Healthcare trajectories before and after critical illness: population-based insight on diverse patients clusters

Transition of Intensive Care Unit Patients and Their Families to Home After Acute Hospital Care

Patients in the intensive care unit (ICU) increasingly are expected to eventually return home after acute hospital care. Yet transitional care for ICU patients and their families is often delayed until the patient is about to be transferred to another location or level of care. Transitions theory is a middle-range nursing theory that aims to provide guidance for safe and effective nursing care and research while an individual experiences a transition. Intensive care unit nurses are well positioned to provide ICU transitional care planning early. This article applies the transitions theory as a theoretical model to guide the study of the transition to home after acute hospital care for ICU patients and their families. This theory application can help ICU nurses provide holistic patient- and family-centered transitional care to achieve optimal outcomes by addressing the predischarge and postdischarge needs of patients and families.

Herpes simplex encephalitis in France: incidence, 6-month rehospitalizations and mortality

BACKGROUND

Herpes simplex encephalitis (HSE) is a disease with unfavorable vital and functional prognoses. There are no recent epidemiological data on HSE at a national level using real-life databases, especially in France. This study aimed to report the incidence, the clinical characteristics and outcomes of the patients with HSE.

METHODS

We conducted a comprehensive retrospective cohort study on all patients hospitalized for HSE in France between 2015 and 2022 using national hospital discharge databases. Incidence, socio-demographic and clinical characteristics (including comorbidities, seizure, stays' features, intensive care supports) were described. The short- (first stay) and long-term (6-month) outcomes were reported, in terms of mortality and rehospitalizations.

RESULTS

1425 HSE patients were included (median age 67 [54-77] years old, M/F sex ratio 1.07), giving a mean yearly hospital incidence of 2.3 [2.1-2.5] per 1,000,000 inhabitants. 51.2% of the patients were admitted in ICU (n = 730), of whom 59.0% were mechanically ventilated. The overall mortality during the first stay was 14.3% (n = 204), up to 17.9% for ICU patients. Within 6 months, among the survivors, 10.1% had at least one rehospitalization related to HSE. At 6 months, 16.5% of all patients had died (n = 235), 20.8% for ICU patients.

CONCLUSION

In France, the incidence of hospitalizations for HSE was 2.3 per 1,000,000 inhabitants with more than half of the patients admitted in ICU and a 6-month in-hospital mortality about 16.5%. This real-life update on the characteristics and severe outcomes of the disease raises awareness among care practitioners, of the serious nature of the disease, and thus can lead to higher vigilance.

Do critical illness survivors with multimorbidity need a different model of care?

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

Factors associated with urinary diversion and fatality of hospitalised acute pyelonephritis patients in France: a national cross-sectional study (FUrTIHF-2)

Acute pyelonephritis (AP) epidemiology has been sparsely described. This study aimed to describe the evolution of AP patients hospitalised in France and identify the factors associated with urinary diversion and fatality, in a cross-sectional study over the 2014-2019 period. Adult patients hospitalised for AP were selected by algorithms of ICD-10 codes (PPV 90.1%) and urinary diversion procedure codes (PPV 100%). 527,671 AP patients were included (76.5% female: mean age 66.1, 48.0% Escherichia coli), with 5.9% of hospital deaths. In 2019, the AP incidence was 19.2/10,000, slightly increasing over the period (17.3/10,000 in 2014). 69,313 urinary diversions (13.1%) were performed (fatality rate 6.7%), mainly in males, increasing over the period (11.7% to 14.9%). Urolithiasis (OR [95% CI] =33.1 [32.3-34.0]), sepsis (1.73 [1.69-1.77]) and a Charlson index ≥3 (1.32 [1.29-1.35]) were significantly associated with urinary diversion, whereas E. coli (0.75 [0.74-0.77]) was less likely associated. The same factors were significantly associated with fatality, plus old age and cancer (2.38 [2.32-2.45]). This nationwide study showed an increase in urolithiasis and identified, for the first time, factors associated with urinary diversion in AP along with death risk factors, which may aid urologists in clinical decision-making.

Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions

BACKGROUND

Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown.

RESEARCH QUESTION

What is the burden of health resource utilization and odds of new prescriptions of benzodiazepines and opioids up to 1-year post-hospital discharge in critically ill patients with new antipsychotic prescriptions at hospital discharge?

STUDY DESIGN & METHODS

We completed a multi-center, propensity-score matched retrospective cohort study of critically ill adult patients. The primary exposure was administration of ≥1 dose of an antipsychotic while the patient was admitted in the ICU and ward with continuation at hospital discharge and a filled outpatient prescription within 1-year following hospital discharge. The control group was defined as no doses of antipsychotics administered in the ICU and hospital ward and no filled outpatient prescriptions for antipsychotics within 1-year following hospital discharge. The primary outcome was health resource utilization (72-hour ICU readmission, 30-day hospital readmission, 30-day emergency room visitation, 30-day mortality). Secondary outcomes were administration of benzodiazepines and/or opioids in-hospital and following hospital discharge in patients receiving antipsychotics.

RESULTS

1,388 propensity-score matched patients were included who did and did not receive antipsychotics in ICU and survived to hospital discharge. New antipsychotic prescriptions were not associated with increased health resource utilization or 30-day mortality following hospital discharge. There was increased odds of new prescriptions of benzodiazepines (adjusted odds ratio [aOR] 1.61 [95%CI 1.19-2.19]) and opioids (aOR 1.82 [95%CI 1.38-2.40]) up to 1-year following hospital discharge in patients continuing antipsychotics at hospital discharge.

INTERPRETATION

New antipsychotic prescriptions at hospital discharge are significantly associated with additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge.

Patterns of Healthcare Resource Utilisation of Critical Care Survivors between 2006 and 2017 in Wales: A Population-Based Study

In this retrospective cohort study, we used the Secure Anonymised Information Linkage (SAIL) Databank to characterise and identify predictors of the one-year post-discharge healthcare resource utilisation (HRU) of adults who were admitted to critical care units in Wales between 1 April 2006 and 31 December 2017. We modelled one-year post-critical-care HRU using negative binomial models and used linear models for the difference from one-year pre-critical-care HRU. We estimated the association between critical illness and post-hospitalisation HRU using multilevel negative binomial models among people hospitalised in 2015. We studied 55,151 patients. Post-critical-care HRU was 11-87% greater than pre-critical-care levels, whereas emergency department (ED) attendances decreased by 30%. Age ≥50 years was generally associated with greater post-critical-care HRU; those over 80 had three times longer hospital readmissions than those younger than 50 (incidence rate ratio (IRR): 2.96, 95% CI: 2.84, 3.09). However, ED attendances were higher in those younger than 50. High comorbidity was associated with 22-62% greater post-critical-care HRU than no or low comorbidity. The most socioeconomically deprived quintile was associated with 24% more ED attendances (IRR: 1.24 [1.16, 1.32]) and 13% longer hospital stays (IRR: 1.13 [1.09, 1.17]) than the least deprived quintile. Critical care survivors had greater 1-year post-discharge HRU than non-critical inpatients, including 68% longer hospital stays (IRR: 1.68 [1.63, 1.74]). Critical care survivors, particularly those with older ages, high comorbidity, and socioeconomic deprivation, used significantly more primary and secondary care resources after discharge compared with their baseline and non-critical inpatients. Interventions are needed to ensure that key subgroups are identified and adequately supported.

Post-Intensive Care Syndrome in Non-COVID-19 ICU Survivors during the COVID-19 Pandemic in South Korea: A Multicenter Prospective Cohort Study

A prospective observational cohort study investigated the prevalence of post-intensive care syndrome (PICS) among non-COVID-19 ICU survivors during the COVID-19 pandemic. Adults who had been admitted to the ICU for more than 24 h were enrolled, and followed-up at 3, 6, and 12 months post-discharge. PICS (mental health, cognitive, and physical domains) was measured using the Hospital Anxiety and Depression Scale, Posttraumatic Diagnosis Scale, Montreal Cognitive Assessment, and Korean Activities of Daily Living (ADL) scale. Data were analyzed from 237 participants who completed all three follow-up surveys. The prevalence of PICS was 44.7%, 38.4%, and 47.3%, at 3, 6, and 12 months of discharge, respectively. The prevalence of PICS in the mental health and cognitive domains decreased at 6 and increased at 12 months. The prevalence of PICS in the physical domain declined over time. Changes in PICS scores other than ADL differed significantly according to whether participants completed follow-up before or after December 2020, when COVID-19 rapidly spread in South Korea. In the recent group, anxiety, depression, post-traumatic stress disorder, and cognition scores were significantly worse at 12 months than at 6 months post-discharge. The COVID-19 pandemic may have adversely affected the recovery of non-COVID-19 ICU survivors.

Days Spent at Home and Mortality After Critical Illness: A Cluster Analysis Using Nationwide Data

BACKGROUND

Beyond the question of short-term survival, days spent at home could be considered a patient-centered outcome in critical care trials.

RESEARCH QUESTION

What are the days spent at home and health care trajectories during the year after surviving critical illness?

STUDY DESIGN AND METHODS

Data were extracted on adult survivors spending at least 2 nights in a French ICU during 2018 who were treated with invasive mechanical ventilation or vasopressors or inotropes. Trauma, burn, organ transplant, stroke, and neurosurgical patients were excluded. Stays at home, death, and hospitalizations were reported before and after ICU stay, using state sequence analysis. An unsupervised clustering method was performed to identify cohorts based on post-ICU trajectories.

RESULTS

Of 77,132 ICU survivors, 89% returned home. In the year after discharge, these patients spent a median of 330 (interquartile range [IQR], 283-349) days at home. At 1 year, 77% of patients were still at home and 17% had died. Fifty-one percent had been re-hospitalized, and 10% required a further ICU admission. Forty-eight percent used rehabilitation facilities, and 5.7%, hospital at home. Three clusters of patients with distinct post-ICU trajectories were identified. Patients in cluster 1 (68% of total) survived and spent most of the year at home (338 [323-354] days). Patients in cluster 2 (18%) had more complex trajectories, but most could return home (91%), spending 242 (174-277) days at home. Patients in cluster 3 (14%) died, with only 37% returning home for 45 (15-90) days.

INTERPRETATION

Many patients had complex health care trajectories after surviving critical illness. Wide variations in the ability to return home after ICU discharge were observed between clusters, which represents an important patient-centered outcome.

A methodology to facilitate critical care research using multiple linked electronic, clinical and administrative health records at population scale

Introduction

Critical Care is a specialty in medicine providing a service for severely ill and high-risk patients who, due to the nature of their condition, may require long periods recovering after discharge. Consequently, focus on the routine data collection carried out in Intensive Care Units (ICUs) leads to reporting that is confined to the critical care episode and is typically insensitive to variation in individual patient pathways through critical care to recovery.A resource which facilitates efficient research into interactions with healthcare services surrounding critical admissions, capturing the complete patient's healthcare trajectory from primary care to non-acute hospital care prior to ICU, would provide an important longer-term perspective for critical care research.

Objective

To describe and apply a reproducible methodology that demonstrates how both routine administrative and clinically rich critical care data sources can be integrated with primary and secondary healthcare data to create a single dataset that captures a broader view of patient care.

Method

To demonstrate the INTEGRATE methodology, it was applied to routine administrative and clinical healthcare data sources in the Secure Anonymised Data Linking (SAIL) Databank to create a dataset of patients' complete healthcare trajectory prior to critical care admission. SAIL is a national, data safe haven of anonymised linkable datasets about the population of Wales.

Results

When applying the INTEGRATE methodology in SAIL, between 2010 and 2019 we observed 91,582 critical admissions for 76,019 patients. Of these, 90,632 (99%) had an associated non-acute hospital admission, 48,979 (53%) had an emergency admission, and 64,832 (71%) a primary care interaction in the week prior to the critical care admission.

Conclusion

This methodology, at population scale, integrates two critical care data sources into a single dataset together with data sources on healthcare prior to critical admission, thus providing a key research asset to study critical care pathways.

Dynamic Delirium Severity Trajectories and Their Association With 2-Year Healthcare Utilization and Mortality Outcomes

Supplemental Digital Content is available in the text.

Delirium severity has been associated with a higher risk of mortality and an increasing morbidity burden. Recently defined delirium severity trajectories were predictive of 30-day mortality in a critically ill patient population. No studies to date have examined associations between delirium severity trajectories and 2-year mortality and healthcare utilization outcomes.

Circulatory trajectories after out-of-hospital cardiac arrest: a prospective cohort study

BACKGROUND

Circulatory failure frequently occurs after out-of-hospital cardiac arrest (OHCA) and is part of post-cardiac arrest syndrome (PCAS). The aim of this study was to investigate circulatory disturbances in PCAS by assessing the circulatory trajectory during treatment in the intensive care unit (ICU).

METHODS

This was a prospective single-center observational cohort study of patients after OHCA. Circulation was continuously and invasively monitored from the time of admission through the following five days. Every hour, patients were classified into one of three predefined circulatory states, yielding a longitudinal sequence of states for each patient. We used sequence analysis to describe the overall circulatory development and to identify clusters of patients with similar circulatory trajectories. We used ordered logistic regression to identify predictors for cluster membership.

RESULTS

Among 71 patients admitted to the ICU after OHCA during the study period, 50 were included in the study. The overall circulatory development after OHCA was two-phased. Low cardiac output (CO) and high systemic vascular resistance (SVR) characterized the initial phase, whereas high CO and low SVR characterized the later phase. Most patients were stabilized with respect to circulatory state within 72 h after cardiac arrest. We identified four clusters of circulatory trajectories. Initial shockable cardiac rhythm was associated with a favorable circulatory trajectory, whereas low base excess at admission was associated with an unfavorable circulatory trajectory.

CONCLUSION

Circulatory failure after OHCA exhibits time-dependent characteristics. We identified four distinct circulatory trajectories and their characteristics. These findings may guide clinical support for circulatory failure after OHCA.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02648061.

[Post-intensive care syndrome]

Post-intensive care syndrome is an entity defined in 2010 and covering any sequelae following an extended hospitalization in intensive care unit. It comprises psychological, cognitive and physical disorders (neuromyopathy, respiratory dysfunction, joint stiffness, among others). These sequelae have important consequences on autonomy and quality of life of these patients, as well as on their healthcare consumption and on mortality. Psychological sequelae can also be seen in hospitalized patients' relatives. Screening and management of these disorders is more and more frequent but no method has formally proven effective. The number of patients surviving an intensive care unit hospitalization is increasing, and management of post-intensive care syndrome is a major issue. It seems important that the internist be aware of this syndrome, given his pivotal role in global management of patients and frequent implication into care after the intensive care unit.

Mobilization During Critical Illness: A Higher Level of Mobilization Improves Health Status at 6 Months, a Secondary Analysis of a Prospective Cohort Study

OBJECTIVES

To determine the influence of active mobilization during critical illness on health status in survivors 6 months post ICU admission.

DESIGN

Post hoc secondary analysis of a prospective cohort study conducted between November 2013 and March 2015.

SETTING

Two tertiary hospital ICU's in Victoria, Australia.

PATIENTS

Of 194 eligible patients admitted, mobility data for 186 patients were obtained. Inclusion and exclusion criteria were as per the original trial.

INTERVENTIONS

The dosage of mobilization in ICU was measured by 1) the Intensive Care Mobility Scale where a higher Intensive Care Mobility Scale level was considered a higher intensity of mobilization or 2) the number of active mobilization sessions performed during the ICU stay. The data were extracted from medical records and analyzed against Euro-quality of life-5D-5 Level version answers obtained from phone interviews with survivors 6 months following ICU admission. The primary outcome was change in health status measured by the Euro-quality of life-5D-5 Level utility score, with change in Euro-quality of life-5D-5 Level mobility domain a secondary outcome.

MEASUREMENTS AND MAIN RESULTS

Achieving higher levels of mobilization (as per the Intensive Care Mobility Scale) was independently associated with improved outcomes at 6 months (Euro-quality of life-5D-5 Level utility score unstandardized regression coefficient [β] 0.022 [95% CI, 0.002-0.042]; p = 0.033; Euro-quality of life-5D-5 Level mobility domain β = 0.127 [CI, 0.049-0.205]; p = 0.001). Increasing the number of active mobilization sessions was not found to independently influence health status. Illness severity, total comorbidities, and admission diagnosis also independently influenced health status.

CONCLUSIONS

In critically ill survivors, achieving higher levels of mobilization, but not increasing the number of active mobilization sessions, improved health status 6 months after ICU admission.

2-year survival among elderly hospitalised for acute respiratory infection versus hip fracture: a useful comparison to raise awareness

We read with great interest the article by Cillónizet al. [1]. The authors nicely reported and discussed recent literature showing that pneumonia is a common lung infection that can be life-threatening, with particular concern for the elderly. Indeed, the annual incidences of hospitalisation for respiratory infections increase with age from 0.2% (for patients aged <75 years) to 1.9% (for age 80–84 years), 3.2% (for age 85–89 years) and 5.0% (for age ≥90 years) [2]. For the elderly, pneumonia has the greatest risk of death among the common causes of hospitalisation [3]. We do agree with the authors when they concluded that preventive interventions are of pivotal importance to improve outcomes and reduce the occurrence of adverse consequences [1]. However, we would like to emphasise that there is a mismatch between the high morbidity and mortality caused by respiratory infection and the low public awareness of this disease. A large pneumonia awareness survey involving over 9000 adults aged ≥50 years highlighted that most fail to accurately gauge their own pneumonia risk, leading to inadequate pneumonia prevention efforts including low uptake of existing vaccines [4]. The low public awareness of respiratory infection risk and severity in the elderly is a barrier to healthcare delivery and a driver of unhealthy ageing [5]. It is critical to raise awareness of this disease among the general public to improve the management of this largely preventable infectious disease [5].

If breaking a hip feels like a concern for the elderly, then getting pneumonia should be twice as concerning: patients hospitalised for lung infection had 3.3-fold greater in-hospital mortality and 1.8-fold increased risk of death at 2 yearshttps://bit.ly/2Xqsrf6

Postcritical illness vulnerability

PURPOSE OF REVIEW

Critical illness survivorship is associated with new and worsening physical, cognitive, and emotional status. Survivors are vulnerable to further health set-backs, most commonly because of infection and exacerbation of chronic medical conditions. Awareness of survivors' challenges are important given the anticipated rise in critical illness survivors because of SARS-CoV-2 viral sepsis.

RECENT FINDINGS

Studies continue to document challenges of critical illness survivorship. Beyond the cognitive, physical, and mental health sequelae encompassed by postintensive case syndrome, patients commonly experience persistent immunosuppression, re-hospitalization, inability to resume prior employment, and reduced quality of life. Although recommended practices for enhancing recovery from sepsis are associated with better outcomes, only a minority of patients receive all recommended practices. ICU follow-up programs or peer support groups remain important interventions to learn about and address the multifaceted challenges of critical illness survivorship, but there is little evidence of benefit to date.

SUMMARY

Survivors of sepsis and critical illness commonly experience impaired health status, reduced quality of life, and inability to return to prior employment. Although the challenges of critical illness survivorship are increasingly well documented, there are relatively few studies on enhancing recovery. Future studies must focus on identifying best practices for optimizing recovery and strategies to promote their implementation.

Long-term survival of elderly patients after intensive care unit admission for acute respiratory infection: a population-based, propensity score-matched cohort study

Background

Intensive care unit (ICU) hospitalisations of elderly patients with acute respiratory infection have increased, yet the long-term effects of ICU admission among elderly individuals remain unknown. We examined differences over the 2 years after discharge in mortality, healthcare utilisation and frailty score between elderly survivors of ARI in the ICU and an elderly control population.

Methods

We used 2009–2017 data from 39 hospital discharge databases. Patients ≥ 80 years old discharged alive from ICU hospitalisation for acute respiratory infection were propensity score-matched with controls (cataract surgery) discharged from the hospital at the same time and adjusted for age, sex and comorbidities present before hospitalisation. We reported 2-year mortality and compared healthcare utilisation and frailty scores in the 2-year periods before and after ICU hospitalisation.

Results

One thousand two hundred and twenty elderly survivors of acute respiratory infection in the ICU were discharged, and 988 were successfully matched with controls. After discharge, patients had a 10.1-fold [95% CI, 6.1–17.3] higher risk of death at 6 months and 3.6-fold [95% CI, 2.9–4.6] higher risk of death at 2 years compared with controls. They also had a 2-fold increase in both healthcare utilisation and frailty score in the 2 years after hospital discharge, whereas healthcare utilisation and frailty scores among controls were stable before and after hospitalisation.

Conclusions

We observed a substantially increased rate of death in the years following ICU hospitalisation for elderly patients along with elevated healthcare resource use and accelerated age-associated decline as assessed by frailty score. These findings provide data for better informed goals-of-care discussions and may help target post-ICU discharge services.