Long-term survival following intensive care: subgroup analysis and comparison with the general population

Plasma and Urinary Biomarkers Improve Prediction of Mortality through 1 Year in Intensive Care Patients: An Analysis from FROG-ICU

BACKGROUND

This study aimed to assess the value of blood and urine biomarkers in addition to routine clinical variables in risk stratification of patients admitted to ICU.

METHODS

Multivariable prognostic models were developed in this post hoc analysis of the French and EuRopean Outcome ReGistry in Intensive Care Units study, a prospective observational study of patients admitted to ICUs. The study included 2087 patients consecutively admitted to the ICU who required invasive mechanical ventilation or a vasoactive agent for more than 24 h. The main outcome measures were in-ICU, in-hospital, and 1 year mortality.

RESULTS

Models including only SAPS II or APACHE II scores had c-indexes for in-hospital and 1 year mortality of 0.64 and 0.65, and 0.63 and 0.61, respectively. The c-indexes for a model including age and estimated glomerular filtration rate were higher at 0.69 and 0.67, respectively. Models utilizing available clinical variables increased the c-index for in-hospital and 1 year mortality to 0.80 and 0.76, respectively. The addition of biomarkers and urine proteomic markers increased c-indexes to 0.83 and 0.78.

CONCLUSIONS

The commonly used scores for risk stratification in ICU patients did not perform well in this study. Models including clinical variables and biomarkers had significantly higher predictive values.

Psychometric properties of the healthy aging brain care monitor self-report tool in patients discharged from the intensive care unit

PURPOSE

Intensive care unit survivors experience new and ongoing physical, psychological, and cognitive complications known as postintensive care syndrome. The study aimed to investigate the psychometric properties of the healthy aging brain care monitor self-report tool for assessing postintensive care syndrome in Iranian patients.

METHODS

The study is a methodological study investigating the psychometric properties of the healthy aging brain care monitor self-report tool in 153 patients discharged from the intensive care unit. The instrument's psychometric properties were examined to determine content validity, construct validity (factor analysis, convergent validity, and discriminant validity), concurrent validity, and internal consistency.

FINDINGS

The factor structure of the healthy aging brain care monitor self-report tool was examined in the form of two models: the three-factor model with 27 items and the three-factor model with 19 items. Regarding fit indices and results of the convergent, discriminant validities and the internal consistency the 19-item model is better than the original 27-item model.

CONCLUSIONS

The study showed that the appropriate model for the healthy aging brain care monitor self-report tool in Iranian society is a tool with 19 items with the best conditions in terms of factor structure, internal consistency, and overall psychometric characteristics.

IMPLICATIONS FOR NURSING PRACTICE

The present study led to the introduction of a valid instrument with a 19-item factor structure to assess the postintensive care syndrome by nurses and other healthcare providers in hospitals, clinics, palliative care centers, and home care centers.

Long-Term Outcome of Severe Metabolic Acidemia in ICU Patients, a BICAR-ICU Trial Post Hoc Analysis

OBJECTIVES

Long-term prognosis of ICU survivors is a major issue. Severe acidemia upon ICU admission is associated with very high short-term mortality. Since the long-term prognosis of these patients is unknown, we aimed to determine the long-term health-related quality of life and survival of these patients.

DESIGN

Post hoc analysis of a multicenter, randomized, controlled trial.

SETTING

Twenty-six French ICUs.

PATIENTS

Day 28 critically ill survivors admitted with severe acidemia and enrolled in the BICAR-ICU trial.

INTERVENTION

Sodium bicarbonate versus no sodium bicarbonate infusion according to the randomization group.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was health-related quality of life (HRQoL) measured with the 36-item Short Form Health Survey and the EuroQol 5-D questionnaires. Secondary outcomes were mortality, end-stage renal disease treated with renal replacement therapy or renal transplantation, place of residence, professional status, and ICU readmission. HRQoL was reduced with no significant difference between the two groups. HRQoL was reduced particularly in the role-physical health domain (64/100 ± 41 in the control group and 49/100 ± 43 in the bicarbonate group, p = 0.28), but it was conserved in the emotional domains (96/100 ± 19 in the control group and 86/100 ± 34 in the bicarbonate group, p = 0.44). Forty percent of the survivors described moderate to severe problems walking, and half of the survivors described moderate to severe problems dealing with usual activities. Moderate to severe anxiety or depression symptoms were present in one third of the survivors. Compared with the French general population, HRQoL was decreased in the survivors mostly in the physical domains. The 5-year overall survival rate was 30% with no significant difference between groups.

CONCLUSIONS

Long-term HRQoL was decreased in both the control and the sodium bicarbonate groups of the BICAR-ICU trial and was lower than the general population, especially in the physical domains.

Long-term Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-analysis

Importance

Data on long-term survival beyond 12 months after out-of-hospital cardiac arrest (OHCA) of a presumed cardiac cause are scarce.

Objective

To investigate the long-term survival of adult patients after surviving the initial hospital stay for an OHCA.

Data Sources

A systematic search of the EMBASE and MEDLINE databases was performed from database inception to March 25, 2021.

Study Selection

Clinical studies reporting long-term survival after OHCA were selected based on predefined inclusion and exclusion criteria according to a preregistered study protocol.

Data Extraction and Synthesis

Patient data were reconstructed from Kaplan-Meier curves using an iterative algorithm and then pooled to generate survival curves. As a separate analysis, an aggregate data meta-analysis was performed.

Main Outcomes and Measures

The primary outcome was long-term survival (>12 months) after OHCA for patients surviving to hospital discharge or 30 days after OHCA.

Results

The search identified 15 347 reports, of which 21 studies (11 800 patients) were included in the Kaplan-Meier-based meta-analysis and 33 studies (16 933 patients) in an aggregate data meta-analysis. In the Kaplan-Meier-based analysis, the median survival time for patients surviving to hospital discharge was 5.0 years (IQR, 2.3-7.9 years). The estimated survival rates were 82.8% (95% CI, 81.9%-83.7%) at 3 years, 77.0% (95% CI, 75.9%-78.0%) at 5 years, 63.9% (95% CI, 62.3%-65.4%) at 10 years, and 57.5% (95% CI, 54.8%-60.1%) at 15 years. Compared with patients with a nonshockable initial rhythm, patients with a shockable rhythm had a lower risk of long-term mortality (hazard ratio, 0.30; 95% CI, 0.23-0.39; P < .001). Different analyses, including an aggregate data meta-analysis, confirmed these results.

Conclusions and Relevance

In this comprehensive systematic review and meta-analysis, long-term survival after 10 years in patients surviving the initial hospital stay after OHCA was between 62% and 64%. Additional research is needed to understand and improve the long-term survival in this vulnerable patient population.

Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study

BACKGROUND

In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness.

AIM

The aim of the Renal Replacement Anticoagulant Management study was to evaluate the clinical and health economic impacts of intensive care units moving from systemic heparin anticoagulation to regional citrate anticoagulation for continuous renal replacement therapy.

DESIGN

This was an observational comparative effectiveness study.

SETTING

The setting was NHS adult general intensive care units in England and Wales.

PARTICIPANTS

Participants were adults receiving continuous renal replacement therapy in an intensive care unit participating in the Intensive Care National Audit & Research Centre Case Mix Programme national clinical audit between 1 April 2009 and 31 March 2017.

INTERVENTIONS

Exposure - continuous renal replacement therapy in an intensive care unit after completion of transition to regional citrate anticoagulation. Comparator - continuous renal replacement therapy in an intensive care unit before starting transition to regional citrate anticoagulation or had not transitioned.

OUTCOME MEASURES

Primary effectiveness - all-cause mortality at 90 days. Primary economic - incremental net monetary benefit at 1 year. Secondary outcomes - mortality at hospital discharge, 30 days and 1 year; days of renal, cardiovascular and advanced respiratory support in intensive care unit; length of stay in intensive care unit and hospital; bleeding and thromboembolic events; prevalence of end-stage renal disease at 1 year; and estimated lifetime incremental net monetary benefit.

DATA SOURCES

Individual patient data from the Intensive Care National Audit & Research Centre Case Mix Programme were linked with the UK Renal Registry, Hospital Episode Statistics (for England), Patient Episodes Data for Wales and Civil Registrations (Deaths) data sets, and combined with identified periods of systemic heparin anticoagulation and regional citrate anticoagulation (survey of intensive care units). Staff time and consumables were obtained from micro-costing. Continuous renal replacement therapy system failures were estimated from the Post-Intensive Care Risk-adjusted Alerting and Monitoring data set. EuroQol-3 Dimensions, three-level version, health-related quality of life was obtained from the Intensive Care Outcomes Network study.

RESULTS

Out of the 188 (94.9%) units that responded to the survey, 182 (96.8%) use continuous renal replacement therapy. After linkage, data were available from 69,001 patients across 181 intensive care units (60,416 during periods of systemic heparin anticoagulation use and 8585 during regional citrate anticoagulation use). The change to regional citrate anticoagulation was not associated with a step change in 90-day mortality (odds ratio 0.98, 95% confidence interval 0.89 to 1.08). Secondary outcomes showed step increases in days of renal support (difference in means 0.53 days, 95% confidence interval 0.28 to 0.79 days), advanced cardiovascular support (difference in means 0.23 days, 95% confidence interval 0.09 to 0.38 days) and advanced respiratory support (difference in means, 0.53 days, 95% CI 0.03 to 1.03 days) with a trend toward fewer bleeding episodes (odds ratio 0.90, 95% confidence interval 0.76 to 1.06) with transition to regional citrate anticoagulation. The micro-costing study indicated that regional citrate anticoagulation was more expensive and was associated with an estimated incremental net monetary loss (step change) of -£2376 (95% confidence interval -£1912 to £911). The estimated likelihood of cost-effectiveness at 1 year was less than 0.1%.

LIMITATIONS

Lack of patient-level treatment data means that the results represent average effects of changing to regional citrate anticoagulation in intensive care units. Administrative data are subject to variation in data quality over time, which may contribute to observed trends.

CONCLUSIONS

The introduction of regional citrate anticoagulation has not improved outcomes for patients and is likely to have substantially increased costs. This study demonstrates the feasibility of evaluating effects of changes in practice using routinely collected data.

FUTURE WORK

(1) Prioritise other changes in clinical practice for evaluation and (2) methodological research to understand potential implications of trends in data quality.

TRIAL REGISTRATION

This trial is registered as ClinicalTrials.gov NCT03545750.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 13. See the NIHR Journals Library website for further project information.

Tropical Australian Health-Data Linkage Shows Excess Mortality Following Severe Infectious Disease Is Present in the Short-Term and Long-Term after Hospital Discharge

BACKGROUND

In this study, we aimed to assess the risk factors associated with mortality due to an infectious disease over the short-, medium-, and long-term based on a data-linkage study for patients discharged from an infectious disease unit in North Queensland, Australia, between 2006 and 2011.

METHODS

Age-sex standardised mortality rates (SMR) for different subgroups were estimated, and the Kaplan-Meier method was used to estimate and compare the survival experience among different groups.

RESULTS

Overall, the mortality rate in the hospital cohort was higher than expected in comparison with the Queensland population (SMR: 15.3, 95%CI: 14.9-15.6). The long-term mortality risks were significantly higher for severe infectious diseases than non-infectious diseases for male sex, Indigenous, residential aged care and elderly individuals.

CONCLUSION

In general, male sex, Indigenous status, age and comorbidity were associated with an increased hazard for all-cause deaths.

Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care

OBJECTIVES

Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care.

DESIGN

We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system.

SETTING

Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units.

PATIENTS

The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days.

INTERVENTION

ABCDE bundle.

MEASUREMENTS AND MAIN RESULTS

We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675-$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year.

CONCLUSIONS

The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.

Quality of life and long-term outcomes after hospitalization for COVID-19: Protocol for a prospective cohort study (Coalition VII)

INTRODUCTION

The long-term effects caused by COVID-19 are unknown. The present study aims to assess factors associated with health-related quality of life and long-term outcomes among survivors of hospitalization for COVID-19 in Brazil.

METHODS

This is a multicenter prospective cohort study nested in five randomized clinical trials designed to assess the effects of specific COVID-19 treatments in over 50 centers in Brazil. Adult survivors of hospitalization due to proven or suspected SARS-CoV-2 infection will be followed-up for a period of 1 year by means of structured telephone interviews. The primary outcome is the 1-year utility score of health-related quality of life assessed by the EuroQol-5D3L. Secondary outcomes include all-cause mortality, major cardiovascular events, rehospitalizations, return to work or study, physical functional status assessed by the Lawton-Brody Instrumental Activities of Daily Living, dyspnea assessed by the modified Medical Research Council dyspnea scale, need for long-term ventilatory support, symptoms of anxiety and depression assessed by the Hospital Anxiety and Depression Scale, symptoms of posttraumatic stress disorder assessed by the Impact of Event Scale-Revised, and self-rated health assessed by the EuroQol-5D3L Visual Analog Scale. Generalized estimated equations will be performed to test the association between five sets of variables (1- demographic characteristics, 2- premorbid state of health, 3- characteristics of acute illness, 4- specific COVID-19 treatments received, and 5- time-updated postdischarge variables) and outcomes.

ETHICS AND DISSEMINATION

The study protocol was approved by the Research Ethics Committee of all participant institutions. The results will be disseminated through conferences and peer-reviewed journals.

Machine learning-based patient classification system for adult patients in intensive care units: A cross-sectional study

AIM

This study aimed to develop a patient classification system that stratifies patients admitted to the intensive care unit based on their disease severity and care needs.

BACKGROUND

Classifying patients into homogenous groups based on clinical characteristics can optimize nursing care. However, an objective method for determining such groups remains unclear.

METHODS

Predictors representing disease severity and nursing workload were considered. Patients were clustered into subgroups with different characteristics based on the results of a clustering algorithm. A patient classification system was developed using a partial least squares regression model.

RESULTS

Data of 300 patients were analysed. Cluster analysis identified three subgroups of critically patients with different levels of clinical trajectories. Except for blood potassium levels (p = .29), the subgroups were significantly different according to disease severity and nursing workload. The predicted value ranges of the regression model for Classes A, B and C were <1.44, 1.44-2.03 and >2.03. The model was shown to have good fit and satisfactory prediction efficiency using 200 permutation tests.

CONCLUSIONS

Classifying patients based on disease severity and care needs enables the development of tailored nursing management for each subgroup.

IMPLICATIONS FOR NURSING MANAGEMENT

The patient classification system can help nurse managers identify homogeneous patient groups and further improve the management of critically ill patients.

Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study

BACKGROUND

Prolonged immobility has detrimental consequences for critically ill patients admitted to the intensive care unit (ICU). Previous work has shown that early mobilization of ICU patients is a safe, feasible and effective strategy to improve outcomes; however, few of these studies focused on trauma ICU patients. Our objective was to assess the impact of implementing an ICU early mobilization protocol (EMP) on trauma outcomes.

METHODS

We conducted a retrospective pre-post study of adult trauma patients (>18 years old) admitted to ICU at a Level I trauma center over a 2-year period prior to and following EMP implementation, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared outcomes (mortality, length of stay [LOS], ventilator-free days) between patients admitted during pre-EMP and post-EMP periods, and assessed for factors associated with outcomes using binary logistic regression and generalized linear models.

RESULTS

Overall, 526 patients were included in the analysis (292 pre-EMP, 234 post-EMP). Ages ranged from 18 years to 92 years (mean, 49.0 ± 20.4 years) and 74.3% were men. The post-EMP group had lower ICU mortality (21.6% vs. 12.8%; p = 0.009) and in-hospital mortality (25.3% vs. 17.5%; p = 0.031). After controlling for confounders, patients in the post-EMP group were less likely to die in the ICU (odds ratio, 0.43; 95% confidence interval, 0.24-0.79; p = 0.006) or in-hospital (odds ratio, 0.55; 95% confidence interval; 0.32-0.94; p = 0.03). In-hospital LOS, ICU LOS, ICU-free days, and number of ventilator-free days were similar between the two groups.

CONCLUSION

Trauma patients admitted to ICU during the post-EMP period had decreased odds of ICU mortality and in-hospital mortality. This is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.

LEVEL OF EVIDENCE

Therapeutic, level III.

Early and Late Mortality Following Discharge From the ICU: A Multicenter Prospective Cohort Study

OBJECTIVES

To identify the frequency, causes, and risk factors of early and late mortality among general adult patients discharged from ICUs.

DESIGN

Multicenter, prospective cohort study.

SETTING

ICUs of 10 tertiary hospitals in Brazil.

PATIENTS

One-thousand five-hundred fifty-four adult ICU survivors with an ICU stay greater than 72 hours for medical and emergency surgical admissions or greater than 120 hours for elective surgical admissions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main outcomes were early (30 d) and late (31 to 365 d) mortality. Causes of death were extracted from death certificates and medical records. Twelve-month cumulative mortality was 28.2% (439 deaths). The frequency of early mortality was 7.9% (123 deaths), and the frequency of late mortality was 22.3% (316 deaths). Infections were the leading cause of death in both early (47.2%) and late (36.4%) periods. Multivariable analysis identified age greater than or equal to 65 years (hazard ratio, 1.65; p = 0.01), pre-ICU high comorbidity (hazard ratio, 1.59; p = 0.02), pre-ICU physical dependence (hazard ratio, 2.29; p < 0.001), risk of death at ICU admission (hazard ratio per 1% increase, 1.008; p = 0.03), ICU-acquired infections (hazard ratio, 2.25; p < 0.001), and ICU readmission (hazard ratio, 3.76; p < 0.001) as risk factors for early mortality. Age greater than or equal to 65 years (hazard ratio, 1.30; p = 0.03), pre-ICU high comorbidity (hazard ratio, 2.28; p < 0.001), pre-ICU physical dependence (hazard ratio, 2.00; p < 0.001), risk of death at ICU admission (hazard ratio per 1% increase, 1.010; p < 0.001), and ICU readmission (hazard ratios, 4.10, 4.17, and 1.82 for death between 31 and 60 days, 61 and 90 days, and greater than 90 days after ICU discharge, respectively; p < 0.001 for all comparisons) were associated with late mortality.

CONCLUSIONS

Infections are the main cause of death after ICU discharge. Older age, pre-ICU comorbidities, pre-ICU physical dependence, severity of illness at ICU admission, and ICU readmission are associated with increased risk of early and late mortality, while ICU-acquired infections are associated with increased risk of early mortality.

The association between depression and length of stay in the intensive care unit

Depression is common after patients are discharged from the intensive care unit (ICU) and has a negative impact on quality of life and mortality. There is inconsistent information about ICU admission and the risk of depression. The aim of our study was to investigate the association between the risk of depression and length of ICU stay.ICU survivors between 20 and 65 years old were enrolled in this study using data from Taiwan's nationwide population database. All study subjects were followed for a maximum of 1 year or until they were diagnosed with new-onset depression. The association between the length of ICU stay and the depression risk among ICU survivors was estimated using a Cox regression model. The screened diagnostic records of ICU survivors with depression were also investigated to find the potential disease effect of depression.Compared to patients with ICU stays between 8 and 14 days, the adjusted HR (95% confidence interval) for depression in patients with ICU stays between 1 to 3 days, 4 to 7 days, 15 to 21 days, and ≥22 days were 1.08 (1.03-1.13), 1.01 (0.96-1.05), 1.08 (1.01-1.14), and 1.12 (1.06-1.19), respectively. For patients with depression after discharge from the ICU, the most common primary diagnosis was intracerebral hemorrhage.There is a risk of depression after ICU discharge, and the incidence of depression may be higher among patients between 20 and 49 years old. The risk of depression was U-shaped, with higher risks associated with ICU stays of 1 to 3 days and more than 15 days.

Long-term survival after intensive care: A retrospective cohort study

Background Limited data exist on long-term survival of patients requiring admission to intensive care units (ICUs). The aim of this study was to investigate long-term survival of ICU patients in Iceland and assess changes over a 15-year period. Methods Data were collected on age, gender, admission cause, length of stay, comorbidities, mechanical ventilation and survival of patients 18 years and older admitted to the ICUs in Landspitali during 2002-2016. Long-term survival of patients surviving more than 30 days from admission was estimated and its predictors assessed with Cox regression analysis. Long-term survival was compared to the survival of an age- and gender-matched reference group from the general population. Results Of 15 832 ICU admissions, 55% was medical, 38% was surgical and 7% was due to trauma. The 5-year survival of medical, surgical and trauma patients was 66%, 76% and 92% respectively. Significant survival differences were found between admission subgroups. Higher age and comorbidity burden was related to decreased survival in all patient groups. After correcting for age, gender, comorbidities, length of ICU stay and mechanical ventilation, patient survival improved during the study period only for patients admitted for infections. There was a high variability in the estimated time point where the ICU admission had no residual effect on survival. Conclusions Long-term survival of ICU patients is substantially decreased compared to the general population, but varies based on admission causes. Improved long-term survival of patients admitted with infections could be explained by earlier detection and improved treatment of septic shock.

Development and validation of a questionnaire to measure post-intensive care syndrome

OBJECTIVE

This study aimed to develop a Post-Intensive Care Syndrome Questionnaire (PICSQ) and assess the psychometric properties of PICSQ in intensive care unit survivors.

METHODS

PICSQ items were generated through relevant literature reviews, qualitative interviews among survivors, and multiple rounds of content validity evaluations by experts. Data were collected from 536 survivors at seven health care facilities in three cities of Korea from June to August 2018. The validity and reliability of PICSQ were assessed using exploratory factor analysis, confirmatory factor analysis, internal consistency and correlation coefficients.

RESULTS

The final PICSQ consisted of 18 items. Through exploratory factor analysis, three factors (mental, cognitive and physical) were derived. The reliability of PICSQ was represented by a Cronbach's α of 0.93, while the internal consistency of each factor was good (Cronbach's α = 0.84 to 0.90). The model fit of PICSQ was satisfactory and confirmatory factor analysis demonstrated good convergent and discriminant validity of the questionnaire.

CONCLUSION

Because PICSQ is valid and reliable, it is recommended for use in clinical practice and research to assess post-intensive care syndrome in intensive care survivors.

A nurse-led, preventive, psychological intervention to reduce PTSD symptom severity in critically ill patients: the POPPI feasibility study and cluster RCT

Background

High numbers of patients experience severe acute stress in critical care units. Acute stress has been linked to post-critical care psychological morbidity, including post-traumatic stress disorder (PTSD). Previously, a preventive, complex psychological intervention [Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients (POPPI)] was developed by this research team, to be led by nurses, to reduce the development of PTSD symptom severity at 6 months.

Objectives

The objectives were to (1) standardise and refine the POPPI intervention, and, if feasible, (2) evaluate it in a cluster randomised clinical trial (RCT).

Design

Two designs were used – (1) two feasibility studies to test the delivery and acceptability (to patients and staff) of the intervention, education package and support tools, and to test the trial procedures (i.e. recruitment and retention), and (2) a multicentre, parallel-group, cluster RCT with a baseline period and staggered roll-out of the intervention.

Setting

This study was set in NHS adult, general critical care units.

Participants

The participants were adult patients who were > 48 hours in a critical care unit, receiving level 3 care and able to consent.

Interventions

The intervention comprised three elements – (1) creating a therapeutic environment in critical care, (2) three stress support sessions for patients identified as acutely stressed and (3) a relaxation and recovery programme for patients identified as acutely stressed.

Main outcome measures

Primary outcome – patient-reported symptom severity using the PTSD Symptom Scale – Self Report (PSS-SR) questionnaire (to measure clinical effectiveness) and incremental costs, quality-adjusted life-years (QALYs) and net monetary benefit at 6 months (to measure cost-effectiveness). Secondary outcomes – days alive and free from sedation to day 30; duration of critical care unit stay; PSS-SR score of > 18 points; depression, anxiety and health-related quality of life at 6 months; and lifetime cost-effectiveness.

Results

(1) A total of 127 participants were recruited to the intervention feasibility study from two sites and 86 were recruited to the RCT procedures feasibility study from another two sites. The education package, support tools and intervention were refined. (2) A total of 24 sites were randomised to the intervention or control arms. A total of 1458 participants were recruited. Twelve sites delivered the intervention during the intervention period: > 80% of patients received two or more stress support sessions and all 12 sites achieved the target of > 80% of clinical staff completing the POPPI online training. There was, however, variation in delivery across sites. There was little difference between baseline and intervention periods in the development of PTSD symptom severity (measured by mean PSS-SR score) at 6 months for surviving patients in either the intervention or the control group: treatment effect estimate −0.03, 95% confidence interval (CI) −2.58 to 2.52; p = 0.98. On average, the intervention decreased costs and slightly improved QALYs, leading to a positive incremental net benefit at 6 months (£835, 95% CI −£4322 to £5992), but with considerable statistical uncertainty surrounding these results. There were no significant differences between the groups in any of the secondary outcomes or in the prespecified subgroup analyses.

Limitations

There was a risk of bias because different consent processes were used and as a result of the lack of blinding, which was mitigated as far as possible within the study design. The intervention started later than anticipated. Patients were not routinely monitored for delirium.

Conclusions

Among level 3 patients who stayed > 48 hours in critical care, the delivery of a preventive, complex psychological intervention, led by nurses, did not reduce the development of PTSD symptom severity at 6 months, when compared with usual care.

Future work

Prior to development and evaluation of subsequent psychological interventions, there is much to learn from post hoc analyses of the cluster RCT rich quantitative and qualitative data.

Trial registration

This trial is registered as ISRCTN61088114 and ISRCTN53448131.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 23, No. 30. See the NIHR Journals Library website for further project information.

Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Statistical and Health Economic Analysis Plan for the 65 trial

The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65 United Kingdom adult general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. This paper describes the proposed statistical and health economic analysis for the 65 trial.

Long-term mortality of patients discharged from the hospital after successful critical care in the ICU in Korea: a retrospective observational study in a single tertiary care teaching hospital

Background

The long-term outcomes of patients discharged from the hospital after successful care in intensive care unit (ICU) are not briskly evaluated in Korea. The aim of this study was to assess long-term mortality of patients treated in the ICU and discharged alive from the hospital and to identify predictive factors of mortality.

Methods

In 3,679 adult patients discharged alive from the hospital after ICU care between 2006 and 2011, the 1-year mortality rate (primary outcome measure) was investigated. Various factors were entered into multivariate analysis to identify independent factors of 1-year mortality, including sex, age, severity of illness (APACHE II score), mechanical ventilation, malignancy, readmission, type of admission (emergency, elective surgery, and medical), and diagnostic category (trauma and non-trauma).

Results

The 1-year mortality rate was 13.4%. Risk factors that were associated with 1-year mortality included age (hazard ratio: 1.03 [95% CI, 1.02–1.04], P < 0.001), APACHE II score (1.03 [1.01–1.04], P < 0.001), mechanical ventilation (1.96 [1.60–2.41], P < 0.001), malignancy (2.31 [1.82–2.94], P < 0.001), readmission (1.65 [1.31–2.07], P < 0.001), emergency surgery (1.66 [1.18–2.34], P = 0.003), ICU admission due to medical causes (4.66 [3.68–5.91], P < 0.001), and non-traumatic diagnostic category (6.04 [1.50–24.38], P = 0.012).

Conclusions

The 1-year mortality rate was 13.4%. Old age, high APACHE II score, mechanical ventilation, malignancy, readmission, emergency surgery, ICU admission due to medical causes, and non-traumatic diagnostic category except metabolic/endocrinologic category were associated with 1-year mortality.

No association with cardiac death after sepsis: A nationwide observational cohort study

BACKGROUND

Cardiac dysfunction is a well-known complication of sepsis, but its long-term consequences and implications for patients remain unclear. The aim of this study was to investigate cardiac outcome in sepsis by assessing causes of death up to 2 years after treatment in an Intensive Care Unit (ICU) in a nationwide register-based cohort collected from the Swedish Intensive Care Registry.

METHODS

A cohort of 13 669 sepsis and septic shock ICU patients from 2008 to 2014 was collected together with a non-septic control group, matched regarding age, sex and severity of illness (n = 6582), and all without preceding severe cardiac disease. For a large proportion of the severe sepsis and septic shock patients (n = 7087), no matches were found. Information on causes of death up to 2 years after ICU admission was sought in the Swedish National Board of Health and Welfare's Cause of Death Registry.

RESULTS

Intensive Care Unit mortality was nearly identical in a matched comparison of sepsis patients to controls (24% in both groups) but higher in more severely ill sepsis patients for whom no matches were found (33% vs 24%, P < 0.001). There was no association of sepsis to cardiac deaths in the first month (OR 1.03, 95%CI 0.87 to 1.20, P = 0.76) nor up to 2 years after ICU admission (OR 1.01, 95%CI 0.82 to 1.25, P = 0.94) in an adjusted between-group comparison.

CONCLUSIONS

There was no association with an increased risk of death related to cardiac disease in patients with severe sepsis or septic shock when compared to other ICU patients with similar severity of illness.

Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study

Background

Survivors of intensive care are known to be at increased risk of developing longer-term psychopathology issues. We present a large UK multicentre study assessing the anxiety, depression and post-traumatic stress disorder (PTSD) caseness in the first year following discharge from an intensive care unit (ICU).

Methods

Design: prospective multicentre follow-up study of survivors of ICU in the UK.

Setting: patients from 26 ICUs in the UK.

Inclusion criteria: patients who had received at least 24 h of level 3 ICU care and were 16 years of age or older.

Interventions: postal follow up: Hospital Anxiety and Depression Score (HADS) and the Post-Traumatic Stress Disorder (PTSD) Check List-Civilian (PCL-C) at 3 and 12 months following discharge from ICU.

Main outcome measure: caseness of anxiety, depression and PTSD, 2-year survival.

Results

In total, 21,633 patients admitted to ICU were included in the study. Postal questionnaires were sent to 13,155 survivors; of these 38% (4943/13155) responded and 55% (2731/4943) of respondents passed thresholds for one or more condition at 3 or 12 months following discharge. Caseness prevalence was 46%, 40% and 22% for anxiety, depression and PTSD respectively; 18% (870/4943 patients) met the caseness threshold for all three psychological conditions. Patients with symptoms of depression were 47% more likely to die during the first 2 years after discharge from ICU than those without (HR 1.47, CI 1.19–1.80).

Conclusions

Over half of those who respond to postal questionnaire following treatment on ICU in the UK reported significant symptoms of anxiety, depression or PTSD. When symptoms of one psychological disorder are present, there is a 65% chance they will co-occur with symptoms of one of the other two disorders. Depression following critical illness is associated with an increased mortality risk in the first 2 years following discharge from ICU.

Trial registration

ISRCTN Registry, ISRCTN69112866. Registered on 2 May 2006.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2223-6) contains supplementary material, which is available to authorized users.

Increased risk of death and readmission after hospital discharge of critically ill patients in a developing country: a retrospective multicenter cohort study

PURPOSE

To describe long-term mortality and hospital readmissions of patients admitted to Brazilian intensive care units (ICU).

METHODS

Retrospective cohort study of adult patients admitted to Brazilian hospitals affiliated to the Public Healthcare System from 10 state capitals. ICU patients were paired to non-ICU patients by frequency matching (ratio 1:2), according to postal code and admission semester. Hospitalization records were linked through deterministic linkage to national mortality data. Primary outcome was mortality up to 1 year. Other outcomes were mortality and readmissions at 30 and 90 days and 3 years. Multiple Cox regressions were used adjusting for age, sex, cancer diagnosis, type of hospital, and surgical status.

RESULTS

We included 324,594 patients (108,302 ICU and 216,292 non-ICU). ICU patients had increased hospital length of stay [9 (5-17) vs. 3 (1-6) days, p < 0.001] and mortality (18.5 vs. 3.6%, p < 0.001) versus non-ICU patients. One year after discharge, ICU patients were more frequently readmitted to hospital (25.4 vs. 17.4%, p < 0.001) and to ICU (31.4 vs. 7.3%, p < 0.001) than controls. Mortality up to 1 year was also higher for ICU patients (14.3 vs. 3.9%, p < 0.001). A significant interaction between surgical status and mortality was found, with adjusted hazard ratios (HRs) up to 1 year of 2.7 [95% confidence interval (CI) 2.5-2.9] for surgical patients, and 3.4 (95%CI 3.3-3.5) for medical patients. The risk for death and readmission diminished over time up to 3 years.

CONCLUSIONS

In a public healthcare system of a developing country, ICU patients have excessive long-term mortality and frequent readmissions. The ICU burden tended to reduce over time after hospital discharge.

Time trend analysis of long term outcome of patients with haematological malignancies admitted at dutch intensive care units

A few decades ago, the chances of survival for patients with a haematological malignancy needing Intensive Care Unit (ICU) support were minimal. As a consequence, ICU admission policy was cautious. We hypothesized that the long-term outcome of patients with a haematological malignancy admitted to the ICU has improved in recent years. Furthermore, our objective was to evaluate the predictive value of the Acute Physiology and Chronic Health Evaluation (APACHE) II score. A total of 1095 patients from 5 Dutch university hospitals were included from 2003 until 2015. We studied the prevalence of patients' characteristics over time. By using annual odds ratios, we analysed which patients' characteristics could have had influenced possible trends in time. A approximated mortality rate was compared with the ICU mortality rate, to study the predictive value of the APACHE II score. Overall one-year mortality was 62%. The annual decrease in one-year mortality was 7%, whereas the APACHE II score increased over time. Decreased mortality rates were particularly observed in high-risk patients (acute myeloid leukaemia, old age, low platelet count, bleeding as admission reason and need for mechanical ventilation within 24 h of ICU admission). Furthermore, the APACHE II score overestimates mortality in this patient category.

Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients (POPPI): protocol for a cluster-randomised clinical trial of a complex intervention

INTRODUCTION

Acute psychological stress, as well as unusual experiences including hallucinations and delusions, are common in critical care unit patients and have been linked to post-critical care psychological morbidity such as post-traumatic stress disorder (PTSD), depression and anxiety. Little high-quality research has been conducted to evaluate psychological interventions that could alleviate longer-term psychological morbidity in the critical care unit setting. Our research team developed and piloted a nurse-led psychological intervention, aimed at reducing patient-reported PTSD symptom severity and other adverse psychological outcomes at 6 months, for evaluation in the POPPI trial.

METHODS AND ANALYSIS

This is a multicentre, parallel group, cluster-randomised clinical trial with a staggered roll-out of the intervention. The trial is being carried out at 24 (12 intervention, 12 control) NHS adult, general, critical care units in the UK and is evaluating the clinical effectiveness and cost-effectiveness of a nurse-led preventative psychological intervention in reducing patient-reported PTSD symptom severity and other psychological morbidity at 6 months. All sites deliver usual care for 5 months (baseline period). Intervention group sites are then trained to carry out the POPPI intervention, and transition to delivering the intervention for the rest of the recruitment period. Control group sites deliver usual care for the duration of the recruitment period. The trial also includes a process evaluation conducted independently of the trial team.

ETHICS AND DISSEMINATION

This protocol was reviewed and approved by the National Research Ethics Service South Central - Oxford B Research Ethics Committee (reference: 15/SC/0287). The first patient was recruited in September 2015 and results will be disseminated in 2018. The results will be presented at national and international conferences and published in peer reviewed medical journals.

TRIAL REGISTRATION NUMBER

ISRCTN53448131; Pre-results.

Psychological outcomes following a nurse-led preventative psychological intervention for critically ill patients trial: Statistical and health economic analysis plan

The Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients trial is a cluster-randomised controlled trial of the clinical and cost-effectiveness of a complex nurse-led preventative psychological intervention compared with usual care in reducing patient-reported post-traumatic stress disorder symptom severity, and other reported psychological morbidities, at six months among Level 3 (intensive care) patients in adult general critical care units in England, Wales and Northern Ireland. This paper describes the proposed statistical and health economic analyses for the Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients trial. It is important to complete and publish this plan before inspecting and locking the trial data to ensure that post hoc and data-derived decisions are avoided. Trial registration: ISRCTN53448131.

Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study

BACKGROUND

Intensive care unit (ICU) survivors have reduced long-term survival compared to the general population. Identifying parameters at ICU discharge that are associated with poor long-term outcomes may prove useful in targeting an at-risk population. The main objective of the study was to identify clinical and biological determinants of death in the year following ICU discharge.

METHODS

FROG-ICU was a prospective, observational, multicenter cohort study of ICU survivors followed 1 year after discharge, including 21 medical, surgical or mixed ICUs in France and Belgium. All consecutive patients admitted to intensive care with a requirement for invasive mechanical ventilation and/or vasoactive drug support for more than 24 h following ICU admission and discharged from ICU were included. The main outcome measure was all-cause mortality at 1 year after ICU discharge. Clinical and biological parameters on ICU discharge were measured, including the circulating cardiovascular biomarkers N-terminal pro-B type natriuretic peptide, high-sensitive troponin I, bioactive-adrenomedullin and soluble-ST2. Socioeconomic status was assessed using a validated deprivation index (FDep).

RESULTS

Of 1570 patients discharged alive from the ICU, 333 (21%) died over the following year. Multivariable analysis identified age, comorbidity, red blood cell transfusion, ICU length of stay and abnormalities in common clinical factors at the time of ICU discharge (low systolic blood pressure, temperature, total protein, platelet and white cell count) as independent factors associated with 1-year mortality. Elevated biomarkers of cardiac and vascular failure independently associated with 1-year death when they are added to multivariable model, with an almost 3-fold increase in the risk of death when combined (adjusted odds ratio 2.84 (95% confidence interval 1.73-4.65), p < 0.001).

CONCLUSIONS

The FROG-ICU study identified, at the time of ICU discharge, potentially actionable clinical and biological factors associated with poor long-term outcome after ICU discharge. Those factors may guide discharge planning and directed interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01367093 . Registered on 6 June 2011.

Self-Rated Health as a Predictor of Death after Two Years: The Importance of Physical and Mental Wellbeing Postintensive Care

INTRODUCTION

The objective of this study is, among half-year intensive care survivors, to determine whether self-assessment of health can predict two-year mortality.

METHODS

The study is a prospective cohort study based on the Procalcitonin and Survival Study trial. Half-year survivors from this 1200-patient multicenter intensive care trial were sent the SF-36 questionnaire. We used both a simple one-item question and multiple questions summarized as a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score. The responders were followed for vital status 730 days after inclusion. Answers were dichotomized into a low-risk and a high-risk group and hazard ratios (HR) with 95% confidence interval (CI) were calculated by Cox proportional hazard analyses.

CONCLUSION

We found that self-rated health measured by a single question was a strong independent predictor of two-year all-cause mortality (HR: 1.8; 95% CI: 1.1-3.0). The multi-item component scores of the SF-36 also predicted two-year mortality (PCS: HR: 2.9; 95% CI 1.7-5.0) (MCS: HR: 1.9; 95% CI 1.1-3.4). These results suggest that self-rated health questions could help in identifying patients at excess risk. Randomized controlled trials are needed to test whether our findings represent causality.

Different Mortality Time Points in Critical Care Trials: Current Practice and Influence on Effect Estimates in Meta-Analyses

OBJECTIVE

Mortality is frequently used as an outcome in critical care trials, being a patient-orientated variable and robust against information/selection bias. Mortality frequency, however, should be measured at a defined time point of follow-up. Practice of meta-analysis shows that follow-up times of trials in critical care medicine differ substantially. This may have substantial implications on potential pooling of effect estimates. We aimed to describe the current practice of mortality follow-up time definitions in a representative sample of published critical care randomized controlled trials and to analyze the influence of different follow-up times on subsequently pooled effect estimates.

DATA SOURCES

Cochrane CENTRAL, EMBASE, MEDLINE, PASCAL Biomed, and PsycINFO.

STUDY SELECTION

Databases were searched for critical care randomized controlled trials published after 2000. A random sample of 50% was drawn for further review.

DATA EXTRACTION

Study characteristics were extracted, as well as the number and time points of mortality ascertainment. Additional data were extracted from Kaplan-Meier plots, as available.

DATA SYNTHESIS

Meta-regression and multilevel mixed-effects linear regression were used to analyze the influence of follow-up time (independent variable) on deviation of pooled risk ratios from study baseline (dependent variable). From 9,246 retrieved references, we included 106 studies representing 63,713 participants. Among these, 45 studies (43%) reported more than one time point, with 24 different time points at all, only three (28, 30, and 90 d) being reported in more than 10% of studies. Limiting meta-analyses to only one predefined time point would reduce the number of eligible studies by at least 60%. No influence of time points on meta-analytic summary effect estimates was found.

CONCLUSIONS

In a large sample of critical care randomized controlled trials, numerous different mortality time points are reported. Mortality time points did not influence pooled point estimates of the effects. Consequently, it seems possible to pool effect estimates, which in turn will increase the precision of these effect estimates.

Outcomes of elderly critically ill medical and surgical patients: a multicentre cohort study

PURPOSE

Very elderly (over 80 yr of age) critically ill patients admitted to medical-surgical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and dependent living conditions should they survive. The primary purpose of this study is to describe the outcomes and differences in outcomes between very elderly medical patients and their surgical counterparts admitted to Canadian ICUs, thereby informing decision-making for clinicians and substitute decision-makers.

METHODS

This was a prospective multicentre cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Outcome measures included ICU length of stay and mortality, hospital length of stay and mortality, and disposition following hospital discharge.

RESULTS

There were 1,671 patients evaluated in this study. Patient demographics included a mean age of 84.5 yr, baseline Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22.4, baseline Sequential Organ Failure Assessment (SOFA) score of 5.3, overall ICU mortality of 21.8%, and overall hospital mortality of 35.0%. Medical patient median ICU length of stay was 4.1 days, hospital length of stay was 16.2 days, ICU mortality was 26.5%, and hospital mortality was 41.5%. Surgical patient median ICU length of stay was 3.8 days, hospital length of stay was 20.1 days, ICU mortality was 18.7%, and hospital mortality was 31.6%. Only 45.0% of medical patients and 41.6% of surgical emergency patients were able to return home to live.

CONCLUSIONS

In this large sample of critically ill medical and surgical patients, the admission SOFA score and hospital lengths of stay were not different between the two groups, but medical patients had longer ICU lengths of stay and higher ICU and hospital mortality than surgical patients.

A clinical prediction tool for hospital mortality in critically ill elderly patients

BACKGROUND

Very elderly (80 years of age and above) critically ill patients admitted to medical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and living in a dependent state should they survive.

OBJECTIVE

The objective was to develop a clinical prediction tool for hospital mortality to improve future end-of-life decision making for very elderly patients who are admitted to Canadian ICUs.

DESIGN

This was a prospective, multicenter cohort study.

SETTING

Data from 1033 very elderly medical patients admitted to 22 Canadian academic and nonacademic ICUs were analyzed.

INTERVENTIONS

A univariate analysis of selected predictors to ascertain prognostic power was performed, followed by multivariable logistic regression to derive the final prediction tool.

MAIN RESULTS

We included 1033 elderly patients in the analyses. Mean age was 84.6±3.5 years, 55% were male, mean Acute Physiology and Chronic Health Evaluation II score was 23.1±7.9, Sequential Organ Failure Assessment score was 5.3±3.4, median ICU length of stay was 4.1 (interquartile range, 6.2) days, median hospital length of stay was 16.2 (interquartile range, 25.0) days, and ICU mortality and all-cause hospital mortality were 27% and 41%, respectively. Important predictors of hospital mortality at the time of ICU admission include age (85-90 years of age had an odds ratio of hospital mortality of 1.63 [1.04-2.56]; >90 years of age had an odds ratio of hospital mortality of 2.64 [1.27-5.48]), serum creatinine (120-300 had an odds ratio of hospital mortality of 1.57 [1.01-2.44]; >300 had an odds ratio of hospital mortality of 5.29 [2.43-11.51]), Glasgow Coma Scale (13-14 had an odds ratio of hospital mortality of 2.09 [1.09-3.98]; 8-12 had an odds ratio of hospital mortality of 2.31 [1.34-3.97]; 4-7 had an odds ratio of hospital mortality of 5.75 [3.02-10.95]; 3 had an odds ratio of hospital mortality of 8.97 [3.70-21.74]), and serum pH (<7.15 had an odds ratio of hospital mortality of 2.44 [1.07-5.60]).

CONCLUSION

We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making.

An Observational Study on a Protocol for Withdrawal of Life-Sustaining Measures on Two Non-Academic Intensive Care Units in The Netherlands: Few Signs of Distress, No Suffering?

CONTEXT

Because anticipation of death is common within the intensive care unit, attention must be paid to the prevention of distressing signs and symptoms, enabling the patient to die peacefully. In the relevant studies on this subject, there has been a lack of focus on measuring determinants of comfort in this population.

OBJECTIVES

To evaluate whether dying without distressing signs after the withdrawal of life-sustaining measures is possible using a newly introduced protocol and to analyze the potential influence of opioids and sedatives on time till death.

METHODS

This was a prospective observational study, in two nonacademic Dutch intensive care units after the introduction of a national protocol for end-of-life care. The study lasted two years and included adult patients in whom mechanical ventilation and/or vasoactive medication was withdrawn. Exclusion criteria included all other causes of death.

RESULTS

During the study period, 450 patients died; of these, 305 patients were eligible, and 241 were included. Ninety percent of patients were well sedated before and after withdrawal. Severe terminal restlessness, death rattle, or stridor was seen in less than 6%. Dosages of opioids and sedatives increased significantly after withdrawal, but did not contribute to a shorter time till death according the regression analysis.

CONCLUSION

The end-of-life protocol seems effective in realizing adequate patient comfort. Most patients in whom life-sustaining measures are withdrawn are well sedated and show few signs of distress. Dosages of opioids and sedatives increase significantly during treatment withdrawal but do not contribute to time until death. Dying with a minimum of distressing signs is thus practically possible and ethically feasible.

Post-ICU discharge and outcome: rationale and methods of the The French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) observational study

BACKGROUND

Previous studies have demonstrated that ICU (intensive care unit) survivors have decreased long-term survival rates compared to the general population. However, knowledge about how to identify ICU survivors with higher risk of death and the adjustable factors associated with mortality is still lacking.

METHODS AND DESIGN

The FROG-ICU (the French and European Outcome Registry in Intensive Care Units) study is a prospective, observational, multicenter cohort study where ICU survivors are followed up to one year after ICU discharge. Beside one year survival, the study is designed to assess incidence and identifying risk factors for mortality over the year following discharge from the ICU. All consecutive patients admitted in ICU to the 28 participating centers during the study period will be included. Every subject will undergo an evaluation at admission, throughout the ICU stay and at ICU discharge. The global, especially cardiovascular, assessment of each subject will be performed through a complete clinical exam, instrumental tests (electrocardiogram, echocardiogram) and biological parameters. Blood and urine samples will be collected at admission and at discharge with the primary goal to assess effectiveness of routine and novel cardiovascular, inflammatory and renal biomarkers, with potential interest in risk stratification for patients who survive an ICU stay. The follow up will include a careful tracking of patients through telephone calls and questionnaires at 3, 6 and 12 months after ICU discharge. FROG-ICU aims to identify the clinical and biological phenotype of patients with different levels of probability of death in the year after ICU discharge.

DISCUSSION

FROG-ICU has been designed to better understand long term outcome after ICU discharge as well as risk factors for all-cause and cardiovascular morbidity and associated mortality. It is a large prospective multicenter cohort with a biological (on plasma and urine) collection and one-year follow-up of ICU patients. FROG ICU will allow performing a risk stratification of ICU survivors as to recognize the subset of patients who may benefit from an early intervention to allow decreased cardiovascular morbidity and related mortality.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01367093 .

Long-term treated intensive care patients outcomes: the one-year mortality rate, quality of life, health care use and long-term complications as reported by general practitioners

BACKGROUND

The purpose of this study was to determine the one-year mortality rate and its predictors regarding long-term intensive care-treated patients together with their health-related quality of life (HRQL), place of living, healthcare use and long-term complication characteristics after intensive care unit (ICU) discharge.

METHODS

A retrospective cohort study was performed in a 20-bed mixed ICU. The patients that were treated for more than 72 h between 2007 and 2012 were included in this study. The one-year mortality rate was calculated, and the characteristics of the ICU survivors that died within one year after ICU discharge were further analysed. For all patients, the Dutch version of the SF-36 questionnaire was used to assess their current HRQL. The results were compared with a normal population. Additionally, patients were questioned about their place of living, and their general practitioners (GPs) were questioned about the patients' possible long-term complications.

RESULTS

Seven hundred and forty patients were included in this study, and their one-year mortality rate was 28 %, of which half died within the first week after ICU discharge. The one-year mortality rate predictors included age at the time of ICU admission, APACHE IV-predicted mortality score, number of comorbidities and ICU re-admissions. The ICU survivor HRQL was significantly lower compared with the normal population. Half of the patients did not return to their pre-hospital place of living, and numerous possible long-term complications were reported, particularly decreased tolerance, chronic fatigue and processing problems of relatives.

CONCLUSIONS

One-year mortality rate of long-term ICU-treated patient was 28 %, and this was predicted by age, disease severity, comorbidities and ICU re-admissions. The ICU survivors reported a lower HRQL, and a minority of these patients returned home directly after hospital discharge; however, GPs reported numerous possible long-term complications.

Patient outcomes can be associated with organizational changes: a quality improvement case study

AIMS/BACKGROUND

We report the results of a university surgical intensive care (SICU), which are influenced by a reorganization of the department because of a downsizing of beds with the corresponding reduction of personnel resulting in a decrease in nurse-to-bed ratio. Moreover, we report the subsequent interventions and adjustments resulting in favorable results.

DESIGN

We performed a prospective observational cohort study of all consecutive surgical patients entering the SICU of our hospital, over the period 2000-2004.

METHODS

In order to meet the budget cuts, a reduction of number of SICU beds with a corresponding reduction of nursing staff was implemented. In the subsequent period culminating on the year 2002, collaboration problems arose between medical and nursing staff: resulting in fierce discussions on the floor. Supported through external mediators, structures/work ethics/communication/collaborative behavior, and organization of the SICU were reviewed and restructured.

RESULTS

A total of 1477 patients were admitted to the SICU. The characteristics, Acute Physiology and Chronic Health Evaluation II score and therapeutic intervention scoring system points, were not different throughout the years. The intensive care unit-length of stay (ICU-LOS) in the admission year 2002 was significantly longer (P = .001) and the crude ICU mortality was higher (P = .02) compared with the 2 admission years before. The adjusted mortality (ICU standardized mortality ratio) was also worse in 2002, however, statistically not different. After the intervention (2003 and 2004), a better result (crude ICU mortality, length of ICU stay, and ICU standardized mortality ratio) was achieved.

CONCLUSION

Intensive care reorganization, in which higher workload is seen in medical and nursing staff, could have a negative effect on ICU outcome and length of ICU stay.

RELEVANCE TO CLINICAL PRACTICE

Interventions in ICU structures, communication, work ethics, and organization have a positive impact in conflict management.

Changes after transformation from a specialized surgical unit to a general mixed intensive care unit

OBJECTIVES

We report the transition of a specialized surgical intensive care unit to a general mixed intensive care unit (ICU) and its influence on immediate outcome and performance data of the surgical population before and after the reorganization.

METHODS

All consecutive patients (2420 admissions) entering the surgical intensive care unit, period 2004-2007. After the year 2005, all specialized units were combined into 3 general mixed units.

RESULTS

Our population on the former surgical unit changed from mostly surgical patients to a mixed general ICU population, which comprises mostly of cardiac surgery patients. We saw better results in all overall outcome domains (ICU mortality, length of stay, and percentage of ICU readmissions). The ICU standardized mortality ratio remained the same. Surgical patients' outcome did not improve, nor did it decrease after the organizational change.

CONCLUSION

Organizational changes from a surgical ICU to a general mixed unit can have profound influences on performance data. Crude ICU outcome improved after the reorganization. Nevertheless, ICU standardized mortality ratio did not change.

Our paper 20 years later: 1-year survival and 6-month quality of life after intensive care

INTRODUCTION

In the early 1990s, the in-hospital mortality rate of intensive care unit (ICU) patients dropped, and interest in the quality of life (QOL) of ICU survivors increased. In 1996, we published a study to investigate 1-year survival after hospital discharge and 6-month QOL after intensive care. Now, we compare our previous results with those reported in the recent literature to appraise any changes, and new knowledge in the area.

RESULTS

The 1-year survival of ICU patients after hospital discharge is substantial, lower than in the general population, and different among subgroups. Some studies showed a reduction in QOL at 6 months, as in our study, while others showed an improvement. Different results seem to be related mainly to the case mix. Studies on different types of patients found long-term cognitive impairment in ICU survivors, possibly not disease specific. The proportions of patients with neuropsychological morbidities such as posttraumatic stress disorder, anxiety, and depression, described after our study, did not show any change over time.

CONCLUSIONS

Differences between studies on long-term survival and QOL do not allow conclusions to be drawn about change over time. No change was found in neuropsychological morbidities. However, a lack of change may not be viewed negatively, because critically ill patients who survive ICU today may be at higher risk for poor long-term outcome than in the past due to the higher severity of their illness and the more aggressive treatments received. Future studies may provide understanding of the relationships between psychiatric symptoms, cognitive impairment, functional disability, and QOL.

Early organ dysfunction affects long-term survival in acute pancreatitis patients

BACKGROUND

The effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown.

OBJECTIVE

The aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP.

METHODS

A retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥ 2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan-Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Cox's proportional hazards methods.

RESULTS

A total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4-10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2-11.9 years) (log-rank test, P = 0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72-2.176; P = 0.019] along with age (HR: 1.062; P < 0.001), alcohol-related aetiology (HR: 2.027; P = 0.001) and idiopathic aetiology (HR: 1.548; P = 0.048).

CONCLUSIONS

Early organ dysfunction in AP is an independent predictor of long-term survival even when in-hospital deaths are accounted for. Negative predictors also include age, and idiopathic and alcohol-related aetiologies.

Economic evaluation of nurse-led intensive care follow-up programmes compared with standard care: the PRaCTICaL trial

OBJECTIVE

Following intensive care discharge, many patients suffer severe physical and psychological morbidity and a continuing high use of health services. Follow-up programmes have been proposed to improve the outcomes for these patients. We tested the hypothesis that nurse-led intensive care follow-up programmes are cost-effective.

METHODS

A pragmatic, multicentre, randomised controlled trial of nurse-led intensive care unit follow-up programmes versus standard care. A cost-utility analysis was conducted after 12 months' follow-up to compare the two interventions. Costs were assessed from the perspective of the UK NHS and outcomes were measured in quality-adjusted life years (QALYs) based upon responses to the EQ-5D administered at baseline, 6 and 12 months.

RESULTS

A total of 286 patients were recruited to the trial. Total mean cost was £ 5,789 for standard care and £ 7,577 for the discharge clinic. The adjusted difference in means was £ 2,435 [95 % confidence interval (CI) -297 to 5,566]. Mean QALYs were 0.58 for standard care and 0.60 for the discharge clinic. The adjusted mean difference was -0.003 (95 % CI -0.066 to 0.060). If society were willing to pay £ 20,000 per QALY then there would be a 93 % chance that standard care would be considered most efficient.

CONCLUSIONS

A nurse-led intensive care unit (ICU) follow-up programme showed no evidence of being cost-effective at 12 months. Further work should focus on evidence-based development of discharge clinic services and current ICU follow-up programmes should review their practice in light of these results.

Development and validation of a risk model for identification of non-neutropenic, critically ill adult patients at high risk of invasive Candida infection: the Fungal Infection Risk Evaluation (FIRE) Study

BACKGROUND

There is increasing evidence that invasive fungal disease (IFD) is more likely to occur in non-neutropenic patients in critical care units. A number of randomised controlled trials (RCTs) have evaluated antifungal prophylaxis in non-neutropenic, critically ill patients, demonstrating a reduction in the risk of proven IFD and suggesting a reduction in mortality. It is necessary to establish a method to identify and target antifungal prophylaxis at those patients at highest risk of IFD, who stand to benefit most from any antifungal prophylaxis strategy.

OBJECTIVES

To develop and validate risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive Candida infection, who would benefit from antifungal prophylaxis, and to assess the cost-effectiveness of targeting antifungal prophylaxis to high-risk patients based on these models.

DESIGN

Systematic review, prospective data collection, statistical modelling, economic decision modelling and value of information analysis.

SETTING

Ninety-six UK adult general critical care units.

PARTICIPANTS

Consecutive admissions to participating critical care units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Invasive fungal disease, defined as a blood culture or sample from a normally sterile site showing yeast/mould cells in a microbiological or histopathological report. For statistical and economic modelling, the primary outcome was invasive Candida infection, defined as IFD-positive for Candida species.

RESULTS

Systematic review: Thirteen articles exploring risk factors, risk models or clinical decision rules for IFD in critically ill adult patients were identified. Risk factors reported to be significantly associated with IFD were included in the final data set for the prospective data collection.

DATA COLLECTION

Data were collected on 60,778 admissions between July 2009 and March 2011. Overall, 383 patients (0.6%) were admitted with or developed IFD. The majority of IFD patients (94%) were positive for Candida species. The most common site of infection was blood (55%). The incidence of IFD identified in unit was 4.7 cases per 1000 admissions, and for unit-acquired IFD was 3.2 cases per 1000 admissions. Statistical modelling: Risk models were developed at admission to the critical care unit, 24 hours and the end of calendar day 3. The risk model at admission had fair discrimination (c-index 0.705). Discrimination improved at 24 hours (c-index 0.823) and this was maintained at the end of calendar day 3 (c-index 0.835). There was a drop in model performance in the validation sample. Economic decision model: Irrespective of risk threshold, incremental quality-adjusted life-years of prophylaxis strategies compared with current practice were positive but small compared with the incremental costs. Incremental net benefits of each prophylaxis strategy compared with current practice were all negative. Cost-effectiveness acceptability curves showed that current practice was the strategy most likely to be cost-effective. Across all parameters in the decision model, results indicated that the value of further research for the whole population of interest might be high relative to the research costs.

CONCLUSIONS

The results of the Fungal Infection Risk Evaluation (FIRE) Study, derived from a highly representative sample of adult general critical care units across the UK, indicated a low incidence of IFD among non-neutropenic, critically ill adult patients. IFD was associated with substantially higher mortality, more intensive organ support and longer length of stay. Risk modelling produced simple risk models that provided acceptable discrimination for identifying patients at 'high risk' of invasive Candida infection. Results of the economic model suggested that the current most cost-effective treatment strategy for prophylactic use of systemic antifungal agents among non-neutropenic, critically ill adult patients admitted to NHS adult general critical care units is a strategy of no risk assessment and no antifungal prophylaxis.

FUNDING

Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

An integrated approach to evaluating alternative risk prediction strategies: a case study comparing alternative approaches for preventing invasive fungal disease

OBJECTIVES

This article proposes an integrated approach to the development, validation, and evaluation of new risk prediction models illustrated with the Fungal Infection Risk Evaluation study, which developed risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive fungal disease (IFD).

METHODS

Our decision-analytical model compared alternative strategies for preventing IFD at up to three clinical decision time points (critical care admission, after 24 hours, and end of day 3), followed with antifungal prophylaxis for those judged "high" risk versus "no formal risk assessment." We developed prognostic models to predict the risk of IFD before critical care unit discharge, with data from 35,455 admissions to 70 UK adult, critical care units, and validated the models externally. The decision model was populated with positive predictive values and negative predictive values from the best-fitting risk models. We projected lifetime cost-effectiveness and expected value of partial perfect information for groups of parameters.

RESULTS

The risk prediction models performed well in internal and external validation. Risk assessment and prophylaxis at the end of day 3 was the most cost-effective strategy at the 2% and 1% risk threshold. Risk assessment at each time point was the most cost-effective strategy at a 0.5% risk threshold. Expected values of partial perfect information were high for positive predictive values or negative predictive values (£11 million-£13 million) and quality-adjusted life-years (£11 million).

CONCLUSIONS

It is cost-effective to formally assess the risk of IFD for non-neutropenic, critically ill adult patients. This integrated approach to developing and evaluating risk models is useful for informing clinical practice and future research investment.

Outpatient intensive care unit follow-up services in Italy: a national survey: a brief report

This is a brief report of a national Italian survey about the presence and the way of management of outpatient follow-up services for patients who survived in the intensive care unit and after discharge from the hospital.

Long-term survival after intensive care unit discharge in Thailand: a retrospective study

Introduction

Economic evaluations of interventions in the hospital setting often rely on the estimated long-term impact on patient survival. Estimates of mortality rates and long-term outcomes among patients discharged alive from the intensive care unit (ICU) are lacking from lower- and middle-income countries. This study aimed to assess the long-term survival and life expectancy (LE) amongst post-ICU patients in Thailand, a middle-income country.

Methods

In this retrospective cohort study, data from a regional tertiary hospital in northeast Thailand and the regional death registry were linked and used to assess patient survival time after ICU discharge. Adult ICU patients aged at least 15 years who had been discharged alive from an ICU between 1 January 2004 and 31 December 2005 were included in the study, and the death registry was used to determine deaths occurring in this cohort up to 31^st December 2010. These data were used in conjunction with standard mortality life tables to estimate annual mortality and life expectancy.

Results

This analysis included 10,321 ICU patients. During ICU admission, 3,251 patients (31.5%) died. Of 7,070 patients discharged alive, 2,527 (35.7%) were known to have died within the five-year follow-up period, a mortality rate 2.5 times higher than that in the Thai general population (age and sex matched). The mean LE was estimated as 18.3 years compared with 25.2 years in the general population.

Conclusions

Post-ICU patients experienced much higher rates of mortality than members of the general population over the five-year follow-up period, particularly in the first year after discharge. Further work assessing Health Related Quality of Life (HRQOL) in both post-ICU patients and in the general population in developing countries is needed.

Life after critical illness: an overview

AIMS AND OBJECTIVES

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.

BACKGROUND

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.

METHODS

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'.

RESULTS

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.

CONCLUSION

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.

Continuous renal replacement therapy outcomes in acute kidney injury and end-stage renal disease: a cohort study

INTRODUCTION

Continuous renal replacement therapy (CRRT) is a widely used but resource-intensive treatment. Despite its broad adoption in intensive care units (ICUs), it remains challenging to identify patients who would be most likely to achieve positive outcomes with this therapy and to provide realistic prognostic information to patients and families.

METHODS

We analyzed a prospective cohort of all 863 ICU patients initiated on CRRT at an academic medical center from 2008 to 2011 with either new-onset acute kidney injury (AKI) or pre-admission end-stage renal disease (ESRD). We examined in-hospital and post-discharge mortality (for all patients), as well as renal recovery (for AKI patients). We identified prognostic factors for both in-hospital and post-discharge mortality separately in patients with AKI or ESRD.

RESULTS

In-hospital mortality was 61% for AKI and 54% for ESRD. In patients with AKI (n=725), independent risk factors for mortality included age over 60 (OR 1.9, 95% CI 1.3, 2.7), serum lactate over 4 mmol/L (OR 2.2, 95% CI 1.5, 3.1), serum creatinine over 3 mg/dL at time of CRRT initiation (OR 0.63, 95% CI 0.43, 0.92) and comorbid liver disease (OR 1.75, 95% CI 1.1, 2.9). Among patients with ESRD (n=138), liver disease was associated with increased mortality (OR 3.4, 95% CI 1.1, 11.1) as was admission to a medical (vs surgical) ICU (OR 2.2, 95% CI 1.1, 4.7). Following discharge, advanced age became a predictor of mortality in both groups (AKI: HR 1.9, 95% CI 1.2, 3.0; ESRD: HR 4.1, 95% CI 1.5, 10.9). At the end of the study period, only 25% (n=183) of patients with AKI achieved dialysis-free survival.

CONCLUSIONS

Among patients initiating CRRT, risk factors for mortality differ between patients with underlying ESRD or newly acquired AKI. Long-term dialysis-free survival in AKI is low. Providers should consider these factors when assessing prognosis or appropriateness of CRRT.

Factors influencing physical functional status in intensive care unit survivors two years after discharge

Background

Studies suggest that in patients admitted to intensive care units (ICU), physical functional status (PFS) improves over time, but does not return to the same level as before ICU admission. The goal of this study was to assess physical functional status two years after discharge from an ICU and to determine factors influencing physical status in this population.

Methods

The study reviewed all patients admitted to two non-trauma ICUs during a one-year period and included patients with age ≥ 18 yrs, ICU stay ≥ 24 h, and who were alive 24 months after ICU discharge. To assess PFS, Karnofsky Performance Status Scale scores and Lawton-Instrumental Activities of Daily Living (IADL) scores at ICU admission (K-ICU and L-ICU) were compared to the scores at the end of 24 months (K-24mo and L-24mo). Data at 24 months were obtained through telephone interviews.

Results

A total of 1,216 patients were eligible for the study. Twenty-four months after ICU discharge, 499 (41.6%) were alive, agreed to answer the interview, and had all hospital data available. PFS (K-ICU: 86.6 ± 13.8 vs. K-24mo: 77.1 ± 19.6, p < 0.001) and IADL (L-ICU: 27.0 ± 11.7 vs. L-24mo: 22.5 ± 11.5, p < 0.001) declined in patients with medical and unplanned surgical admissions. Most strikingly, the level of dependency increased in neurological patients (K-ICU: 86 ± 12 vs. K-24mo: 64 ± 21, relative risk [RR] 2.6, 95% CI, 1.8–3.6, p < 0.001) and trauma patients (K-ICU: 99 ± 2 vs. K-24mo: 83 ± 21, RR 2.7, 95% CI, 1.6–4.6, p < 0.001). The largest reduction in the ability to perform ADL occurred in neurological patients (L-ICU: 27 ± 7 vs. L-24mo: 15 ± 12, RR 3.3, 95% CI, 2.3–4.6 p < 0.001), trauma patients (L-ICU: 32 ± 0 vs. L-24mo: 25 ± 11, RR 2.8, 95% CI, 1.5–5.1, p < 0.001), patients aged ≥ 65 years (RR 1.4, 95% CI, 1.07–1.86, p = 0.01) and those who received mechanical ventilation for ≥ 8 days (RR 1.48, 95% CI, 1.02–2.15, p = 0.03).

Conclusions

Twenty-four months after ICU discharge, PFS was significantly poorer in patients with neurological injury, trauma, age ≥ 65 tears, and mechanical ventilation ≥ 8 days. Future studies should focus on the relationship between PFS and health-related quality of life in this population.

An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study

INTRODUCTION

The socio-economic impact of critical illnesses on patients and their families in Europe has yet to be determined. The aim of this exploratory study was to estimate changes in family circumstances, social and economic stability, care requirements and access to health services for patients during their first 12 months after ICU discharge.

METHODS

Multi-center questionnaire-based study of survivors of critical illness at 6 and 12 months after ICU discharge.

RESULTS

Data for 293 consenting patients who spent greater than 48 hours in one of 22 UK ICUs were obtained at 6 and 12 months post-ICU discharge. There was little evidence of a change in accommodation or relationship status between pre-admission and 12 months following discharge from an ICU. A negative impact on family income was reported by 33% of all patients at 6 months and 28% at 12 months. There was nearly a 50% reduction in the number of patients who reported employment as their sole source of income at 12 months (19% to 11%) compared with pre-admission. One quarter of patients reported themselves in need of care assistance at 6 months and 22% at 12 months. The majority of care was provided by family members (80% and 78%, respectively), for half of whom there was a negative impact on employment. Amongst all patients receiving care, 26% reported requiring greater than 50 hours a week. Following discharge, 79% of patients reported attending their primary care physician and 44% had seen a community nurse. Mobility problems nearly doubled between pre-admission and 6 months (32% to 64%). Furthermore, 73% reported moderate or severe pain at 12 months and 44% remained significantly anxious or depressed.

CONCLUSIONS

Survivors of critical illness in the UK face a negative impact on employment and commonly have a care requirement after discharge from hospital. This has a corresponding negative impact on family income. The majority of the care required is provided by family members. This effect was apparent by 6 months and had not materially improved by 12 months. This exploratory study has identified the potential for a significant socio-economic burden following critical illness.

Timing and causes of death after injuries

Currently, long-term outcomes are significant because health care system changes will likely lead to a single payment for each occurrence of care, including readmissions-the "bundled payment" system. Therefore, it is essential to understand the outcomes of trauma patients discharged alive from trauma centers. This article reviews the current knowledge base on the timing and causes of deaths after trauma. The trimodal mortality model (immediate deaths, early deaths, and late deaths) is utilized as the early research describing trimodal distribution is discussed. Also covered is the successive work as trauma systems matured, showing a shift toward a bimodal distribution with a decline in late deaths. Finally, studies of long-term outcomes are highlighted. Deaths occurring within minutes or a few hours of injury are largely unchanged, which underscores the enormity of injuries to the central nervous and cardiovascular systems. Late deaths caused by multiple organ failure and sepsis have declined considerably, however. Also, the causes of death in this patient population remain constant. Lastly, a considerable number of deaths after discharge may be due to nontraumatic causes.

Patients with end-stage renal disease admitted to the intensive care unit: systematic review

The number of patients with end-stage renal disease (ESRD) is increasing worldwide, with a growing demand on healthcare services. A systematic review of the literature was performed to determine the requirement for intensive care unit (ICU) services, reasons for admission, predictors of mortality, and short- and long-term outcomes of ESRD patients admitted to ICU. Sixteen studies were identified, comprising 6591 ICU admissions. Cardiovascular disease and sepsis accounted for the majority of admissions. Acute illness severity scores tend to overestimate mortality among ESRD patients. Critical illness associated with acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with significantly higher hospital mortality compared with ESRD patients admitted to the ICU [odds ratio (OR) 3.9; 3.5-4.4; P<0.0001]. However, hospital mortality of ESRD patients is less favourable compared with matched patients with mild AKI (OR 1.5; 1.4-1.6; P<0.0001). Although the mortality rate remains high shortly after hospital discharge, the duration of increased mortality risk is unclear. Patients with ESRD frequently benefit from ICU admission, despite chronic co-morbidity. Further studies are required to modify and validate existing illness severity scores for ESRD patients admitted to the ICU, and to establish the duration of increased mortality risk after discharge from ICU.