post-ICU Discharge Research Articles

Sleep in family caregivers of ICU survivors for two months post-ICU discharge

To describe changes in sleep quality in family caregivers of ICU survivors from the patients' ICU admission until two months post-ICU discharge. Descriptive repeated measure design. Academic hospital medical ICU. Subjective sleep quality (Pittsburgh Sleep Quality Index [PSQI]) and objective sleep/wake variables (SenseWear Armband™) were measured in family caregivers at patients' ICU admission, within two weeks post-ICU discharge and two months post-ICU discharge. In 28 family caregivers of ICU survivors, most caregivers reported poor sleep quality (i.e. PSQI >5) across the three time points (64.3% during patients' ICU admission, 53.6% at each post-ICU time point). Worse trends in sleep quality and objective sleep/wake pattern were observed in caregivers who were employed, and a non-spouse. There were trends of worsening sleep quality in caregivers of patients unable to return home within two months post-ICU discharge compared to patients able to return home. Poor sleep quality was highly prevalent and persisted in family caregivers of ICU survivors for two months post-ICU discharge. Our data support the need for a larger longitudinal study to examine risk factors associated with sleep quality in family caregivers of ICU survivors to develop targeted interventions.

Activities undertaken by Intensive Care Unit Liaison Nurses in Argentina

BackgroundThe Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an advanced practice nursing role that emerged in the late 1990s in Australia and the United Kingdom (UK). Little is known about this role in less developed economies. ObjectiveTo describe the activities undertaken by ICULNs in Argentina. MethodsProspective, descriptive, observational, single site study in an Argentinean metropolitan tertiary referral hospital. Adult patients under ICULN follow up were included in the sample. Data on ICULN activities and patients were collected using an established tool developed by The Australian Intensive Care Unit Liaison Nurse Forum. Descriptive statistics were used to summarise the findings. ResultsTwo hundred patients were visited by the ICULNs during the study period. The mean age of patients was 52.5 years (SD 17.7). Cardiovascular disease (n=104, 52%), respiratory disease (n=90, 45%) and diabetes (n=40, 20%) were the most common comorbidities. 110 (55%) patients had surgical procedures. The primary reasons for ICULN visit were follow up post ICU discharge (n=138, 69%) and ward referral (n=46, 23%). 136 (68%) patients received up to 3 visits; the remaining 64 (32%) patients received ≥4 visits. In those patients in need of ≥4 visits ICULNs initiated more non-medical treatments (100%), referred to escalate treatment (35%) and to a higher level of care (13.8%) than in those who were visited up to 3 times. ConclusionsThis study is the first to document ICULN activity in Argentina using an international framework and data set. These findings can assist with understanding an advanced practice nursing role in Argentina. It may facilitate future comparisons with other contexts and could help managers implementing the role in similar settings. Further investigation will help develop this practice and document its influence on patient outcomes.

Transcriptomic analysis reveals abnormal muscle repair and remodeling in survivors of critical illness with sustained weakness.

ICU acquired weakness (ICUAW) is a common complication of critical illness characterized by structural and functional impairment of skeletal muscle. The resulting physical impairment may persist for years after ICU discharge, with few patients regaining functional independence. Elucidating molecular mechanisms underscoring sustained ICUAW is crucial to understanding outcomes linked to different morbidity trajectories as well as for the development of novel therapies. Quadriceps muscle biopsies and functional measures of muscle strength and mass were obtained at 7 days and 6 months post-ICU discharge from a cohort of ICUAW patients. Unsupervised co-expression network analysis of transcriptomic profiles identified discrete modules of co-expressed genes associated with the degree of muscle weakness and atrophy in early and sustained ICUAW. Modules were enriched for genes involved in skeletal muscle regeneration and extracellular matrix deposition. Collagen deposition in persistent ICUAW was confirmed by histochemical stain. Modules were further validated in an independent cohort of critically ill patients with sepsis-induced multi-organ failure and a porcine model of ICUAW, demonstrating disease-associated conservation across species and peripheral muscle type. Our findings provide a pathomolecular basis for sustained ICUAW, implicating aberrant expression of distinct skeletal muscle structural and regenerative genes in early and persistent ICUAW.

A Binational Multicenter Pilot Feasibility Randomized Controlled Trial of Early Goal-Directed Mobilization in the ICU.

To determine if the early goal-directed mobilization intervention could be delivered to patients receiving mechanical ventilation with increased maximal levels of activity compared with standard care. A pilot randomized controlled trial. Five ICUs in Australia and New Zealand. Fifty critically ill adults mechanically ventilated for greater than 24 hours. Patients were randomly assigned to either early goal-directed mobilization (intervention) or to standard care (control). Early goal-directed mobilization comprised functional rehabilitation treatment conducted at the highest level of activity possible for that patient assessed by the ICU mobility scale while receiving mechanical ventilation. The ICU mobility scale, strength, ventilation duration, ICU and hospital length of stay, and total inpatient (acute and rehabilitation) stay as well as 6-month post-ICU discharge health-related quality of life, activities of daily living, and anxiety and depression were recorded. The mean age was 61 years and 60% were men. The highest level of activity (ICU mobility scale) recorded during the ICU stay between the intervention and control groups was mean (95% CI) 7.3 (6.3-8.3) versus 5.9 (4.9-6.9), p = 0.05. The proportion of patients who walked in ICU was almost doubled with early goal-directed mobilization (intervention n = 19 [66%] vs control n = 8 [38%]; p = 0.05). There was no difference in total inpatient stay (d) between the intervention versus control groups (20 [15-35] vs 34 [18-43]; p = 0.37). There were no adverse events. Key Practice Points: Delivery of early goal-directed mobilization within a randomized controlled trial was feasible, safe and resulted in increased duration and level of active exercises.

Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews.

BackgroundPhysical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery.MethodsSix electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence.ResultsFive eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge.ConclusionsPatients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for design of future interventional trials and SR.Trial registration numberCRD42015001068.

Systemic inflammation after critical illness: relationship with physical recovery and exploration of potential mechanisms

BackgroundPhysical recovery following critical illness is slow, often incomplete and is resistant to rehabilitation interventions. We aimed to explore the contribution of persisting inflammation to recovery, and investigated the potential...

Long-term outcomes and healthcare utilization following critical illness--a population-based study.

BackgroundThe purpose of this study was to examine hospital mortality, long-term mortality, and health service utilization among critically ill patients. We also determined whether these outcomes differed according to demographic and clinical characteristics.MethodsWe conducted a retrospective cohort study of adults (age ≥18 years) who survived admission to an intensive care unit (ICU) in Ontario, Canada, between 1 April 2002 and 31 March 2012, excluding isolated admissions to step-down or intermediate ICUs, coronary care ICUs, or cardiac surgery ICUs. Adults (age ≥18 years) who survived an acute hospitalization that did not include an ICU stay formed the comparator group. The primary outcome was mortality following hospital discharge. Secondary outcomes were healthcare utilization, including emergency room admissions and hospital readmissions during follow-up.ResultsOver the study interval, 500,124 patients were admitted to ICUs and 420,187 (84 %) survived to hospital discharge. Median follow-up for survivors was 5.3 (interquartile range 2.5, 8.2) years. Patients admitted to an ICU were more likely to subsequently visit the emergency department, be readmitted to the hospital and ICU, receive home care support, require rehabilitation, and be admitted for long-term care. Those requiring more resources within the ICU required more resources after discharge. One-third of patients admitted to the ICU died during long-term follow-up, with overall probabilities of death of 11 % and 29 % at 1 year and 5 years, respectively. In the adjusted analysis, there was an increasing hazard of death with increasing age, reaching a hazard ratio of 18.08 (95 % confidence interval 16.60–19.68) for those ≥85 years of age compared with those aged 18–24 years.ConclusionsHealthcare utilization after hospital discharge was higher among ICU patients, and also among those requiring more healthcare resources during their ICU admission, than among all hospitalized patients as a group. One-third of ICU patients died within the 5 years following discharge, and age was the most influential determinant of outcome. These findings should help target post–ICU discharge services for high-risk groups and better inform goals-of-care discussions for elderly critically ill patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1248-y) contains supplementary material, which is available to authorized users.

The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock.

This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors' health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed. Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008-2013) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status. Sixty-five patients (47%) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age >60, female sex, body mass index >25 kg/m(2), Glasgow coma score <6, creatinine >150 μmol/L, lactate (<2, 2-8, or >8 mmol/L), and prothrombin activity <50%. Six months after ECMO, probabilities of survival were 80, 58, 25, 20, and 7% for ENCOURAGE score classes 0-12, 13-18, 19-22, 23-27, and ≥28, respectively. The ENCOURAGE score ROC AUC [0.84 (95% CI 0.77-0.91)] was significantly better than those of the SAVE, SAPS II, and SOFA scores. Survivors' HRQOL evaluated after median follow-up of 32 months revealed satisfactory mental health but persistent physical and emotional-related difficulties, with 34% (95% CI 20-49%) anxiety, 20% (95% CI 8-32%) depression, and 5% (95% CI 0-12%) PTSD symptoms reported. The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients.

Elevated C-reactive protein levels at ICU discharge as a predictor of ICU outcome: a retrospective cohort study.

Background Before discharging a patient from the ICU, an adequate patient evaluation is needed to detect individuals as high risk for unfavorable outcome. A pro- or anti-inflammatory status is a potential risk factor for an adverse outcome, and elevated CRP concentrations have shown to correlate with organ failure. Several studies have been performed to evaluate the use of CRP as a marker of post-ICU prognosis. Results are seemingly conflicting, and it is worthwhile to investigate these markers further as CRP is an adequate marker of pro- and anti-inflammatory status of the patient. We aimed to test the hypothesis that elevated CRP levels at ICU discharge are associated with an increased risk of ICU readmission and in-hospital mortality in patients with a prolonged ICU stay.MethodsA retrospective cohort study was performed in a single-center hospital with an 18-bed mixed medical/surgical ICU. Patients discharged alive from the ICU with at least 48-h ICU length of stay were evaluated. Patients were distributed into two groups: ‘high CRP’ (≥75 mg/L) and ‘low CRP’ (<75 mg/L) at ICU discharge. We assessed the difference in adverse outcome (ICU readmission and/or in-hospital mortality) between these groups.ResultsA total of 998 patients were included. Compared to the ‘low CRP’ group, patients in the ‘high CRP’ group had a higher readmission rate (13.1 vs. 7.4 %; p = 0.003). The post-ICU mortality rate in the ‘high CRP’ group and ‘low CRP’ group was 6.9 % and 4.7 %, respectively; p = 0.127. Combined readmission and mortality rates were significantly higher in the ‘high CRP’ group in comparison with the ‘low CRP’ group (17.9 vs. 10.1 %; p = 0.001). Hospital mortality in patients readmitted to the ICU was significantly higher than in non-readmitted patients (20 vs. 4.3 %; p < 0.001). Strikingly, the ‘high CRP’ group had significantly lower APACHE II and SOFA scores at ICU admission compared to the ‘low CRP’ group. This highlights the potential for ICU-acquired risk factors, including CRP.ConclusionsA high CRP concentration (≥75 mg/L) within 24 h before ICU discharge is associated with an increased risk of adverse outcome post-ICU discharge. However, CRP at discharge represents only a very moderate risk factor and may not be used for individual clinical decision-making.

Depressive symptoms and anxiety in intensive care unit (ICU) survivors after ICU discharge

BackgroundThe association between intensive care unit (ICU) survivors' psychological sequelae, individual care needs, and discharge disposition has not been evaluated. ObjectiveTo describe depressive symptoms and anxiety in ICU survivors and explore these symptoms based on individual care needs and discharge disposition for 4 months post-ICU discharge. MethodsWe analyzed data from 39 ICU survivors who self-reported measures of depressive symptoms (Center for Epidemiologic Studies-Depression 10 items [CESD-10]) and anxiety (Shortened Profile of Mood States-Anxiety subscale [POMS-A]). ResultsA majority of patients reported CESD-10 scores above the cut off (≥ 8) indicating risk for clinical depression. POMS-A scores were highest within 2 weeks post-ICU discharge and decreased subsequently. Data trends suggest worse depressive symptoms and anxiety when patients had moderate to high care needs and/or were unable to return home. ConclusionICU survivors who need caregiver assistance and extended institutional care reported trends of worse depressive symptoms and anxiety.

Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology

Over the last 10 years we have significantly reduced hospital mortality from sepsis and critical illness. However, the evidence reveals that over the same period we have tripled the number of patients being sent to rehabilitation settings. Further, given that as many as half of the deaths in the first year following ICU admission occur post ICU discharge, it is unclear how many of these patients ever returned home. For those who do survive, the latest data indicate that 50-70% of ICU "survivors" will suffer cognitive impairment and 60-80% of "survivors" will suffer functional impairment or ICU-acquired weakness (ICU-AW). These observations demand that we as intensive care providers ask the following questions: "Are we creating survivors ... or are we creating victims?" and "Do we accomplish 'Pyrrhic Victories' in the ICU?" Interventions to address ICU-AW must have a renewed focus on optimal nutrition, anabolic/anticatabolic strategies, and in the future employ the personalized muscle and exercise evaluation techniques utilized by elite athletes to optimize performance. Specifically, strategies must include optimal protein delivery (1.2-2.0 g/kg/day), as an athlete would routinely employ. However, as is clear in elite sports performance, optimal nutrition is fundamental but alone is often not enough. We know burn patients can remain catabolic for 2 years post burn; thus, anticatabolic agents (i.e., beta-blockers) and anabolic agents (i.e., oxandrolone) will probably also be essential. In the near future, evaluation techniques such as assessing lean body mass at the bedside using ultrasound to determine nutritional status and ultrasound-measured muscle glycogen as a marker of muscle injury and recovery could be utilized to help find the transition from the acute phase of critical illness to the recovery phase. Finally, exercise physiology testing that evaluates muscle substrate utilization during exercise can be used to diagnose muscle mitochondrial dysfunction and to guide a personalized ideal heart rate, assisting in recovery of muscle mitochondrial function and functional endurance post ICU. In the end, future ICU-AW research must focus on using a combination of modern performance-enhancing nutrition, anticatabolic/anabolic interventions, and muscle/exercise testing so we can begin to create more "survivors" and fewer victims post ICU care.

Predictors of ICU Admission and Outcomes 1 Year Post-Admission in Persons with IBD: A Population-based Study.

To determine predictors of intensive care unit (ICU) admission and to assess health care utilization (HCU) post-ICU admission among persons with inflammatory bowel disease (IBD). We matched a population-based database of Manitobans with IBD to a general population cohort on age, sex, and region of residence and linked these cohorts to a population-based ICU database. We compared the incidence rates of ICU admission among prevalent IBD cases according to HCU in the year before admission using generalized linear models adjusting for age, sex, socioeconomic status, region, and comorbidity. Among incident cases of IBD who survived their first ICU admission, we compared HCU with matched controls who survived ICU admission. Risk factors for ICU admission from the year before admission included cumulative corticosteroid use (incidence rate ratio, 1.006 per 100 mg of prednisone; 95% confidence interval, 1.004-1.008) and IBD-related surgery (incidence rate ratio, 2.79; 95% confidence interval, 1.99-3.92). Use of immunomodulatory therapies within 1 year, or surgery for IBD beyond 1 year prior, were not associated with ICU admission. In those who used corticosteroids and immunomodulatory medications in the year before ICU admission, the use of immunomodulatory medications conferred a 30% risk reduction in ICU admission (incidence rate ratio, 0.70; 95% confidence interval, 0.50-0.97). Persons with IBD who survived ICU admission had higher HCU in the year following ICU discharge than controls. Corticosteroid use and surgery within the year are associated with ICU admission in IBD while immunomodulatory therapy is not. Surviving ICU admission is associated with high HCU in the year post-ICU discharge.

Emotional disorders in pairs of patients and their family members during and after ICU stay.

IntroductionPatients and family members undergo different experiences of suffering from emotional disorders during ICU stay and after ICU discharge. The purpose of this study was to compare the incidence of anxiety, depression and post-traumatic stress disorder (PTSD) symptoms in pairs (patient and respective family member), during stay at an open visit ICU and at 30 and 90-days post-ICU discharge. We hypothesized that there was a positive correlation with the severity of symptoms among pairs and different patterns of suffering over time.MethodsA prospective study was conducted in a 22-bed adult general ICU including patients with >48 hours stay. The Hospital Anxiety and Depression Scale (HADS) was completed by the pairs (patients/respective family member). Interviews were made by phone at 30 and 90-days post-ICU discharge using the Impact of Event Scale (IES) and the HADS. Multivariate models were constructed to predict IES score at 30 days for patients and family members.ResultsFour hundred and seventy one family members and 289 patients were interviewed in the ICU forming 184 pairs for analysis. Regarding HADS score, patients presented less symptoms than family members of patients who survived and who deceased at 30 and 90-days (p<0.001). However, family members of patients who deceased scored higher anxiety and depression symptoms (p = 0.048) at 90-days when compared with family members of patients who survived. Patients and family members at 30-days had a similar IES score, but it was higher in family members at 90-days (p = 0.019). For both family members and patients, age and symptoms of anxiety and depression during ICU were the major determinants for PTSD at 30-days.ConclusionsAnxiety, depression and PTSD symptoms were higher in family members than in the patients. Furthermore, these symptoms in family members persisted at 3 months, while they decreased in patients.

Advanced practitioner-driven critical care outreach to reduce intensive care unit readmission mortality

Objectives: Intensive care unit (ICU) readmission is associated with poorer outcomes as compared to primary admissions. Recognizing new or recurrent critical care issues on the wards postICU discharge may improve outcomes, especially in those subsequently requiring readmission. Herein, we describe and evaluate a pilot surgical critical care outreach initiative to reduce mortality in patients ultimately requiring ICU readmission. Methods: Each patient discharged from the ICU was visited within 48 h by a Critical Care Advanced practitioner who examined the patient, reviewed the chart, recent laboratory results, and orders, and then communicated any concerns to the primary service. Patient demographics, outreach issues identified, and severity of issues were recorded prospectively. Retrospectively, patient outcomes were assessed including the need and timing of any ICU readmission and mortality both before and after outreach implementation. Results: Pre and postoutreach readmission rates were 2.41% (37/1534) versus 3.54% (54/1524), respectively (P = 0.07). Mortality rates before and after outreach were 5.08% (n = 78) versus 5.64% (n = 86) overall (P = 0.052) and 18.9% (n = 7) versus 9.25% (n = 5) for readmissions (P = 0.21), respectively. Conclusions: Critical care outreach postICU discharge did not decrease readmission mortality in this pilot study. Further studies are required to evaluate its effects on not only readmission mortality but also readmission rates and timing along with the incident of subsequent ICU complications. The following core competencies are addressed in this article: Patient care, Systems based practice, Communication.

Functional status after critical illness: agreement between patient and proxy assessments.

assessment of baseline functional status of older patients during and after intensive care unit (ICU) admission is often hampered by challenges related to the critical illness such as cognitive dysfunction, neuropsychological morbidity and pain. To explore the reliability of assessments by carefully chosen proxies, we designed a discriminating selection of proxies and evaluated agreement between patient and proxy responses by assessing activities of daily living (ADLs) at 1 month post-ICU discharge. patients ≥60 years old admitted to the medical ICU were enrolled in a prospective parent cohort studying delirium. Proxies were carefully screened at ICU admission to choose the best available respondent. Follow-up interviews, including instruments for ADLs, were conducted 1 month after ICU discharge. We examined 179 paired patient-proxy follow-up interviews. Kappa statistics assessed inter-observer agreement, and McNemar's exact test assessed response differences. patients averaged 73.3 ± 8.1 years old with 29% having evidence of cognitive impairment. Proxies were most commonly spouses (38%) or children (39%). Overall, there was substantial (κ ≥ 0.6) to excellent agreement (κ ≥ 0.8) between patients and proxies on assessment of all but one basic and one instrumental ADL. proxies carefully chosen at ICU admission show high levels of inter-observer agreement with older patients when assessing current functional status at 1 month post-ICU discharge. This motivates further study of proxy assessments that could be used earlier in critical illness to assess premorbid functional status.

English

To study intensive care unit (ICU) patients' and relatives' satisfaction in regard to communication with medical staff (nurses and physicians), perceived support, environmental strain and their psychological distress. Patients and relatives were more satisfied with the communication than expected by the staff. The staff overestimated the patients and relatives' psychological distress. Relatives report more psychological distress symptoms post-ICU discharge compared to the patients. Medical staff is aware of psychological distress in ICU patients and relatives and effort to reduce this during ICU stay and afterwards should be implemented.

A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial

BackgroundIncreasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause ongoing disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland).MethodsThe intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development.ResultsThe final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains (physiotherapy, dietetics, occupational therapy, and speech/language therapy), with specific training in post-critical illness issues. The intervention was from ICU discharge to 3 months post-discharge, including inpatient and post-hospital discharge elements. Clear strategies to provide information to patients/families were included. A detailed taxonomy was developed to define and describe the processes undertaken, and capture them during the trial. The detailed process measure description, together with a range of patient, health service, and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions.ConclusionsThe MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention. Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting. These data will be useful when interpreting the results of the randomised trial, will increase internal and external trial validity, and help others implement the intervention if the intervention proves clinically and cost effective.

Fatigue in Family Caregivers of Adult Intensive Care Unit Survivors

ContextFamily caregivers are a vital resource in the recovery of intensive care unit (ICU) survivors. Of concern, the stress associated with this role can negatively affect caregiver health. Fatigue, an important health indicator, has been identified as a predictor of various illnesses, greater use of health services, and early mortality. Examining the impact of fatigue on caregivers' physical health can assist in identifying critical time points and potential targets for intervention. ObjectivesTo describe self-reported fatigue in caregivers of ICU survivors from patients' ICU admission to ≤2 weeks, two- and four-months post-ICU discharge. MethodsPatient-caregiver pairs were enrolled from a medical ICU. Caregiver fatigue was measured using the Short-Form 36 Health Survey Vitality subscale (SF-36 Vitality). Caregiver psychobehavioral stress responses included depressive symptoms, burden, health risk behaviors, and sleep quality. Patient data included self-reported physical symptoms and disposition (home vs. institution). ResultsForty-seven patient-caregiver pairs were initially enrolled. Clinically significant fatigue (SF-36 Vitality ≤45) was reported by 43%–53% of caregivers across the time points, and these caregivers reported worse scores in measures of depressive symptoms, burden, health risk behaviors and sleep quality, and patients' symptom burden. In 26 caregivers with data for all time points (55% of the total sample), SF-36 Vitality scores showed trends of improvement when the patient returned home and greater impairment when institutionalization continued. ConclusionIn caregivers of ICU survivors, fatigue is common and potentially linked with poor psychobehavioral responses. Worsening fatigue was associated with greater symptom distress and long-term patient institutionalization.

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Introduction: ICU discharge has remained a subjective decision and providers continue to have difficulty developing an objective mechanism predicting post discharge safety or adverse outcomes. The purpose of this study is to prospectively determine the performance of a DRS designed to predict post-ICU discharge death and readmission in a 450 bed tele-ICU program. Methods: All pts in 25 ICUs from 13 hospitals and 4 states, from 1/1/2013 to 1/28/2013 had their risk of post-ICU death and readmission determined (without clinical intervention) using a previously described DRS as part of 24/7 tele-ICU surveillance system (Philips). Based on the DRS, patients were classified as either: high, medium, or low risk of death and readmission within 48 hours, per predefined thresholds. Adverse outcomes (post-discharge deaths and/or readmissions within 48 hrs) were compared to the DRS. Statistical analysis of DRS performance was based on ROC curves, positive (PPV) and negative (NPV) predictive values, sensitivity, and specificity. Results: 1,866 pts with a mean (SD) age of 63.5 (16.5) yrs; 51% male; 79% medical, surgical or mixed ICU patients. None of the 455 pts classified as low risk had an adverse outcome. 1,021 pts were moderate risk with 20 (2%) having an adverse outcome and 123 pts were high risk with 25 (20%) having an adverse outcome. There were 4 adverse outcomes among 267 pts who were not scored at DC due to missing data. Within 48 hrs of ICU DC, there were 13 readmissions (0.7%) and 37 deaths (2.0%). 32 of the 37 deaths had an active 'comfort measures only' (CMO) order at time of DC. Of the 13 readmissions, none were classified as low risk and 4 were high risk. Of the 37 deaths, none were classified as low risk while 21 were high risk. The ROC predicting the combined endpoint was 0.82 (0.75-0.90) and were similar when excluding the 32 CMO-related deaths (0.81; 0.69-0.93). The sensitivity, specificity, PPV and NPV for the high risk threshold were 51%, 95%, 20% and 99% respectively; low risk threshold were 100%, 25%, 3.5%, and 99% respectively. Conclusions: This DRS allows facilities to have evidence based confidence that low risk patients can be safely transferred out of the ICU. None of the patients discharged having adverse outcomes were low risk. Less than 7% of discharges were identified as high risk with 1 in 5 of these dying or being readmitted within the subsequent 48 hrs. Larger numbers of patients are needed in order to validate that the above statistical outcomes are maintained.

S134 Activity monitoring in intensive care unit survivors: Assessing daily physical activity with objective outcome measures

Introduction and ObjectivesIntensive care unit (ICU) survivors commonly report long-term functional disability and reduced daily physical activity (PA). This adversely impacts on their health-related quality of life (HRQL). We aimed...