Core Domains for Clinical Research in Acute Respiratory Failure Survivors: An International Modified Delphi Consensus Study

Measuring Quality-weighted Hospital-Free Days in Acute Respiratory Failure: A Modified Delphi Study

Rationale: Hospital-free days (HFDs), a measure of the number of days alive spent outside the hospital, is increasingly used as an endpoint in studies of patients with acute respiratory failure (ARF) or other critical and serious illnesses. Current approaches to measuring HFDs do not account for decrements in functional status or quality of life that ARF survivors and family members value. Objectives: To develop an acceptable approach to measure quality-weighted HFDs using patient-reported outcomes. Methods: We conducted a four-round modified Delphi process among ARF experts: those with lived or professional experience. Experts rated survivorship domains, instrument and data collection characteristics, and methods to translate responses into quality-weighted HFDs. The consensus threshold was that ⩾70% of respondents rated an item "totally acceptable" or "acceptable" and ⩽15% of respondents rated the item "totally unacceptable," "unacceptable," or "slightly unacceptable." Results: Fifty-seven experts participated in round 1. Response rates were 82-93% for subsequent rounds. Priority survivorship domains were physical function and health-related quality of life. Participants reached a consensus that data collection during ARF recovery should take less than 15 minutes per assessment, allow surrogate completion when patients are unable, and continue for at least 24 months of follow-up. Using the EuroQol-5 Dimensions (EQ-5D) questionnaire to quality weight HFDs met consensus criteria for acceptability. A majority of panelists preferred quality-weighted HFDs to unweighted HFDs or survival for use in future ARF studies. Conclusions: Quality-weighting HFDs using patient and/or surrogate responses to the EQ-5D captured stakeholder priorities and was acceptable to this Delphi panel.

Tackling Brain and Muscle Dysfunction in Acute Respiratory Distress Syndrome Survivors: NHLBI Workshop Report

Acute respiratory distress syndrome (ARDS) is associated with long-term impairments in brain and muscle function that significantly impact the quality of life of those who survive the acute illness. The mechanisms underlying these impairments are not yet well understood, and evidence-based interventions to minimize the burden on patients remain unproved. The NHLBI of the NIH assembled a workshop in April 2023 to review the state of the science regarding ARDS-associated brain and muscle dysfunction, to identify gaps in current knowledge, and to determine priorities for future investigation. The workshop included presentations by scientific leaders across the translational science spectrum and was open to the public as well as the scientific community. This report describes the themes discussed at the workshop as well as recommendations to advance the field toward the goal of improving the health and well-being of ARDS survivors.

Representation of published core outcome sets in practice guidelines

OBJECTIVES

A core outcome set (COS) is an agreed standardized set of outcomes that should be measured and reported, as a minimum, in specific areas of health or health care. A COS is developed through a consensus process to ensure health care outcomes to be measured are relevant to decision-makers, including patients and health-care professionals. Use of COS in guideline development is likely to increase the relevance of the guideline to those decision-makers. Previous work has looked at the uptake of COS in trials, systematic reviews, health technology assessments and regulatory guidance but to date there has been no evaluation of the use of COS in practice guideline development. The objective of this study was to investigate the representation of core outcomes in a set of international practice guidelines.

STUDY DESIGN AND SETTING

We searched for clinical guidelines relevant to ten high-quality COS (with focus on the United Kingdom, Germany, China, India, Canada, Denmark, United States and World Health Organisation). We matched scope between COS and guideline in terms of condition, population and outcome. We calculated the proportion of guidelines mentioning or referencing COS and the proportion of COS domains specifically, or generally, matching to outcomes specified in each guideline populations, interventions, comparators and outcome (PICO) statement.

RESULTS

We found 38 guidelines that contained 170 PICO statements matching the scope of the ten COS and of sufficient quality to allow data extraction. None of the guidelines reviewed explicitly mentioned or referenced the relevant COS. The median (range) of the proportion of core outcomes covered either specifically or generally by the guideline PICO was 30% (0%-100%).

CONCLUSION

There is no evidence that COS are being used routinely to inform the guideline development process, and concordance between outcomes in published guidelines and those in COS is limited. Further work is warranted to explore barriers and facilitators in the use of COS when developing clinical guidelines.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BACKGROUND

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.

METHODS

A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.

RESULTS

Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.

CONCLUSIONS

The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Oxygen-Saturation Targets and Cognitive and Functional Outcomes in Mechanically Ventilated Adults

Rationale: Among mechanically ventilated critically ill adults, the PILOT (Pragmatic Investigation of Optimal Oxygen Targets) trial demonstrated no difference in ventilator-free days among lower, intermediate, and higher oxygen-saturation targets. The effects on long-term cognition and related outcomes are unknown.Objectives: To compare the effects of lower (90% [range, 88-92%]), intermediate (94% [range, 92-96%]), and higher (98% [range, 96-100%]) oxygen-saturation targets on long-term outcomes.Methods: Twelve months after enrollment in the PILOT trial, blinded neuropsychological raters conducted assessments of cognition, disability, employment status, and quality of life. The primary outcome was global cognition as measured using the Telephone Montreal Cognitive Assessment. In a subset of patients, an expanded neuropsychological battery measured executive function, attention, immediate and delayed memory, verbal fluency, and abstraction.Measurements and Main Results: A total of 501 patients completed follow-up, including 142 in the lower, 186 in the intermediate, and 173 in the higher oxygen target groups. Median (interquartile range) peripheral oxygen saturation values in the lower, intermediate, and higher target groups were 94% (91-96%), 95% (93-97%), and 97% (95-99%), respectively. Telephone Montreal Cognitive Assessment score did not differ between lower and intermediate (adjusted odds ratio [OR], 1.36 [95% confidence interval (CI), 0.92-2.00]), intermediate and higher (adjusted OR, 0.90 [95% CI, 0.62-1.29]), or higher and lower (adjusted OR, 1.22 [95% CI, 0.83-1.79]) target groups. There was also no difference in individual cognitive domains, disability, employment, or quality of life.Conclusions: Among mechanically ventilated critically ill adults who completed follow-up at 12 months, oxygen-saturation targets were not associated with cognition or related outcomes.

Long-term functional disabilities in intensive care unit survivors: A prospective cohort study

BACKGROUND

Functional disabilities are common in intensive care unit (ICU) survivors and may affect their ability to live independently. Few previous studies have investigated long-term functional outcomes with health status before ICU admission (pre-ICU health), and they are limited to specific patient groups.

OBJECTIVES

The objective of this study was to investigate the prevalence of functional disabilities and examine pre-ICU health variables as possible predictive factors of functional disabilities 12 months after ICU admission in a mixed population of ICU survivors.

METHODS

This prospective cohort study was conducted in six ICUs in Norway. Data on pre-ICU health were collected as soon as possible after ICU admission using patients, proxies, and patient electronic health records and at 12 months after ICU admission. Self-reported functional status was assessed using the Katz Index of independence in personal activities of daily living (P-ADL) and the Lawton instrumental activities of daily living scale (I-ADL).

RESULTS

A total of 220 of 343 (64%) ICU survivors with data on pre-ICU health completed the questionnaires at 12 months and reported the following functional disabilities at 12 months: 31 patients (14.4%) reported P-ADL dependencies (new in 16 and persisting in 15), and 80 patients (36.4%) reported I-ADL dependencies (new in 41 and persisting in 39). In a multivariate analysis, worse baseline P-ADL and I-ADL scores were associated with dependencies in P-ADLs (odds ratio [OR]: 1.87; 95% confidence interval [CI]: 1.14-3.06) and I-ADLs (OR: 1.52; 95% CI: 1.03-2.23), respectively, at 12 months. Patients who were employed were less likely to report I-ADL dependencies at 12 months (OR: 0.34; 95% CI: 0.12-0.95).

CONCLUSION

In a subsample of ICU survivors, patients reported functional disabilities 12 months after ICU admission, which was significantly associated with their pre-ICU functional status. Early screening of pre-ICU functional status may help identify patients at risk of long-term functional disabilities. ICU survivors with pre-ICU functional disabilities may find it difficult to improve their functional status.

Practice Standards for the Use of Multimodality Neuromonitoring: A Delphi Consensus Process

OBJECTIVES

To address areas in which there is no consensus for the technologies, effort, and training necessary to integrate and interpret information from multimodality neuromonitoring (MNM).

DESIGN

A three-round Delphi consensus process.

SETTING

Electronic surveys and virtual meeting.

SUBJECTS

Participants with broad MNM expertise from adult and pediatric intensive care backgrounds.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two rounds of surveys were completed followed by a virtual meeting to resolve areas without consensus and a final survey to conclude the Delphi process. With 35 participants consensus was achieved on 49% statements concerning MNM. Neurologic impairment and the potential for MNM to guide management were important clinical considerations. Experts reached consensus for the use of MNM-both invasive and noninvasive-for patients in coma with traumatic brain injury, aneurysmal subarachnoid hemorrhage, and intracranial hemorrhage. There was consensus that effort to integrate and interpret MNM requires time independent of daily clinical duties, along with specific skills and expertise. Consensus was reached that training and educational platforms are necessary to develop this expertise and to provide clinical correlation.

CONCLUSIONS

We provide expert consensus in the clinical considerations, minimum necessary technologies, implementation, and training/education to provide practice standards for the use of MNM to individualize clinical care.

Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients

IMPORTANCE

Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness.

OBJECTIVE

To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients.

DESIGN, SETTING, AND PARTICIPANTS

The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022.

EXPOSURES

Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90).

MAIN OUTCOMES AND MEASURES

Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality.

RESULTS

The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28.

CONCLUSIONS AND RELEVANCE

In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cognitive Outcomes in the Pragmatic Investigation of optimaL Oxygen Targets (CO-PILOT) trial: protocol and statistical analysis plan

INTRODUCTION

Long-term cognitive impairment is one of the most common complications of critical illness among survivors who receive mechanical ventilation. Recommended oxygen targets during mechanical ventilation vary among international guidelines. Different oxygen targets during mechanical ventilation have the potential to alter long-term cognitive function due to cerebral hypoxemia or hyperoxemia. Whether higher, intermediate or lower SpO2 targets are associated with better cognitive function at 12-month follow-up is unknown.

METHODS AND ANALYSIS

The Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial is an ongoing pragmatic, cluster-randomised, cluster-crossover trial comparing the effect of a higher SpO2 target (target 98%, goal range 96%-100%), an intermediate SpO2 target (target 94%, goal range 92%-96%) and a lower SpO2 target (target 90%, goal range 88%-92%) on clinical outcomes in mechanically ventilated patients admitted to the medical intensive care unit at a single centre in the USA. For this ancillary study of long-term Cognitive Outcomes (CO-PILOT), survivors of critical illness who are in the PILOT trial and who do not meet exclusion criteria for CO-PILOT are approached for consent. The anticipated number of patients for whom assessment of long-term cognition will be performed in CO-PILOT is 612 patients over 36 months of enrolment. Cognitive, functional and quality of life assessments are assessed via telephone interview at approximately 12 months after enrolment in PILOT. The primary outcome of CO-PILOT is the telephone version of the Montreal Cognitive Assessment. A subset of patients will also complete a comprehensive neuropsychological telephone battery to better characterise the cognitive domains affected.

ETHICS AND DISSEMINATION

The CO-PILOT ancillary study was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.

A Core Outcome Measurement Set for Pediatric Critical Care

OBJECTIVES

To identify a PICU Core Outcome Measurement Set (PICU COMS), a set of measures that can be used to evaluate the PICU Core Outcome Set (PICU COS) domains in PICU patients and their families.

DESIGN

A modified Delphi consensus process.

SETTING

Four webinars attended by PICU physicians and nurses, pediatric surgeons, rehabilitation physicians, and scientists with expertise in PICU clinical care or research ( n = 35). Attendees were from eight countries and convened from the Pediatric Acute Lung Injury and Sepsis Investigators Pediatric Outcomes STudies after PICU Investigators and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network PICU COS Investigators.

SUBJECTS

Measures to assess outcome domains of the PICU COS are as follows: cognitive, emotional, overall (including health-related quality of life), physical, and family health. Measures evaluating social health were also considered.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measures were classified as general or additional based on generalizability across PICU populations, feasibility, and relevance to specific COS domains. Measures with high consensus, defined as 80% agreement for inclusion, were selected for the PICU COMS. Among 140 candidate measures, 24 were delineated as general (broadly applicable) and, of these, 10 achieved consensus for inclusion in the COMS (7 patient-oriented and 3 family-oriented). Six of the seven patient measures were applicable to the broadest range of patients, diagnoses, and developmental abilities. All were validated in pediatric populations and have normative pediatric data. Twenty additional measures focusing on specific populations or in-depth evaluation of a COS subdomain also met consensus for inclusion as COMS additional measures.

CONCLUSIONS

The PICU COMS delineates measures to evaluate domains in the PICU COS and facilitates comparability across future research studies to characterize PICU survivorship and enable interventional studies to target long-term outcomes after critical illness.

A comprehensive mobility discharge assessment framework for older adults transitioning from hospital-to-home in the community—What mobility factors are critical to include? Protocol for an international e-Delphi study

Background

Mobility deficits have been identified as an independent risk factor for hospital readmission for adults ≥65 years. Despite evidence indicating how determinants additively influence and predict mobility, no hospital-to-home care transition models comprehensively assess all seven mobility determinants, cognitive, financial, environmental, personal, physical, psychological, and social. There is currently a lack of clarity regarding what factors clinicians and researchers should evaluate for each mobility determinant. The purpose of this e-Delphi study is to prioritize and reach consensus on the factors for each mobility determinant that are critical to assess as part of the Comprehensive Mobility Discharge Assessment Framework (CMDAF) when older adults are discharged from hospital-to-home.

Methods

This protocol paper is an international modified e-Delphi study following the Recommendations for the Conducting and Reporting of Delphi Studies. International researchers, clinicians, older adults and family caregivers residing in a country with universal or near-universal health coverage will be invited to participate as ‘experts’ in three e-Delphi rounds administered through DelphiManager©. The e-Delphi Round 1 questionnaire will be developed based on scoping review findings and will be pilot tested. For each round, experts will be asked to rate factors for each determinant that are critical to assess as part of the CMDAF using a 9-point scale: Not Important (1–3), Important but Not Critical (4–6), and Critical (7–9). The scale will include a selection option of "unable to score" and experts will also be asked to provide a rationale for their scoring and suggest missing factors. Experts will receive feedback summaries in Rounds 2 and 3 to guide them in reflecting on their initial responses and re-rating of factors that have not reached consensus. The criteria for reaching consensus will be if ≥70% of experts rate a factor as "critical" (scores ≥7) and ≤ 15% of experts rate a factor as "not important" (scores≤ 3). Quantitative data will be analyzed using median values, frequencies, percentages, interquartile range, and bar graphs; Wilcoxon matched-pairs signed-rank test will be used to assess the stability of participants’ responses. Rationale (qualitative data) provided in the open-ended comments section will be analyzed using content analysis.

Conclusion

This study is a first step in developing the CMDAF and will be used to guide a subsequent e-Delphi survey to decide on the tools that should be used to measure the examples of each factor included in our framework.

Development of a performance standard for physiotherapists delivering exercise and mobilisation to the critically ill: A modified Delphi consensus study

BACKGROUND

The provision of early mobilisation to critically ill patients has the potential to improve long term outcomes, but, is complex to deliver. There is minimal literature detailing the training and expertise required to deliver these interventions safely and effectively.

OBJECTIVE

The objective of this study was to determine the key elements of a performance standard for assessment of physiotherapists delivering exercise and mobilisation interventions to the critically ill.

METHOD

This is a modified eDelphi expert consensus study. Fifty-one physiotherapists from Australia and New Zealand with relevant clinical, educational, or research experience were included on the expert panel. Background information and the initial pool of items were developed from review of relevant literature. Five survey rounds were administered across two study phases to determine the elements, performance criteria, and assessment scale of the performance standard. Items were modified, amalgamated, and added based upon panel comments.

RESULTS

Consensus was achieved for 69 mandatory, and two supplementary performance criteria which were arranged under 15 elements encompassing knowledge, assessment, analysis, intervention, and professional behaviours. A 3-point rating scale was selected to assess item achievement and global performance.

CONCLUSION

Binational expert consensus was reached to define the assessment criteria for physiotherapists delivering exercise and mobilisation interventions to the critically ill. This standard can be utilised in clinical, educational, and research practice environments to guide training, assessment, and skill recognition in critical care physiotherapy.

PICU Survivorship: Factors Affecting Feasibility and Cohort Retention in a Long-Term Outcomes Study

Our understanding of longitudinal outcomes of Pediatric Intensive Care Unit (PICU) survivors is limited by the heterogeneity of follow-up intervals, populations, and outcomes assessed. We sought to demonstrate (1) the feasibility of longitudinal multidimensional outcome assessment and (2) methods to promote cohort retention. The objective of this presented study was to provide details of follow-up methodology in a PICU survivor cohort and not to present the outcomes at long-term follow-up for this cohort. We enrolled 152 children aged 0 to 17 years admitted to the PICU in a prospective longitudinal cohort study. We examined resource utilization, family impact of critical illness, and neurodevelopment using the PICU Outcomes Portfolio (POP) Survey which included a study-specific survey and validated tools: 1. Functional Status Scale, 2. Pediatric Evaluation of Disability Inventory Computer Adaptive Test, 3. Pediatric Quality of Life Inventory, 4. Strengths and Difficulties Questionnaire, and 5. Vanderbilt Assessment Scales for Attention Deficit-Hyperactivity Disorder. POP Survey completion rates were 89%, 78%, and 84% at 1, 3, and 6 months. Follow-up rates at 1, 2, and 3 years were 80%, 55%, and 43%. Implementing a longitudinal multidimensional outcome portfolio for PICU survivors is feasible within an urban, tertiary-care, academic hospital. Our attrition after one year demonstrates the long-term follow-up challenges in this population. Our findings inform ongoing efforts to implement core outcome sets after pediatric critical illness.

Core outcome measures for research in traumatic injury survivors: The National Trauma Research Action Plan modified Delphi consensus study

BACKGROUND

Until recently, survival has been the main outcome measure for injury research. Given the impact of injury on quality of life, the National Academies of Science, Engineering, and Medicine has called for advancing the science of research evaluating the long-term outcomes of trauma survivors. This is necessary so that treatments and interventions can be assessed for their impact on a trauma patients' long-term functional and psychosocial outcomes. We sought to propose a set of core domains and measurement instruments that are best suited to evaluate long-term outcomes after traumatic injury with a goal for these measures to be adopted as a national standard.

METHODS

As part of the development of a National Trauma Research Action Plan, we conducted a two-stage, five-round modified online Delphi consensus process with a diverse panel of 50 key stakeholders including clinicians, researchers, and trauma survivors from more than 9 professional areas across the United States. Before voting, panelists reviewed the results of a scoping review on patient-reported outcomes after injury and standardized information on measurement instruments following the Consensus-based Standards for the Selection of Health Measurement Instruments guidelines.

RESULTS

The panel considered a preliminary list of 74 outcome domains (patient-reported outcomes) and ultimately reached the a priori consensus criteria for 29 core domains that encompass aspects of physical, mental, social, and cognitive health. Among these 29 core domains, the panel considered a preliminary list of 199 patient-reported outcome measures and reached the a priori consensus criteria for 14 measures across 13 core domains. Participation of panelists ranged from 65% to 98% across the five Delphi rounds.

CONCLUSION

We developed a core outcome measurement set that will facilitate the synthesis, comparison, and interpretation of long-term trauma outcomes research. These measures should be prioritized in all future studies in which researchers elect to evaluate long-term outcomes of traumatic injury survivors.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study

Introduction

Survivors of acute respiratory failure (ARF) commonly experience long-lasting physical, cognitive, and/or mental health impairments. Unmet medication needs occurring immediately after hospital discharge may have an important effect on subsequent recovery.

Methods and analysis

In this multicenter prospective cohort study, we enrolled ARF survivors who were discharged directly home from their acute care hospitalization. The primary exposure was unmet medication needs. The primary outcome was hospital readmission or death within 3 months after discharge. We performed a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the exposure–outcome association, with an a priori sample size of 200 ARF survivors.

Results

We enrolled 200 ARF survivors, of whom 107 (53%) were female and 77 (39%) were people of color. Median (IQR) age was 55 (43–66) years, APACHE II score 20 (15–26) points, and hospital length of stay 14 (9–21) days. Of the 200 participants, 195 (98%) were in the analytic cohort. One hundred fourteen (57%) patients had at least one unmet medication need; the proportion of medication needs that were unmet was 6% (0–15%). Fifty-six (29%) patients were readmitted or died by 3 months; 10 (5%) died within 3 months. Unmet needs were not associated (risk ratio 1.25; 95% CI 0.75–2.1) with hospital readmission or death, although a higher proportion of unmet needs may have been associated with increased hospital readmission (risk ratio 1.7; 95% CI 0.96–3.1) and decreased mortality (risk ratio 0.13; 95% CI 0.02–0.99).

Discussion

Unmet medication needs are common among survivors of acute respiratory failure shortly after discharge home. The association of unmet medication needs with 3-month readmission and mortality is complex and requires additional investigation to inform clinical trials of interventions to reduce unmet medication needs.

Study registration number: NCT03738774. The study was prospectively registered before enrollment of the first patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03848-3.

Impact on Mental, Physical and Cognitive functioning of a Critical care sTay during the COVID-19 pandemic (IMPACCT COVID-19): protocol for a prospective, multicentre, mixed-methods cohort study

INTRODUCTION

The ongoing pandemic could affect the duration, variety and severity of the mental, physical, and cognitive impairments intensive care unit (ICU) survivors and their families frequently present. We aim to determine the impact of the COVID-19 pandemic on the mental, physical, and cognitive health of survivors, the experience of their families and their treating healthcare professionals.

METHODS AND ANALYSIS

Prospective, multicentre, mixed-methods cohort study in seven Chilean ICUs.

SAMPLE

450 adults, able to walk independently prior to admission, in ICU and mechanical ventilation >48 hours with and without COVID-19. Clinical Frailty Scale, Charlson comorbidity index, mobility (Functional Status Score for the Status Score for the Intensive Care Unit) and muscle strength (Medical Research Council Sum Score) will be assessed at ICU discharge. Cognitive functioning (Montreal Cognitive Assessment-blind), anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Impact of Event Scale-Revised) symptoms, disability (WHO Disability Assessment Schedule 2.0), quality of life (European Quality of Life Health Questionnaire), employment and survival will be assessed at ICU discharge, 3 months and 6 months. A sample will be assessed using actigraphy and the Global Physical Activity Questionnaire at 6 months after ICU discharge. Trajectories of mental, physical, and cognitive impairments will be estimated using multilevel longitudinal modelling. A sensitivity analysis using multiple imputations will be performed to account for missing data and loss-to-follow-up. Survival will be analysed using Kaplan-Meier curves. The perceptions of family members regarding the ICU stay and the later recovery will be explored 3 months after discharge. Healthcare professionals will be invited to discuss the challenges faced during the pandemic using semistructured interviews. Interviews will be thematically analysed by two independent coders to identify the main themes of the experience of family members and healthcare professionals.

ETHICS AND DISSEMINATION

The study was approved by the Clinica Alemana Universidad del Desarrollo Ethics Committee (2020-78) and each participating site. Study findings will be published in peer-reviewed journals and disseminated through social media and conference meetings.

TRIAL REGISTRATION NUMBER

NCT04979897.

Hospital-free Days: A Pragmatic and Patient-centered Outcome for Trials Among Critically and Seriously Ill Patients

Hospital-free days (HFDs), alternatively known as "days alive and outside the hospital," is increasingly used as a primary or secondary outcome in randomized trials among critically and seriously ill patients. This novel outcome measure addresses an existing gap in the availability of patient-centered, reliably obtained outcome measures among patients with acute respiratory failure, advanced lung diseases, lung transplantation, and other serious and critical illnesses. Traditional outcomes such as mortality, organ-failure-free days, and longitudinal patient-reported measures have distinct drawbacks that limit their suitability as endpoints in trials of patients with serious illness, particularly those trials with pragmatic designs. By contrast, HFDs provides a summary measure of important health events and is easily calculated from administrative or electronic health record data, thereby balancing the goals of patient-centeredness and pragmatic measurement. However, before HFDs can be widely adopted as an endpoint in trials of patients with respiratory and critical illnesses, several questions must be addressed regarding the optimal definition, measurement, and analysis of HFDs. In this perspective, we outline important considerations relevant to the use of HFDs as a trial endpoint and suggest directions for further development of the measure.

Feasibility of Nurse-Led Multidimensional Outcome Assessments in the Neuroscience Intensive Care Unit

BACKGROUND

The outcome focus for survivors of critical care has shifted from mortality to patient-centered outcomes. Multidimensional outcome assessments performed in critically ill patients typically exclude those with primary neurological injuries.

OBJECTIVE

To determine the feasibility of measurements of physical function, cognition, and quality of life in patients requiring neurocritical care.

METHODS

This evaluation of a quality improvement initiative involved all patients admitted to the neuroscience intensive care unit at the University of Cincinnati Medical Center.

INTERVENTIONS

Telephone assessments of physical function (Glasgow Outcome Scale-Extended and modified Rankin Scale scores), cognition (modified Telephone Interview for Cognitive Status), and quality of life (5-level EQ-5D) were conducted between 3 and 6 months after admission.

RESULTS

During the 2-week pilot phase, the authors contacted and completed data entry for all patients admitted to the neuroscience intensive care unit over a 2-week period in approximately 11 hours. During the 18-month implementation phase, the authors followed 1324 patients at a mean (SD) time of 4.4 (0.8) months after admission. Mortality at follow-up was 38.9%; 74.8% of these patients underwent withdrawal of care. The overall loss to follow-up rate was 23.6%. Among all patients contacted, 94% were available by the second attempt to interview them by telephone.

CONCLUSIONS

Obtaining multidimensional outcome assessments by telephone across a diverse population of neurocritically ill patients was feasible and efficient. The sample was similar to those in other cohort studies in the neurocritical care population, and the loss to follow-up rate was comparable with that of the general critical care population.

Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France

BACKGROUND

Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help.

DESIGN AND INTERVENTION

We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months.

PARTICIPANTS

We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less.

OUTCOMES

We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries.

CONCLUSIONS

We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.

Postdischarge Outcome Domains in Pediatric Critical Care and the Instruments Used to Evaluate Them: A Scoping Review

OBJECTIVES

Assessing outcomes after pediatric critical illness is imperative to evaluate practice and improve recovery of patients and their families. We conducted a scoping review of the literature to identify domains and instruments previously used to evaluate these outcomes.

DESIGN

Scoping review.

SETTING

We queried PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials Registry for studies evaluating pediatric critical care survivors or their families published between 1970 and 2017. We identified articles using key words related to pediatric critical illness and outcome domains. We excluded articles if the majority of patients were greater than 18 years old or less than 1 month old, mortality was the sole outcome, or only instrument psychometrics or procedural outcomes were reported. We used dual review for article selection and data extraction and categorized outcomes by domain (overall health, emotional, physical, cognitive, health-related quality of life, social, family).

SUBJECTS

Manuscripts evaluating outcomes after pediatric critical illness.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 60,349 citations, 407 articles met inclusion criteria; 87% were published after 2000. Study designs included observational (85%), interventional (7%), qualitative (5%), and mixed methods (3%). Populations most frequently evaluated were traumatic brain injury (n = 96), general pediatric critical illness (n = 87), and congenital heart disease (n = 72). Family members were evaluated in 74 studies (18%). Studies used a median of 2 instruments (interquartile range 1-4 instruments) and evaluated a median of 2 domains (interquartile range 2-3 domains). Social (n = 223), cognitive (n = 183), and overall health (n = 161) domains were most frequently studied. Across studies, 366 unique instruments were used, most frequently the Wechsler and Glasgow Outcome Scales. Individual domains were evaluated using a median of 77 instruments (interquartile range 39-87 instruments).

CONCLUSIONS

A comprehensive, generalizable understanding of outcomes after pediatric critical illness is limited by heterogeneity in methodology, populations, domains, and instruments. Developing assessment standards may improve understanding of postdischarge outcomes and support development of interventions after pediatric critical illness.

Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study

Supplemental Digital Content is available in the text.

To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries.

Characteristics, management and survival of ICU patients with coronavirus disease-19 in Norway, March-June 2020. A prospective observational study

BACKGROUND

Norwegian hospitals have operated within capacity during the COVID-19 pandemic. We present patient and management characteristics, and outcomes for the entire cohort of adult (>18 years) COVID-19 patients admitted to Norwegian intensive care units (ICU) from 10 March to 19 June 2020.

METHODS

Data were collected from The Norwegian intensive care and pandemic registry (NIPaR). Demographics, co-morbidities, management characteristics and outcomes are described. ICU length of stay (LOS) was analysed with linear regression, and associations between risk factors and mortality were quantified using Cox regression.

RESULTS

In total, 217 patients were included. The male to female ratio was 3:1 and the median age was 63 years. A majority (70%) had one or more co-morbidities, most frequently cardiovascular disease (39%), chronic lung disease (22%), diabetes mellitus (20%), and obesity (17%). Most patients were admitted for acute hypoxaemic respiratory failure (AHRF) (91%) and invasive mechanical ventilation (MV) was used in 86%, prone ventilation in 38% and 25% of patients received a tracheostomy. Vasoactive drugs were used in 79% and renal replacement therapy in 15%. Median ICU LOS and time of MV was 14.0 and 12.0 days. At end of follow-up 45 patients (21%) were dead. Age, co-morbidities and severity of illness at admission were predictive of death. Severity of AHRF and male gender were associated with LOS.

CONCLUSIONS

In this national cohort of COVID-19 patients, mortality was low and attributable to known risk factors. Importantly, prolonged length-of-stay must be taken into account when planning for resource allocation for any next surge.

A Core Outcome Set for Research Evaluating Interventions to Prevent and/or Treat Delirium in Critically Ill Adults: An International Consensus Study (Del-COrS)

OBJECTIVES

Delirium in critically ill adults is highly prevalent and has multiple negative consequences. To-date, trials of interventions to prevent or treat delirium report heterogenous outcomes. To develop international consensus among key stakeholders for a core outcome set for future trials of interventions to prevent and/or treat delirium in critically ill adults.

DESIGN

Core outcome set development, as recommended by the Core Outcome Measures in Effectiveness Trials Handbook. Methods of generating items for the core outcome set included a systematic review and qualitative interviews with ICU survivors and family members. Consensus methods include a two-round web-based Delphi process and a face-to-face meeting using nominal group technique methods.

SUBJECTS

International representatives from three stakeholder groups: 1) clinical researchers, 2) ICU interprofessional clinicians, and 3) ICU survivors and family members.

SETTING

Telephone interviews, web-based surveys, and a face-to-face consensus meeting held at the 2019 European Delirium Association's annual meeting in Edinburgh, Scotland.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Qualitative interviews with 24 ICU survivors and family members identified 36 potential outcomes; six were additional to the 97 identified from the systematic review. After item reduction, 32 outcomes were presented in Delphi Round 1; 179 experts participated, 38 ICU survivors/family members (21%), 100 clinicians (56%), 41 researchers (23%). Three additional outcomes were added to Round 2; 134 Round 1 participants (75%) completed it. Upon conclusion of the consensus building processes, the final core outcome set comprised seven outcomes: delirium occurrence (including prevalence or incidence); delirium severity; time to delirium resolution; health-related quality of life; emotional distress (i.e., anxiety, depression, acute and posttraumatic stress); cognition (including memory); and mortality.

CONCLUSIONS

This core outcome set, endorsed by the American and Australian Delirium Societies and European Delirium Association, is recommended for future clinical trials evaluating delirium prevention or treatment interventions in critically ill adults.

Core Outcome Measures for Trials in People With Coronavirus Disease 2019: Respiratory Failure, Multiorgan Failure, Shortness of Breath, and Recovery

Supplemental Digital Content is available in the text.

OBJECTIVES:

Respiratory failure, multiple organ failure, shortness of breath, recovery, and mortality have been identified as critically important core outcomes by more than 9300 patients, health professionals, and the public from 111 countries in the global coronavirus disease 2019 core outcome set initiative. The aim of this project was to establish the core outcome measures for these domains for trials in coronavirus disease 2019.

DESIGN:

Three online consensus workshops were convened to establish outcome measures for the four core domains of respiratory failure, multiple organ failure, shortness of breath, and recovery.

SETTING:

International.

PATIENTS:

About 130 participants (patients, public, and health professionals) from 17 countries attended the three workshops.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Respiratory failure, assessed by the need for respiratory support based on the World Health Organization Clinical Progression Scale, was considered pragmatic, objective, and with broad applicability to various clinical scenarios. The Sequential Organ Failure Assessment was recommended for multiple organ failure, because it was routinely used in trials and clinical care, well validated, and feasible. The Modified Medical Research Council measure for shortness of breath, with minor adaptations (recall period of 24 hr to capture daily fluctuations and inclusion of activities to ensure relevance and to capture the extreme severity of shortness of breath in people with coronavirus disease 2019), was regarded as fit for purpose for this indication. The recovery measure was developed de novo and defined as the absence of symptoms, resumption of usual daily activities, and return to the previous state of health prior to the illness, using a 5-point Likert scale, and was endorsed.

CONCLUSIONS:

The coronavirus disease 2019 core outcome set recommended core outcome measures have content validity and are considered the most feasible and acceptable among existing measures. Implementation of the core outcome measures in trials in coronavirus disease 2019 will ensure consistency and relevance of the evidence to inform decision-making and care of patients with coronavirus disease 2019.

What outcomes should be evaluated in critically ill patients?

Randomized clinical trials in intensive care prioritize disease-focused outcomes rather than patient-centered outcomes. A paradigm shift considering the evaluation of measures after hospital discharge and measures focused on quality of life and common symptoms, such as pain and dyspnea, could better reflect the wishes of patients and their families. However, barriers related to the systematization of the interpretation of these outcomes, the heterogeneity of measurement instruments and the greater difficulty in performing the studies, to date, seem to hinder this change. In addition, the joint participation of patients, families, researchers, and clinicians in the definition of study outcomes is not yet a reality.

A Core Outcome Set for Pediatric Critical Care

OBJECTIVES

More children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multistakeholder-recommended pediatric critical care core outcome set for inclusion in clinical and research programs.

DESIGN

A two-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring greater than 69% "critical" and less than 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components.

SETTING

Multinational survey.

PATIENTS

Stakeholder participants from six continents representing clinicians, researchers, and family/advocates.

MEASUREMENTS AND MAIN RESULTS

Overall response rates were 75% and 82% for each round. Participants voted on seven Global Domains and 45 Specific Outcomes in round 1, and six Global Domains and 30 Specific Outcomes in round 2. Using overall (three stakeholder groups combined) results, consensus was defined as outcomes scoring greater than 90% "critical" and less than 15% "not important" and were included in the final PICU core outcome set: four Global Domains (Cognitive, Emotional, Physical, and Overall Health) and four Specific Outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n = 21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU core outcome set-extended.

CONCLUSIONS

The PICU core outcome set and PICU core outcome set-extended are multistakeholder-recommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.

Core Domains for Research on Hospital Inactivity in Acutely Ill Older Adults: A Delphi Consensus Study

OBJECTIVE

To identify core domains for research studies of physical activity and sedentary behavior during hospitalization for older adults with an acute medical illness.

DESIGN

A 4-Round Delphi consensus process. Round 1 invited responses to open-ended questions to generate items for the core domains research. In rounds 2-4, participants were invited to use a Likert scale (1-9) to rate the importance of each core domain for research studies of physical activity and/or sedentary behavior in hospitalized older adults with an acute medical illness.

SETTING

Online surveys.

PARTICIPANTS

A total of 49 participants were invited to each round (international researchers, clinicians, policy makers and patients). Response rates across rounds 1-4 were 94%, 88%, 83% and 81%, respectively.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Consensus was defined a priori as ≥70% of respondents rating an item as "critical" (score≥7) and ≤15% of respondents rating an item as "not important" (score≤3).

RESULTS

In round 2, a total of 9 of 25 core domains reached consensus agreement (physical functioning, general, role functioning, emotional functioning, global quality of life, hospital, psychiatric, cognitive functioning, carer burden). In round 3, an additional 8 reached consensus (adverse events, perceived health status, musculoskeletal, social functioning, vascular, cardiac, mortality, economic). Round 4 participants provided further review and a final rating of all 17 core domains that met consensus in previous rounds. Four core domains were rated as "critically important" to evaluate: physical functioning, social functioning, emotional functioning, and hospital outcomes.

CONCLUSIONS

This preliminary work provides international and expert consensus-based core domains for development toward a core-outcome set for research, with the ultimate goal of fostering consistency in outcomes and reporting to accelerate research on effective strategies to address physical activity and/or sedentary behavior in older adults while hospitalized.

Systematic review of international Delphi surveys for core outcome set development: representation of international patients

OBJECTIVES

A core outcome set (COS) describes a minimum set of outcomes to be reported by all clinical trials of one healthcare condition. Delphi surveys are frequently used to achieve consensus on core outcomes. International input is important to achieve global COS uptake. We aimed to investigate participant representation in international Delphi surveys, with reference to the inclusion of patients and participants from low and middle income countries as stakeholders (LMICs).

DESIGN

Systematic review.

DATA SOURCES

EMBASE, Medline, Web of Science, COMET database and hand-searching.

ELIGIBILITY CRITERIA

Protocols and studies describing Delphi surveys used to develop an international COS for trial reporting, published between 1 January 2017 and 6 June 2019.

DATA EXTRACTION AND SYNTHESIS

Delphi participants were grouped as patients or healthcare professionals (HCPs). Participants were considered international if their country of origin was different to that of the first or senior author. Data extraction included participant numbers, country of origin, country income group and whether Delphi surveys were translated. We analysed the impact these factors had on outcome prioritisation.

RESULTS

Of 90 included studies, 69% (n=62) were completed and 31% (n=28) were protocols. Studies recruited more HCPs than patients (median 60 (IQR 30-113) vs 30 (IQR 14-66) participants, respectively). A higher percentage of HCPs was international compared with patients (57% (IQR 37-78) vs 20% (IQR 0-68)). Only 31% (n=28) studies recruited participants from LMICs. Regarding recruitment from LMICs, patients were under-represented (16% studies; n=8) compared with HCPs (22%; n=28). Few (7%; n=6) studies translated Delphi surveys. Only 3% studies (n=3) analysed Delphi responses by geographical location; all found differences in outcome prioritisation.

CONCLUSIONS

There is a disproportionately lower inclusion of international patients, compared with HCPs, in COS-development Delphi surveys, particularly within LMICs. Future international Delphi surveys should consider exploring for geographical and income-based differences in outcome prioritisation.

PROSPERO REGISTRATION NUMBER

CRD42019138519.

Design and Rationale for Common Data Elements for Clinical Research in Pediatric Critical Care Medicine

OBJECTIVES

Common data elements are a combination of a precisely defined question paired with a specified set of responses. Common data elements contribute to the National Institutes of Health-supported principle of Findable, Accessible, Interoperable, and Reusableness of research data. Routine use of Common data elements and standardized definitions within pediatric critical care research are likely to promote collaboration, improve quality, and consistency of data collection, improve overall efficiency of study or trial setup, and facilitate cross-study comparisons, meta-analysis, and merging of study cohorts. The purpose of this Pediatric Critical Care Medicine Perspective is to establish a road map for the development of multinational, multidisciplinary consensus-based common data elements that could be adapted for use within any pediatric critical care subject area.

METHODS

We describe a multistep process for the creation of "core domains" of research (e.g. patient outcomes, health-related conditions, or aspects of health) and the development of common data elements within each core domain. We define a tiered approach to data collection based on relevance of each common data element to future studies and clinical practice within the field of interest. Additionally, we describe the use of the Delphi methods to achieve consensus of these common data element documents using an international, multidisciplinary panel of experts.

Core Outcomes Set for Trials in People With Coronavirus Disease 2019

OBJECTIVES

The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019.

DESIGN

Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set.

SETTING

International.

SUBJECTS

Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers).

INTERVENTIONS

None.

MEASUREMENTS

None.

MAIN RESULTS

Six themes were identified. "Responding to the critical and acute health crisis" reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. "Capturing different settings of care" highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. "Encompassing the full trajectory and severity of disease" was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). "Distinguishing overlap, correlation and collinearity" meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). "Recognizing adverse events" refers to the potential harms of new and evolving interventions. "Being cognizant of family and psychosocial wellbeing" reflected the pervasive impacts of coronavirus disease 2019.

CONCLUSIONS

Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.

Core outcomes sets for studies evaluating critical illness and patient recovery

PURPOSE OF REVIEW

Given the growing body of critical care clinical research publications, core outcome sets (COSs) are important to help mitigate heterogeneity in outcomes assessed and measurement instruments used, and have potential to reduce research waste. This article provides an update on COS projects in critical care medicine, and related resources and tools for COS developers.

RECENT FINDINGS

We identified 28 unique COS projects, of which 15 have published results as of May 2020. COS topics relevant to critical care medicine include mechanical ventilation, cardiology, stroke, rehabilitation, and long-term outcomes (LTOs) after critical illness. There are four COS projects for coronavirus disease 2019 (COVID-19), with a 'meta-COS' summarizing common outcomes across these projects. To help facilitate COS development, there are existing resources, standards, guidelines, and tools available from the Core Outcome Measures in Effectiveness Trials Initiative (www.comet-initiative.org/) and the National Institutes of Health-funded Improve LTO project (www.improvelto.com/).

SUMMARY

Many COS projects have been completed in critical care, with more on-going COS projects, including foci from across the spectrum of acute critical care, COVID-19, critical care rehabilitation, and patient recovery and LTOs. Extensive resources are accessible to help facilitate rigorous COS development.

Optimizing a self-directed mobile mindfulness intervention for improving cardiorespiratory failure survivors' psychological distress (LIFT2): Design and rationale of a randomized factorial experimental clinical trial

INTRODUCTION

Although as many as 75% of the >2 million annual intensive care unit (ICU) survivors experience symptoms of psychological distress that persist for months to years, few therapies exist that target their symptoms and accommodate their unique needs. In response, we developed LIFT, a mobile app-based mindfulness intervention. LIFT reduced distress symptoms more than either a telephone-based mindfulness program or education control in a pilot randomized clinical trial (LIFT1).

OBJECTIVE

To describe the methods of a factorial experimental clinical trial (LIFT2) being conducted to aid in the development and implementation of the version of the LIFT intervention that is optimized across domains of effect, feasibility, scalability, and costs.

METHODS AND ANALYSIS

The LIFT2 study is an optimization trial conceptualized as a component of a larger multiphase optimization strategy (MOST) project. The goal of LIFT2 is to use a 2 × 2 × 2 factorial experimental trial involving 152 patients to determine the ideal components of the LIFT mobile mindfulness program for ICU survivors across factors including (1) study introduction by call from a therapist vs. app only, (2) response to persistent or worsening symptoms over time by therapist vs. app only, and (3) high dose vs. low dose. The primary trial outcome is change in depression symptoms 1 month from randomization measured by the PHQ-9 instrument. Secondary outcomes include anxiety, post-traumatic stress disorder, and physical symptoms; measures of feasibility, acceptability, and usability; as well as themes assessed through qualitative analysis of semi-structured interviews with study participants conducted after follow up completion. We will use general linear models to compare outcomes across the main effects and interactions of the factors.

The performance of acute versus antecedent patient characteristics for 1-year mortality prediction during intensive care unit admission: a national cohort study

Background

Multiple factors contribute to mortality after ICU, but it is unclear how the predictive value of these factors changes during ICU admission. We aimed to compare the changing performance over time of the acute illness component, antecedent patient characteristics, and ICU length of stay (LOS) in predicting 1-year mortality.

Methods

In this retrospective observational cohort study, the discriminative value of four generalized mixed-effects models was compared for 1-year and hospital mortality. Among patients with increasing ICU LOS, the models included (a) acute illness factors and antecedent patient characteristics combined, (b) acute component only, (c) antecedent patient characteristics only, and (d) ICU LOS. For each analysis, discrimination was measured by area under the receiver operating characteristics curve (AUC), calculated using the bootstrap method. Statistical significance between the models was assessed using the DeLong method (p value < 0.05).

Results

In 400,248 ICU patients observed, hospital mortality was 11.8% and 1-year mortality 21.8%. At ICU admission, the combined model predicted 1-year mortality with an AUC of 0.84 (95% CI 0.84–0.84). When analyzed separately, the acute component progressively lost predictive power. From an ICU admission of at least 3 days, antecedent characteristics significantly exceeded the predictive value of the acute component for 1-year mortality, AUC 0.68 (95% CI 0.68–0.69) versus 0.67 (95% CI 0.67–0.68) (p value < 0.001). For hospital mortality, antecedent characteristics outperformed the acute component from a LOS of at least 7 days, comprising 7.8% of patients and accounting for 52.4% of all bed days. ICU LOS predicted 1-year mortality with an AUC of 0.52 (95% CI 0.51–0.53) and hospital mortality with an AUC of 0.54 (95% CI 0.53–0.55) for patients with a LOS of at least 7 days.

Conclusions

Comparing the predictive value of factors influencing 1-year mortality for patients with increasing ICU LOS, antecedent patient characteristics are more predictive than the acute component for patients with an ICU LOS of at least 3 days. For hospital mortality, antecedent patient characteristics outperform the acute component for patients with an ICU LOS of at least 7 days. After the first week of ICU admission, LOS itself is not predictive of hospital nor 1-year mortality.

Recommendations for older adults' physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international Delphi study

BACKGROUND

Immobility is major contributor to poor outcomes for older people during hospitalisation with an acute medical illness. Yet currently there is no specific mobility guidance for this population, to facilitate sustainable changes in practice. This study aimed to generate draft physical activity (PA) and sedentary behaviour (SB) recommendations for older adults' during hospitalisation for an acute medical illness.

METHODS

A 4-Round online Delphi consensus survey was conducted. International researchers, medical/nursing/physiotherapy clinicians, academics from national PA/SB guideline development teams, and patients were invited to participate. Round 1 sought responses to open-ended questions. In Rounds 2-3, participants rated the importance of items using a Likert scale (1-9); consensus was defined a priori as: ≥70% of respondents rating an item as "critical" (score ≥ 7) and ≤ 15% of respondents rating an item as "not important" (score ≤ 3). Round 4 invited participants to comment on draft statements derived from responses to Rounds 1-3; Round 4 responses subsequently informed final drafting of recommendations.

RESULTS

Forty-nine people from nine countries were invited to each Round; response rates were 94, 90, 85 and 81% from Rounds 1-4 respectively. 43 concepts (items) from Rounds 2 and 3 were incorporated into 29 statements under themes of PA, SB, people and organisational factors in Round 4. Examples of the final draft recommendations (being the revised version of statements with highest participant endorsement under each theme) were: "some PA is better than none", "older adults should aim to minimise long periods of uninterrupted SB during waking hours while hospitalised", "when encouraging PA and minimising SB, people should be culturally responsive and mindful of older adults' physical and mental capabilities" and "opportunities for PA and minimising SB should be incorporated into the daily care of older adults with a focus on function, independence and activities of daily living".

CONCLUSIONS

These world-first consensus-based statements from expert and stakeholder consultation provide the starting point for recommendations to address PA and SB for older adults hospitalised with an acute medical illness. Further consultation and evidence review will enable validation of these draft recommendations with examples to improve their specificity and translation to clinical practice.

Reporting of Outcomes and Outcome Measures in Studies of Interventions to Prevent and/or Treat Delirium in the Critically Ill: A Systematic Review

OBJECTIVES

To inform development of a core outcome set, we evaluated the scope and variability of outcomes, definitions, measures, and measurement time-points in published clinical trials of pharmacologic or nonpharmacologic interventions, including quality improvement projects, to prevent and/or treat delirium in the critically ill.

DATA SOURCES

We searched electronic databases, systematic review repositories, and trial registries (1980 to March 2019).

STUDY SELECTION AND DATA EXTRACTION

We included randomized, quasi-randomized, and nonrandomized intervention studies of pharmacologic and nonpharmacologic interventions. We extracted data on study characteristics, verbatim descriptions of study outcomes, and measurement characteristics. We assessed quality of outcome reporting using the Management of Otitis Media with Effusion in Children with Cleft Palate study scoring system; risk of bias and study quality using the Cochrane tool and Scottish Intercollegiate Guidelines Network checklists. We categorized reported outcomes using Core Outcome Measures in Effectiveness Trials taxonomy.

DATA SYNTHESIS

From 195 studies (1/195 pediatric) recruiting 74,632 participants and reporting a mean (SD) of 10 (6.2) outcome domains, we identified 12 delirium-specific outcome domains. Delirium incidence (147, 75% of studies), duration (67, 34%), and antipsychotic use (42, 22%) were most commonly reported. We identified a further 94 non-delirium-specific outcome domains within 19 Core Outcome Measures in Effectiveness Trials taxonomy categories. For both delirium-specific and nonspecific outcome domains, we found multiple outcomes in domains due to differing descriptions and time-points. The Confusion Assessment Method-ICU with Richmond Agitation-Sedation Scale to assess sedation was the most common measure used to ascertain delirium (51, 35%). Measurement generally began at randomization or ICU admission, and lasted from 1 to 30 days, ICU/hospital discharge. Frequency of measurement was highly variable with daily measurement and greater than daily measurement reported for 36% and 37% of studies, respectively.

CONCLUSIONS

We identified substantial heterogeneity and multiplicity of outcome selection and measurement in published studies. These data will inform the consensus building stage of a core outcome set to inform delirium research in the critically ill.

Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care: NHLBI Working Group Report

Preventing, treating, and promoting recovery from critical illness due to pulmonary disease are foundational goals of the critical care community and the National Heart, Lung, and Blood Institute. Decades of clinical research in acute respiratory distress syndrome, acute respiratory failure, pneumonia, and sepsis have yielded improvements in supportive care, which have translated into improved patient outcomes. Novel therapeutics have largely failed to translate from promising pre-clinical findings into improved patient outcomes in late-phase clinical trials. Recent advances in personalized medicine, "big data", causal inference using observational data, novel clinical trial designs, pre-clinical disease modeling, and understanding recovery from acute illness promise to transform the methods of pulmonary and critical care clinical research. To assess the current state, research priorities, and future directions for adult pulmonary and critical care research, the NHLBI assembled a multidisciplinary working group of investigators. This working group identified recommendations for future research, including: (1) focusing on understanding the clinical, physiological, and biological underpinnings of heterogeneity in syndromes, diseases, and treatment-response with the goal of developing targeted, personalized interventions; (2) optimizing pre-clinical models by incorporating comorbidities, co-interventions, and organ support; (3) developing and applying novel clinical trial designs; and (4) advancing mechanistic understanding of injury and recovery in order to develop and test interventions targeted at achieving long-term improvements in the lives of patients and families. Specific areas of research are highlighted as especially promising for making advances in pneumonia, acute hypoxemic respiratory failure, and acute respiratory distress syndrome.

Development of a core outcome set for pediatric critical care outcomes research

BACKGROUND

Pediatric Intensive Care Unit (PICU) teams provide care for critically ill children with diverse and often complex medical and surgical conditions. Researchers often lack guidance on an approach to select the best outcomes when evaluating this critically ill population. Studies would be enhanced by incorporating multi-stakeholder preferences to better evaluate clinical care. This manuscript outlines the methodology currently being used to develop a PICU Core Outcome Set (COS). This PICU COS utilizes mixed methods, an inclusive stakeholder approach, and a modified Delphi consensus process that will serve as a resource for PICU research programs.

METHODS

A Scoping Review of the PICU literature evaluating outcomes after pediatric critical illness, a qualitative study interviewing PICU survivors and their parents, and other relevant literature will serve to inform a modified, international Delphi consensus process. The Delphi process will derive a set of minimum domains for evaluation of outcomes of critically ill children and their families. Delphi respondents include researchers, multidisciplinary clinicians, families and former patients, research funding agencies, payors, and advocates. Consensus meetings will refine and finalize the domains of the COS, outline a battery instruments for use in future studies, and prepare for extensive dissemination for broad implementation.

DISCUSSION

The PICU COS will be a guideline resource for investigators to assure that outcomes most important to all stakeholders are considered in PICU clinical research in addition to those deemed most important to individual scientists.

TRIAL REGISTRATION

COMET database (http://www.comet-initiative.org/, Record ID 1131, 01/01/18).

Long-term patient-important outcomes after septic shock: A protocol for 1-year follow-up of the CLASSIC trial

BACKGROUND

In patients with septic shock, mortality is high, and survivors experience long-term physical, mental and social impairments. The ongoing Conservative vs Liberal Approach to fluid therapy of Septic Shock in Intensive Care (CLASSIC) trial assesses the benefits and harms of a restrictive vs standard-care intravenous (IV) fluid therapy. The hypothesis is that IV fluid restriction improves patient-important long-term outcomes.

AIM

To assess the predefined patient-important long-term outcomes in patients randomised into the CLASSIC trial.

METHODS

In this pre-planned follow-up study of the CLASSIC trial, we will assess all-cause mortality, health-related quality of life (HRQoL) and cognitive function 1 year after randomisation in the two intervention groups. The 1-year mortality will be collected from electronic patient records or central national registries in most participating countries. We will contact survivors and assess EuroQol 5-Dimension, -5-Level (EQ-5D-5L) and EuroQol-Visual Analogue Scale and Montreal Cognitive Assessment 5-minute protocol score. We will analyse mortality by logistic regression and use general linear models to assess HRQoL and cognitive function.

DISCUSSION

With this pre-planned follow-up study of the CLASSIC trial, we will provide patient-important data on long-term survival, HRQoL and cognitive function of restrictive vs standard-care IV fluid therapy in patients with septic shock.

Understanding and Enhancing Sepsis Survivorship. Priorities for Research and Practice

An estimated 14.1 million patients survive sepsis each year. Many survivors experience poor long-term outcomes, including new or worsened neuropsychological impairment; physical disability; and vulnerability to further health deterioration, including recurrent infection, cardiovascular events, and acute renal failure. However, clinical trials and guidelines have focused on shorter-term survival, so there are few data on promoting longer-term recovery. To address this unmet need, the International Sepsis Forum convened a colloquium in February 2018 titled "Understanding and Enhancing Sepsis Survivorship." The goals were to identify gaps and limitations of current research and shorter- and longer-term priorities for understanding and enhancing sepsis survivorship. Twenty-six experts from eight countries participated. The top short-term priorities identified by nominal group technique culminating in formal voting were to better leverage existing databases for research, develop and disseminate educational resources on postsepsis morbidity, and partner with sepsis survivors to define and achieve research priorities. The top longer-term priorities were to study mechanisms of long-term morbidity through large cohort studies with deep phenotyping, build a harmonized global sepsis registry to facilitate enrollment in cohorts and trials, and complete detailed longitudinal follow-up to characterize the diversity of recovery experiences. This perspective reviews colloquium discussions, the identified priorities, and current initiatives to address them.

Challenges in conducting long-term outcomes studies in critical care

PURPOSE OF REVIEW

Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions.

RECENT FINDINGS

Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience.

SUMMARY

There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Understanding patient-important outcomes after critical illness: a synthesis of recent qualitative, empirical, and consensus-related studies

Purpose of review

Patients surviving critical illness frequently experience long-lasting morbidities. Consequently, researchers and clinicians are increasingly focused on evaluating and improving survivors’ outcomes after hospital discharge. This review synthesizes recent research aimed at understanding the postdischarge outcomes that patients consider important (i.e., patient-important outcomes) for the purpose of advancing future clinical research in the field.

Recent findings

Across multiple types of studies, patients, family members, researchers, and clinicians have consistently endorsed physical function, cognition, and mental health as important outcomes to evaluate in future research. Aspects of social health, such as return to work and changes in interpersonal relationships, also were noted in some research publications. Informed by these recent studies, an international Delphi consensus process (including patient and caregiver representatives) recommended the following core set of outcomes for use in all studies evaluating acute respiratory failure survivors after hospital discharge: survival, physical function (including muscle/nerve function and pulmonary function), cognition, mental health, health-related quality of life, and pain. The Delphi panel also reached consensus on recommended measurement instruments for some of these core outcomes.

Summary

Recent studies have made major advances in understanding patient-important outcomes to help guide future clinical research aimed at improving ICU survivors’ recovery.

Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6)

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms are common in acute respiratory distress syndrome (ARDS) survivors. Brief screening instruments are needed for clinical and research purposes. We evaluated internal consistency, external construct, and criterion validity of the Impact of Event Scale-6 (IES-6; 6 items) compared to the original Impact of Event Scale-Revised (IES-R; 22 items) and to the Clinician Administered PTSD Scale (CAPS) reference standard evaluation in ARDS survivors.

METHODS

This study is a secondary analysis from two independent multi-site, prospective studies of ARDS survivors. Measures of internal consistency, and external construct and criterion validity were evaluated.

RESULTS

A total of 1001 ARDS survivors (51% female, 76% white, mean (SD) age 49 (14) years) were evaluated. The IES-6 demonstrated internal consistency over multiple time points up to 5 years after ARDS (Cronbach’s alpha = 0.86 to 0.91) and high correlation with the IES-R (0.96; 95% confidence interval (CI): 0.94 to 0.97). The IES-6 demonstrated stronger correlations with related constructs (e.g., anxiety and depression; |r| = 0.32 to 0.52) and weaker correlations with unrelated constructs (e.g., physical function and healthcare utilization measures (|r| = 0.02 to 0.27). Criterion validity evaluation with the CAPS diagnosis of PTSD in a subsample of 60 participants yielded an area under receiver operating characteristic curve (95% CI) of 0.93 (0.86, 1.00), with an IES-6 cutoff score of 1.75 yielding 0.88 sensitivity and 0.85 specificity.

CONCLUSIONS

The IES-6 is reliable and valid for screening for PTSD in ARDS survivors and may be useful in clinical and research settings.

Nutrition and Exercise in Critical Illness Trial (NEXIS Trial): a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness

INTRODUCTION

Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a 'usual care' control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU).

METHODS AND ANALYSIS

In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses.

ETHICS AND DISSEMINATION

The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms.

TRIAL REGISTRATION NUMBER

NCT03021902; Pre-results.