risk of death. Among 10,348 intensive care patients who survived to hospital discharge, dementia was newly diagnosed in 1,648 (15.0%) over the 3 yr of follow-up versus 12.2% in controls (incidence per 1,000 person-years, 73.6; 95% CI, 70.0 to 77.1 vs. 45.8; 95% CI, 43.2 to 48.3; hazard ratio [HR], 1.61; 95% CI, 1.50 to 1.74; P < 0.001). After accounting for the known risk factors in the year before the index hospitalization, the risk of receiving a diagnosis of dementia remained increased in patients who received intensive care (adjusted HR, 1.43; 95% CI, 1.32 to 1.54; P < 0.001). Inclusion of identifiable risk factors accrued during the quarter of critical illness accounted for almost all of the increased risks (adjusted HR, 1.09; 95% CI, 1.00 to 1.20; P = 0.06). Elderly critical care survivors have a 60% increased relative risk, but only 3% increased absolute risk, of receiving a diagnosis of dementia in the subsequent 3 yr compared with the general population. This increased risk is not accounted for by risk factors preexisting the critical illness. Surveillance bias, which increases the likelihood of receiving a diagnosis of dementia, could account for some or all of these additional risks.

Key Measurement and Feasibility Characteristics When Selecting Outcome Measures

Selection of appropriate outcome measures to assess progress in physical rehabilitation across the complete recovery continuum is essential but may pose challenges in clinical practice. This paper examines key measurement and feasibility characteristics for outcome measures, using critical care survivors as an exemplar. With increased survivorship following a critical illness, initiatives to improve the recovery trajectory for patients have become a focus for clinicians and researchers. For this patient cohort, we present a 3-tier framework and use of standing and non-standing patient phenotypes to guide instrument selection. Key measurement issues for clinicians to consider include the responsiveness, criterion validity, and reliability of functional assessment instruments. Patient-centered factors that may influence performance and the effectiveness of assessments include frailty, fatigue, and other varied symptoms of patient discomfort. Suggestions to address these challenges are discussed, specifically prioritizing outcome measurement according to tier, consideration of patient and ICU-related factors, and recommendations to standardize outcome measurement to a core set.

Psychosocial outcomes in informal caregivers of the critically ill: a systematic review.

The objective of the review was to evaluate and synthesize the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. A systematic search of MEDLINE, PsychInfo, PubMed, CINAHL, Cochrane Library, Scopus, PILOTS, EMBASE, and Physiotherapy Evidence Database was undertaken between January and February 2014. Citations were screened independently by two reviewers for studies that investigated psychosocial outcomes (depression, anxiety, stress, posttraumatic stress disorder, burden, activity restriction, and health-related quality of life) for informal caregivers of critical care survivors (mechanically ventilated for 48 hr or more). Data on study outcomes were extracted into a standardized form and quality assessed by two independent reviewers using the Newcastle-Ottawa Scale, the Physiotherapy Evidence Database, and the National Health and Medical Research Council Hierarchy of Evidence guide. Preferred Reporting Items for Systematic Reviews guidelines were followed. Fourteen studies of 1,491 caregivers were included. Depressive symptoms were the most commonly reported outcome with a prevalence of 75.5% during critical care and 22.8-29% at 1-year follow-up. Risk factors for depressive symptoms in caregivers included female gender and younger age. The greatest period of risk for all outcomes was during the patient's critical care admission although psychological symptoms improved over time. The overall quality of the studies was low. Depressive symptoms were the most prevalent in informal caregivers of survivors of intensive care who were ventilated for more than 48 hours and persist at 1 year with a prevalence of 22.8-29.0%, which is comparable with caregivers of patients with dementia. Screening for caregiver risks could be performed during the ICU admission where intervention can be implemented and then evaluated. Further high-quality studies are needed to quantify anxiety, stress, caregiver burden, and posttraumatic stress disorder outcomes in informal caregivers of long-stay patients surviving ICU.

Sedation and analgesia for critically ill children

Abstract Effective sedation and analgesia in the critically ill child ensures physical comfort and minimises psychological distress. In the UK the most commonly used sedative and analgesic agents for critically ill children are midazolam and either morphine or fentanyl. Consensus clinical practice guidelines for the provision of sedation and analgesia in critically ill children were published in 2006 by the UK Paediatric Intensive Care Society, but considerable variation in practice persists. It is important to treat pain, and in addition to the obvious immediate effects of untreated pain there is increasing evidence that pain experienced early in life may result in long-term changes in neurosensory function. There are however also concerns that sedative and analgesic agents may themselves be associated with developmental neurotoxicity, particularly amongst neonates, and adverse psychological outcomes in survivors of critical care. Withdrawal syndrome and delirium remain poorly understood, although we have emerging tools such as the Sophia Observation withdrawal Symptoms-scale (SOS) and the paediatric Confusion Assessment Method for the ICU (pCAM-ICU). The most important single factor in reducing avoidable psychological morbidity in survivors of PICU is to minimise the administered doses of sedative and analgesic agents.

Respiratory physiotherapy in the critical care unit

Physiotherapists are an integral part of the multidisciplinary team in the critical care unit and are skilled in the multisystem patient assessment and treatment of both intubated and spontaneously breathing patients. In addition to respiratory management, other key roles include the management of neurological and musculoskeletal complications of critical care. Historically, the main focus of physiotherapy in critical care had been the management of respiratory complications; however, there is now evidence that survivors of critical care have long-standing weakness and limitations of functional capacity that has led to exercise rehabilitation being incorporated into standard practice. Respiratory pathologies are among the most common cause of admission to critical care. A number of patients will also progress to respiratory failure during their admission; this could be secondary to postoperative respiratory failure, the development of pneumonia, in particular ventilator-associated pneumonia (VAP) or after a failed extubation. While the exact role of the physiotherapist varies across critical care units within the UK and also worldwide, many of the techniques outlined below are likely to be used. There is a lack of randomized controlled trials to support the role of the physiotherapist, but there is a long history of physiotherapists playing a pivotal part in critical care teams. The aim of this article is to provide an overview of these techniques.

Utilisation of existing community rehabilitation services by critical care survivors

Patients recovering from critical illness suffer many physical and psychological problems during their recovery, including muscle weakness, fatigue, signs and symptoms of PTSD, anxiety and depression [1]. At present, specialist intensive care follow-up and rehabilitation is inconsistent and in many geographical areas is nonexistent. As a result, many survivors of critical illness will require using existing community rehabilitation services [2]. The aim of this present service evaluation was to understand the utilisation of community rehabilitation services by critical care survivors.

Do generic measures fully capture health-related quality of life in adult, general critical care survivors?

We examined the extent to which the two generic health- related quality of life (HRQL) measures recommended for use in adult, general critical care [1] - the SF-36 and EQ-5D - captured survivors' HRQL, which is important in assessing the effectiveness of critical care. Unlike other fields of healthcare that employ both generic and specific HRQL measures, most recent studies in critical care have used only generic measures, despite uncertainty as to their appropriateness.

Life after critical illness: an overview

To illustrate the potential physical and psychological problems faced by patients after an episode of critical illness, highlight some of the interventions that have been tested and identify areas for future research. Recovery from critical illness is an international problem and as an issue is likely to increase. For some, recovery from critical illness is prolonged, subject to physical and psychological problems that may negatively impact upon health-related quality of life. The literature accessed for this review includes the work of a number of key researchers in the field of critical care research. These were identified from a number of sources include (1) personal knowledge of the research field accumulated over the last decade and (2) using the search engine 'The Knowledge Network Scotland'. Fatigue and weakness are significant problems for critical care survivors and are common in patients who have been in ICU for more than one week. Psychological problems include anxiety, depression, post-traumatic stress, delirium and cognitive impairment. Prevalence of these problems is difficult to establish for a number of methodological reasons that include the use of self-report questionnaires, the number of different questionnaires used and the variation in administration and timing. Certain subgroups of ICU survivors especially those at the more severe end of the illness severity spectrum are more at risk and this has been demonstrated for both physical and psychological problems. Findings from international studies of a range of potential interventions are presented. However, establishing effectiveness for most of these still has to be empirically demonstrated. What seems clear is the need for a co-ordinated, multidisciplinary, designated recovery and rehabilitation pathway that begins as soon as the patient is admitted into an intensive care unit.

Cognitive Dysfunction in ICU Patients

In contrast to other clinical outcomes, long-term cognitive function in critical care survivors has not been deeply studied. In this narrative review, we summarize the existing literature on the prevalence, mechanisms, risk factors, and prediction of cognitive impairment after surviving critical illness. Depending on the exact clinical subgroup, up to 100% of critical care survivors may suffer some degree of long-term cognitive impairment at hospital discharge; in approximately 50%, decrements in cognitive function will persist years later. Although the mechanisms of acquiring this impairment are poorly understood, several risk factors have been identified. Unfortunately, no easy means of predicting long-term cognitive impairment exists. Despite this barrier, research is ongoing to test possible treatments for cognitive impairment. In particular, the potential role of exercise on cognitive recovery is an exciting area of exploration. Opportunities exist to incorporate physical and cognitive rehabilitation strategies across a spectrum of environments (in the ICU, on the hospital ward, and at home, posthospital discharge).

Late Onset and Persistence of Post-Traumatic Stress Disorder Symptoms in Survivors of Critical Care

Several recent studies have reported that post-traumatic stress disorder (PTSD) is a frequent occurrence in survivors of an intensive care unit (ICU) admission. To assess the frequency of PTSD symptoms at three and nine months post-ICU admission and examine possible risk factors that predispose to the development of PTSD symptoms. Using the following scales: Davidson Trauma Scale, Impact of Event Scale and the Post-traumatic Symptom Scale, 69 ICU survivors were assessed for PTSD symptoms at three months post-ICU admission. Of the original 69 patients, 37 completed the same questionnaires at the second follow-up at nine months post-ICU admission. Mean symptom levels for avoidance, intrusive thoughts and hyperarousal were calculated, and risk factors for the development of PTSD symptomatology were examined. Depending on which scale was used, 16% to 33% of ICU survivors met the criteria for PTSD at either three or nine months. Younger age and the use of a prescription psychoactive medication at time of ICU admission were both independently associated with a higher risk of developing PTSD symptoms. Interestingly, symptoms of hyperarousal worsened during the follow-up interval for female patients, while they remained constant for males. The frequency of PTSD symptoms was high in patients who survived an admission to the ICU. Depending on sex, symptoms may present and evolve differently. The adoption of screening tools and a multicentre ICU database in Canada is recommended to identify patients who are most at risk.

The assessment and risk stratification of psychological morbidity in critical care survivors

Along with the ageing population, there is an expanding number of critical care survivors in the community. This group is at risk for both physical and psychological morbidity following their stay. Factors that predispose patients to commonly reported sequelae such as post-traumatic stress disorder, anxiety and depression remain incompletely elucidated. A tool to identify and stratify survivors at discharge may improve outcomes by allowing early and targeted intervention. Looking forward, the identification of aspects of practice associated with long-term adverse consequences should allow us to evolve our current protocols in a way that provides long-term benefit for patients.

Anemia among Pediatric Critical Care Survivors: Prevalence and Resolution

To determine the incidence of anemia among pediatric critical care survivors and to determine whether it resolves within 6 months of discharge. Design. A prospective observational study. Patients with anemia upon discharge from the pediatric critical care unit (PCCU) underwent in hospital and post hospital discharge followup (4–6 months) for hemoglobin (Hb) levels. Setting. A medical-surgical PCCU in a tertiary care center. Patients. Patients aged 28 days to 18 years who were treated in the PCCU for over 24 hours. Measurements and Main Results. 94 (24%) out of 392 eligible patients were anemic at time of discharge. Patients with anemia were older, median 8.0 yrs [(IQR 1.0–14.4) versus 3.2 yrs (IQR 0.65–9.9) (P < 0.001)], and had higher PeLOD [median 11 (IQR 10–12) versus 1.5 (1–4) (P < 0.001)], and PRISM [median 5 (IQR 2–11) versus 3 (IQR 0–6) (P < 0.001)] scores. The Hb level normalized in 32% of patients before discharge from hospital. Of the 28 patients who completed followup, all had normalization of their Hb in the absence of medical intervention. Conclusions. Anemia is not common among patients discharged from the PCCU and recovers spontaneously within 4–6 months.

Understanding Hospital 30-Day Readmissions in Critical Care Survivors After Requiring Mechanical Ventilation

SESSION TYPE: Improving Processes and Outcomes in Adult Critical Care

Survivors of critical illness: victims of our success?

> ‘For many patients the recovery after critical illness is relatively straightforward and it is important not to lose sight of this. What is clear is that tens of thousands of patients leave critical care to go home each year, and it is likely that poor-quality recovery represents a substantial problem. Given the individual impact on patients and ripple effects on families and society in general, poor-quality rehabilitation and impaired recovery from severe illness should be regarded as a major public health issue.’1 From its origins in Copenhagen during the poliomyelitis epidemic of 1952, the critical care unit has grown into a facility central to modern hospital medicine. Changes in medical practice and public expectation are placing increasing demands on critical care services. The Intensive Care National Audit & Research Centre recorded 96 810 admissions from April 2009 to March 2010 to 188 critical care units in England, Wales, and Northern Ireland, of whom 83.1% were discharged alive from critical care and 74.8% from hospital.2 Most patients admitted to critical care stay short periods of time and make complete and uncomplicated recoveries. However, follow-up of critical care survivors and caregivers has consistently shown that many report physical and psychological problems affecting quality-of-life, sometimes years after the admitting insult.3 These long-term effects were often overlooked by all but a few enthusiastic researchers.4 In 2009, the National Institute for Health and Clinical …

Transitions Experienced by Older Survivors of Critical Care

The transition from hospital to home is complicated for older adults who experience a serious or life-threatening illness. The specific aims of this prospective, observational cohort study were to determine the number of older adults who experience a change in their functional ability and residence after an intensive care unit (ICU) stay and to explore risk factors for functional decline and new institutionalization at hospital discharge. We found high rates of unrecognized preexisting cognitive impairment, delirium, complications, functional decline, and new institutionalization in this sample (N = 43). A number of variables were associated with functional decline or new institutionalization, including narcotic agent use (p = 0.03), ICU complications (p = 0.05), comorbidities (p = 0.01), depression (p = 0.05), and severity of illness (p = 0.05). We identified device self-removal, admission type, and ICU delirium as also potentially associated with these outcomes (p ≤ 0.25). There are a number of important and potentially modifiable factors that influence an older adult's ability to recover after a critical illness.

Transitions Experienced by Older Survivors of Critical Care

The transition from hospital to home is complicated for older adults who experience a serious or life-threatening illness. The specific aims of this prospective, observational cohort study were to determine the number of older adults who experience a change in their functional ability and residence after an intensive care unit (ICU) stay and to explore risk factors for functional decline and new institutionalization at hospital discharge. We found high rates of unrecognized preexisting cognitive impairment, delirium, complications, functional decline, and new institutionalization in this sample (N = 43). A number of variables were associated with functional decline or new institutionalization, including narcotic agent use (p = 0.03), ICU complications (p = 0.05), comorbidities (p = 0.01), depression (p = 0.05), and severity of illness (p = 0.05). We identified device self-removal, admission type, and ICU delirium as also potentially associated with these outcomes (p ≤ 0.25). There are a number of important and potentially modifiable factors that influence an older adult's ability to recover after a critical illness.

P248 Measuring physical recovery in the critical care population: development of the Chelsea critical care physical assessment tool (CPAx)

IntroductionThe secondary physical effects of critical illness, for example, muscle atrophy, can be detrimental to functional outcome and quality of life in critical care survivors. To minimise these problems early...

Evaluation of Exercise Rehabilitation for Survivors of Intensive Care: Protocol for a Single Blind Randomised Controlled Trial

Introduction: Intensive care (ICU) survivors have poor quality of life (QoL) and physical outcomes compared to people of the same age and sex (1). Although rehabilitation of patients in ICU is now advocated as routine clinical prac- tice (2) there are few randomised controlled trials (RCTs) examining patient outcomes. The primary aim of this single blind randomised controlled trial is to investigate the efficacy of a comprehensive rehabilitation intervention begun in ICU compared to standard care on health related quality of life (HRQoL) and physical function. Method: Participants who have been in one tertiary ICU for � 5 days, aged � 18 years, who can understand written and spoken English, will be randomly allocated to receive either standard care or a comprehensive physiotherapy rehabilita- tion program beginning in ICU and continuing upon discharge to the ward and as an out patient (OP). Blinded assessment of the primary outcome measures physical function, health status and HRQoL will be performed at baseline, 3, 6 and 12 months after discharge. Physical function measures will be obtained at ICU and hospital discharge and for the intervention group, pre and post OP classes. The intervention will include individualised exercises prescribed by physiotherapists in ICU and on the ward and given by an exercise physiologist and physiotherapist in OP. Results: We aim to enrol 200 participants over two years. The study will determine whether comprehensive physiotherapy rehabilitation from ICU to discharge and OP attendance will improve physical functioning, health status and quality of life in critical care survivors. The cost utility (CUA) and cost effectiveness of such a program will also be evaluated using util- ity scores and a purpose designed economics questionnaire. Secondary outcomes related to proxy and subject HRQoL comparisons, mechanical ventilation, critical illness neuromyopathy, ICU readmission and discharge destination will also be examined. Conclusion: The outcomes measured are of significance to critical care patients. The CUA of the intervention will be of interest to health service providers. The results will enable development of clinical practice guidelines for the appropriate exercises in survivors of ICU. Registered with the Australian and New Zealand Clinical Trials Network (ACTRN 12605000776606).

Quality of Life Outcome of Critical Care Survivors Eighteen Months after Discharge from Intensive Care

To assess the changes in health-related quality of life in patients discharged from the intensive care unit (ICU). At the General University ICU, Trauma Hospital in Athens, 242 patients were enrolled prospectively over a study period of 18 months. Out of these, 116 participants (47.9%) completed all survey components at 6, 12, and 18 months. We used Quality of Life-Spanish (QOL-SP) to assess the health-related quality of life. Patients or their relatives were interviewed on ICU admission and at 6, 12, and 18 months after discharge from the ICU. Mean quality of life score of the patients increased from 2.9+/-4.8 (out of maximum 25 points) on ICU admission to 7.0+/-7.2 points at 6 months after discharge, and then decreased to 5.6+/-6.9 points at 18 months (P<0.001; Friedman Test). Multilinear regression analysis showed that the variables which had the strongest association with the quality of life on admission were age (P=0.002) and male sex (P=0.001), whereas age (P<0.001), length of ICU stay (P<0.001), and male sex (P=0.002) had the strongest association 18 months after discharge from the ICU. Survival rate was 66.9% at discharge from ICU and 61.6% at hospital discharge. There were 33% deaths in the ICU, 5.3% in the hospital, and 6.2% after ICU discharge. There were 7.4% patients lost to follow-up. After discharge from the ICU, patients' quality of life was poor and showed an improvement at 18 months after discharge, but was still worse than on admission. Age, ICU length of stay, and male sex were the factors that had the strongest impact on the quality of life on admission and at 18 months after discharge from the ICU.