Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE). Early evaluation of a complex intervention

Remote multicomponent rehabilitation compared to standard care for survivors of critical illness after hospital discharge (iRehab): a protocol for a randomised controlled assessor-blind clinical and cost-effectiveness trial

Background

The consequences of critical illness can be substantial and multifactorial, encompassing physical deconditioning, mental health impairments, fatigue, and declines in health-related quality of life. We hypothesise that for people discharged after intensive care unit (ICU) for a critical illness, a six-week remote multicomponent rehabilitation intervention improves health-related quality of life, physical function, fatigue, mood, and other health-related outcomes after eight weeks, compared to standard care.

Methods

This is a pragmatic, randomised controlled, open-label, assessor blind, multicentre, clinical and cost effectiveness trial with internal pilot and embedded process evaluation. Recruitment will take place in NHS hospitals across the UK. Adults (n=428: control n= 197; intervention: n=231) within 12 weeks of discharge from hospital following an ICU admission for critical illness, requiring mechanical ventilation ≥48hours will be recruited.The intervention is a six week multicomponent, structured, rehabilitation programme, delivered remotely by a trained intervention team. The intervention includes four components: weekly symptom management; targeted exercise; psychological support, and peer support and information. The control group will receive standard NHS care.The primary outcome is Health-related quality of life (HRQoL) at eight weeks post-randomisation measured using the EQ-5D-5L. Secondary outcomes are: HRQoL (six months), physical function, fatigue, anxiety and depression, healthcare resource use at eight weeks and six months and intervention acceptability.

Conclusions

This trial will test a centrally delivered mulitcomponent rehabilitation intervention for survivors of critical illness, irrespective of geographic location or critical illness diagnosis.

Trial registration

The trial is registered (04.07.2022) with the International Standard Randomised Controlled Trial Number (ISRCTN) Register ISRCTN11266403 https://doi.org/10.1186/ISRCTN11266403.

Barriers to and facilitators of rehabilitation according to socio-economic status, after acute respiratory distress syndrome due to COVID-19: A qualitative study in the RECOVIDS cohort

BACKGROUND

The COVID-19 pandemic may have compounded social disparities in access to healthcare, with possible deleterious consequences on the functional prognosis of patients after a stay in the intensive care unit (ICU). In the previous RECOVIDS study, we reported that despite comparable pulmonary sequelae and similar access to rehabilitation, socio-economically "vulnerable" patients had lower quality of life at 6 months after an ICU stay. We aimed to describe the barriers to, and facilitators of participation in rehabilitation, among patients from the RECOVIDS study, regardless of their socio-economic situation.

METHODS

Qualitative study using semi-structured interviews with adult patients admitted to ICU for PCR-proven SARS-CoV-2 infection, and who had acute respiratory distress syndrome (ARDS) or had received high flow nasal oxygen. In addition, patients had to have been living at home for the month prior to the interview and had to be proficient in French. Eligible patients were randomly selected, aiming to select the same number of socially deprived and non-socially-deprived patients. Interviews were transcribed for thematic analysis.

RESULTS

In total, 31 interviews were performed from 10/2021 to 01/2022; 16 with socially deprived, and 15 with non-deprived participants. Average age was 65.2 (±11.6) years. Four themes emerged from the analysis of the interviews, namely: (1) the impact of the patient's professional and socio-economic situation; (2) the feeling that age and socio-economic situation influence access to rehabilitation; (3) a perception that the healthcare system was saturated, and that inequalities exist in access to rehabilitation resources; (4) perception of previous own health and expectations of post-resuscitation health status.

CONCLUSION

A precarious socio-economic situation has a substantial impact on access to rehabilitation after ICU admission for ARDS caused by COVID-19. It represents a barrier to rehabilitation through the combined action of various social determinants that deserve to be detected early, in order to take appropriate action to ensure that the most socially vulnerable individuals can benefit from access to rehabilitation.

Factors to consider when designing post-hospital interventions to support critical illness recovery: Systematic review and qualitative evidence synthesis

Background

Survivors of intensive care unit (ICU) admission experience significant deficits in health-related quality of life due to long-term physical, psychological, and cognitive sequelae of critical illness, which may persist for many years. There has been a proliferation of post-hospital interventions in recent years which aim to support ICU-survivors, however there is currently limited evidence to inform optimal approach. We therefore aimed to synthesise factors which impacted the implementation of these interventions from the perspective of healthcare providers, patients, and their carers, and to compare different intervention designs.

Methods

We conducted a systematic review and synthesis of qualitative evidence using four databases (MEDLINE, EMBASE, CINAHL and Web of Science) which were searched from inception to May 2024. The extraction and synthesis of factors which impacted intervention implementation was informed by the domains of the Consolidated Framework for Implementation Research (CFIR) and Template for Intervention Description and Replication (TIDieR) checklist.

Results

Thirty-seven studies were included, reporting on a range of interventions including follow-up clinics and rehabilitation programmes. We identified some overarching principles and specific intervention component and design factors which may support in the design of future strategies to improve outcomes for ICU survivors. For each intervention characteristic, various patient, staff, and setting factors were found to impact implementation. Considering how the intervention will rely on and integrate with existing outpatient and community resources is likely to be important.

Conclusion

This review provides a framework to future research examining the optimal approach to supporting ICU survivor recovery following hospital discharge.

More self-efficacy is associated with longitudinally higher health-related quality of life in mechanically ventilated COVID-19 ICU survivors: The prospective MaastrICCht cohort

BACKGROUND

More self-efficacy leads to greater confidence in one's ability to perform actions to achieve treatment goals. Therefore, self-efficacy may affect patient recovery and health-related quality of life (HRQoL) after ICU discharge.

AIM

In a cohort of mechanically ventilated COVID-19 survivors, we examined the associations between self-efficacy at 3 months and HRQoL at 3, 12 and 24 months after discharge.

STUDY DESIGN

Mechanically ventilated survivors of the MaastrICCht cohort that completed a self-efficacy assessment with the General Self-Efficacy Scale (GSES) were included. HRQoL was measured using the EuroQol 5 Dimensions 5 Levels (EQ-5D-5L), subdivided into a health utility score (EQ-HUS) and visual analogue scale (EQ-VAS). Linear regression models were used to investigate associations between self-efficacy and HRQoL and were adjusted for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, ICU length of stay and hospital discharge location.

RESULTS

In 87 ICU survivors, more self-efficacy at 3 months after ICU discharge was associated with longitudinally higher EQ-HUS (β = 0.01; 95% CI: 0.01-0.02; p < 0.001) and higher EQ-VAS (β = 1.00; 95% CI: 0.66-1.35; p < 0.001) up to 2 years after ICU discharge. After adjustment for age, sex, BMI, APACHE II score, ICU length of stay, and hospital discharge location, associations were similar.

CONCLUSIONS

More self-efficacy at 3 months after ICU discharge was associated with longitudinally higher HRQoL up to 2 years after ICU discharge in mechanically ventilated COVID-19 survivors.

RELEVANCE TO CLINICAL PRACTICE

Screening for self-efficacy in patients post-ICU as well as developing interventions to improve self-efficacy are a target post-ICU to enhance HRQoL over the long term.

Patients' and relatives' experiences of cognitive impairment following an intensive care unit admission. A qualitative study

BACKGROUND

Cognitive impairment poses a significant challenge following critical illness in the intensive care unit. A knowledge gap exists concerning how patients experience cognitive impairments.

OBJECTIVES

The aim was to explore patients' and relatives' experiences of patients' cognitive impairment due to critical illness following an intensive care unit admission.

METHODS

A qualitative multicentre study was conducted in Denmark with 3- and 6-month follow-ups using single and dyadic interviews. A phenomenological hermeneutic approach was adopted using a Ricoeur-inspired textual in-depth analysis method. The Consolidated Criteria for Reporting Qualitative Research checklist was used.

RESULTS

Three themes emerged from interviews with 18 patients and 14 relatives: 'It feels like living in a parallel world', 'Getting back to a normal everyday life with a vulnerable self', and 'Managing everyday life using self-invented strategies'. Patients used self-invented strategies to manage their vulnerability and newly acquired cognitive impairments when no help or support was provided specifically targeting their cognitive impairments. Not being as cognitively capable as they previously had been turned their lives upside down. Losing control and not being themselves made them vulnerable. Patients did not want to burden others. However, support from relatives was invaluable in their recovery and rehabilitation.

CONCLUSIONS

Patients experienced multiple cognitive impairments affecting their adaption to everyday life. They strove to overcome their vulnerability using a variety of self-invented strategies and activities.

The Financial Impact of Post Intensive Care Syndrome

This review explores the financial consequences that survivors of critical illness often face following hospitalization in an intensive care unit (ICU). As part of the "post-intensive care syndrome" (PICS), these survivors often experience, in addition to physical and emotional challenges of PICS, major financial burdens resulting from their prolonged ICU treatments. The escalating costs of ICU care, coupled with the potential long-term effects on survivors' ability to work and maintain financial stability, have brought financial toxicity to the forefront of health care discussions. The current review examines the causes and consequences of financial toxicity.

Intensive care unit follow-up clinic activities: a scoping review

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3 months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

Post-ICU psychology support during the COVID-19 pandemic

BACKGROUND

Critical illness survival rates have improved, but patients frequently face prolonged new or worsened physical, cognitive and psychosocial impairments. These difficulties associated with critical care admission are known as post-intensive care syndrome (PICS).

AIMS

The multidisciplinary Intensive care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme was developed to support patients in the recovery period from critical illness. During the COVID-19 pandemic, the psychology support offered by this service was adapted from an in-person group to individual remote review. This audit evaluated both the extent to which this input aligned with the recommended guidelines and the acceptability of this adapted delivery to this patient group, which could help guide post-pandemic psychology input to the service.

STUDY DESIGN

The records of 207 patients were analysed retrospectively. The nature of support offered to a sub-sample of 50 patients detailed in clinical summary letters was compared with the Faculty of Intensive Care Medicine (2019) guidelines. Telephone calls were made to gather feedback on the virtual psychology support from 10 patients.

RESULTS

Psychological difficulties were identified by 111 of the 207 patients who attended the virtual clinic. A total of 88 of these patients accepted referral for virtual psychology support and 67 (76%) of those patients attended. The virtual psychology support offered was found to be largely in accordance with ICU aftercare guidance and acceptable to patients. Patients found the summary letters of consultations accurate and helpful. Most patients expressed a preference for in-person support and the opportunity to meet other patients.

CONCLUSIONS

The adaptations to the psychology support offered by InS:PIRE during the COVID-19 pandemic were found to be largely in line with ICU aftercare psychology guidelines and were acceptable to patients. Further research is needed on future methods of delivering psychology support for this patient group.

RELEVANCE TO CLINICAL PRACTICE

This audit highlights issues important to patients in the post-ICU period based on individual consultations not previously possible. Patient opinion was sought on the impact of changing the delivery of post-ICU psychological support, which will help guide future improvements in the service.

Factors Associated With New Analgesic Requirements Following Critical Illness

BACKGROUND

Chronic opioid use represents a significant burden to global healthcare with adverse long-term outcomes. Elevated patient reported pain levels and analgesic prescriptions have been reported following discharge from critical care. We describe analgesic requirements following discharge from hospital and identify if a critical care admission is a significant factor for stronger analgesic prescriptions.

METHODS

This retrospective observational cohort study identified patients in the UK Biobank with a registered admission to any UK hospital between January 1, 2010 and December 31, 2015 and information on prescriptions drawn both prior to and following hospital discharge. Two matched cohorts were created from the dataset: critical care patients and hospital patients admitted without a critical care encounter. Outcomes were analgesic requirements following hospital discharge and factors associated with increased analgesic prescriptions. Multivariable logistic regression was used to identify factors associated with prescriptions from higher steps on the World Health Organization (WHO) analgesic ladder.

RESULTS

In total, 660 formed the total study population. Strong opioid prescriptions following discharge were significantly higher in the critical care cohort (P value <.001). Critical care admission (OR = 1.45) and increasing Townsend deprivation (OR = 1.04) index were significantly associated with increasing strength of analgesic prescriptions following discharge.

CONCLUSIONS

Critical care patients require stronger analgesic prescriptions in the 12 months following hospital discharge. Patients from areas of high socioeconomic deprivation may also be associated with increased analgesic requirements. Multidisciplinary support is required for patients who may be at risk of chronic opioid use and could be delivered within critical care recovery programs.

"How Do I Test the Waters? How Do I Go Forward?": Codesigning a Supportive Pathway after Critical Illness

Rationale: Long-term recovery after critical illness can be affected by post-intensive care syndrome (PICS), a significant burden, which can impact return to activities and work. There is a need for streamlined support for intensive care unit (ICU) patients in their recovery while enduring PICS symptoms. Objectives: To explore critical illness recovery from the experiences, perspectives, and beliefs of former ICU patients, their caregivers, and multidisciplinary clinicians to design a future rehabilitation intervention prototype to support ICU patients. Methods: This was an experience-based codesign (EBCD) study underpinned by the Behavior Change Wheel framework involving ICU patients (<5 years after illness), caregivers, and multidisciplinary clinicians with current clinical experience with ICU recovery at any point along the care continuum (ICU, acute, subacute, or community settings) from two metropolitan hospitals in Melbourne, Australia. Two rounds of experience-based codesign workshops were held between August 2021 and February 2022. Workshop content was analyzed via a reflective thematic approach to determine themes and develop an intervention. The intervention was mapped according to the template for intervention description and replication framework. Results: Forty people participated in the codesign process: 15 ICU patients, 2 caregivers, and 23 clinicians. Fifteen major themes were identified in the experience of ICU recovery. Returning home was a key time point for change, acceptance, and adjustment, with the burden of physical limitations and mental health problems becoming apparent. Most participants expressed that PICS was poorly understood in the community, and there was a lack of support to aid recovery. Based on these results, an intervention prototype was developed with a primary goal of improving care after hospital discharge. This was further refined in the second round of workshops. A resource toolkit was deemed most acceptable to end-users, including a hospital-directed support program involving psychology and physical therapy and an accompanying digital health package. Conclusions: A critical time point for more support in the recovery journey was the transition from hospital to home. To address this, a rehabilitation prototype including a physical and psychological support intervention and supporting digital health toolkit was codesigned. The intervention package will be developed and trialed with future ICU patients and their families. Clinical trial registered with www.clinicaltrials.gov (NCT05044221).

Characterizing Cardiac Function in ICU Survivors of Sepsis: A Pilot Study Protocol

Background

Sepsis is one of the most common reasons for ICU admission and a leading cause of mortality worldwide. More than one-half of survivors experience significant physical, psychological, or cognitive impairments, often termed post-intensive care syndrome (PICS). Sepsis is recognized increasingly as being associated with a risk of adverse cardiovascular events that is comparable with other major cardiovascular risk factors. It is plausible that sepsis survivors may be at risk of unidentified cardiovascular disease, and this may play a role in functional impairments seen after ICU discharge.

Research Question

What is the prevalence of myocardial dysfunction after an ICU admission with sepsis and to what extent might it be associated with physical impairments in PICS?

Study Design and Methods

Characterisation of Cardiovascular Function in ICU Survivors of Sepsis (CONDUCT-ICU) is a prospective, multicenter, pilot study characterizing cardiovascular function and functional impairments in survivors of sepsis taking place in the west of Scotland. Survivors of sepsis will be recruited at ICU discharge and followed up 6 to 10 weeks after hospital discharge. Biomarkers of myocardial injury or dysfunction (high sensitivity troponin and N-terminal pro B-type natriuretic peptide) and systemic inflammation (C-reactive protein, IL-1β, IL-6, IL-10, and tumor necrosis factor alpha) will be measured in 69 patients at recruitment and at follow-up. In addition, a cardiovascular magnetic resonance substudy will be performed at follow-up in 35 patients. We will explore associations between cardiovascular magenetic resonance indexes of cardiac function, biomarkers of cardiac dysfunction and inflammation, and patient-reported outcome measures.

Interpretation

CONDUCT-ICU will provide data regarding the cause and prevalence of cardiac dysfunction in survivors of sepsis and will explore associations with functional impairment. It will provide feasibility data and operational learning for larger studies investigating mechanisms of functional impairment after ICU admission and the association between sepsis and adverse cardiovascular events.

Trial Registry

ClinicalTrials.gov; No.: NCT05633290; URL: www.clinicaltrials.gov.

Barriers to and Facilitators of Family Caregiving of Patients With COVID-19 Early in the Pandemic

BACKGROUND

In 2020, many family members were thrust into the role of caregiving for a relative with COVID-19 with little preparation, training, or understanding of the disease and its symptoms.

OBJECTIVES

To explore the barriers to and facilitators of caregiving experienced by family caregivers of patients with COVID-19 who had been in intensive care in the pandemic's earliest months.

METHODS

In-depth qualitative interviews were conducted by web conference with 16 adults recovering at home after intubation for COVID-19 in an intensive care unit at a major academic medical center and their primary caregivers from March to August 2020 (N = 32). Thematic qualitative analysis was done using Watkins' rigorous and accelerated data reduction technique with MAXQDA software.

RESULTS

Seven themes emerged regarding factors that facilitated or posed barriers to care: other health conditions that increased complexity of care, interactions and experiences in the health care system, COVID-19's proliferation into other areas of life, the psychological well-being of the patient-caregiver dyad, experience of support from the dyad's network, the role of caregiving in the dyad, and contextual circumstances of the dyad. The themes often included both barriers and facilitators, depending on the experience of the dyad (eg, feeling encouraged vs fatigued by their support network).

CONCLUSIONS

Understanding how patients with COVID-19 and their caregivers experience illness management across the recovery journey can help clarify the COVID-19 care-giving process and identify intervention targets to improve overall health and well-being of the care dyad.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): feasibility of a pragmatic randomised controlled trial

BACKGROUND

ICU survivors often suffer from prolonged physical and mental impairments resulting in the so called "Post-Intensive Care Syndrome" (PICS). The aftercare of former ICU patients affected by PICS in particular has not been addressed sufficiently in Germany so far. The aim of this study was to evaluate the feasibility of a pragmatic randomised trial (RCT) comparing an intensive care unit (ICU) follow-up clinic intervention to usual care.

METHODS

This pilot study in a German university hospital evaluated the feasibility of a pragmatic RCT. Patients were assigned in a 1:1 ratio to an ICU follow-up clinic intervention or to usual care. The concept of this follow-up clinic was previously developed in a participatory process with patients, next of kin, health care professionals and researchers. We performed a process evaluation and determined acceptability, fidelity, completeness of measurement instruments and practicality as feasibility outcomes. The RCT's primary outcome (health-related quality of life) was assessed six months after ICU discharge by means of the physical component scale of the Short-Form-12 self-report questionnaire.

RESULTS

The pilot study was conducted from June 2020 to May 2021 with 21 and 20 participants in the intervention and control group. Principal findings related to feasibility were 85% consent rate (N = 48), 62% fidelity rate, 34% attrition rate (N = 41) and 77% completeness of outcome measurements. The primary effectiveness outcome (health-related quality of life) could be measured in 93% of participants who completed the study (N = 27). The majority of participants (85%) needed assistance with follow-up questionnaires (practicality). Median length of ICU stay was 13 days and 85% (N = 41) received mechanical ventilation, median Sequential Organ Failure Assessment Score was nine. Six-month follow-up assessment was planned for all study participants and performed for 66% (N = 41) of the participants after 197 days (median).

CONCLUSION

The participatory developed intervention of an ICU follow-up clinic and the pragmatic pilot RCT both seem to be feasible. We recommend to start a pragmatic RCT on the effectiveness of the ICU follow-up clinic.

TRIAL REGISTRATION

ClinicalTrials.gov US NLM, NCT04186468, Submission: 02/12/2019, Registration: 04/12/2019, https://clinicaltrials.gov/ct2/show/NCT04186468.

Patients' experiences of cognitive impairment following critical illness treated in an intensive care unit: A scoping review

INTRODUCTION

Treatment with modern technology in an intensive care unit has increased critical illness survival. However, many patients are affected by their critical illness for months or years following discharge, as they experience cognitive impairments. Long-term cognitive impairments can severely affect patients' quality of life. Exploring patients' experiences on how and which cognitive impairments affect their everyday lives is important to improve planning of relevant research into interventions that may alleviate the burden of post-intensive cognitive impairments.

AIM

To review the literature on patients' experiences of cognitive impairment following critical illness treated in an intensive care unit.

METHODS

A systematic search was conducted in PubMed, Cinahl, PsycInfo and Embase in March-May 2021. References and citations in relevant studies were explored. The Covidence tool was used by two independent researchers to identify relevant studies for inclusion. The Mixed Methods Appraisal Tool was used for critical appraisal. The JBI methodology for scoping reviews and the PRISMA-ScR checklist were used (Supporting Information File 1).

RESULTS

We identified 11 relevant qualitative and/or quantitative studies. Four themes were found: 'Experiencing poor memory', 'Managing everyday life', 'Unsupported by the healthcare system' and 'Strategies for support in recovery'. Patients used various strategies during their recovery and rehabilitation to regain independence and avoid being a burden. They needed information to support their recovery and rehabilitation; otherwise, they felt unsupported and betrayed by the healthcare system.

CONCLUSION

Patients experienced various cognitive impairments following critical illness in the intensive care unit, affecting and challenging their quality of life and adaption to everyday life.

RELEVANCE TO CLINICAL PRACTICE

Knowledge gained by exploring patients' experience of cognitive impairments following critical illness in the intensive care unit can contribute to improve clinical practice by targeting and optimising patients' rehabilitation process.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement in this scoping review.

Examining the needs of survivors of critical illness through the lens of palliative care: A qualitative study of survivor experiences

OBJECTIVE

To examine the needs of adult survivors of critical illness through a lens of palliative care.

RESEARCH METHODOLOGY

A qualitative study of adult survivors of critical illness using semi-structured interviews and framework analysis.

SETTING

Participants were recruited from the post-intensive care unit clinic of a mid-Atlantic academic medical center in the United States.

FINDINGS

Seventeen survivors of critical illness aged 34-80 (median, 66) participated in the study. The majority of patients were female (64.7 %, n = 11) with a median length of index ICU stay of 12 days (interquartile range [IQR] 8-19). Interviews were conducted February to March 2021 and occurred a median of 20 months following the index intensive care stay (range, 13-33 months). We identified six key themes which align with palliative care principles: 1) persistent symptom burden; 2) critical illness as a life-altering experience; 3) spiritual changes and significance; 4) interpreting/managing the survivor experience; 5) feelings of loss and burden; and 6) social support needs.

CONCLUSION

Our findings suggest that palliative care components such as symptom management, goals of care discussions, care coordination, and spiritual and social support may assist in the assessment and treatment of survivors of critical illness.

Patient Safety: Cognitive Assessment at Intensive Care Unit Discharge

Topic

Assessing functional cognition is a critical need for intensive care unit survivors transitioning to another level of care.

Clinical Relevance

Up to 62% of patients discharged from an intensive care unit have significant cognitive impairment that is not associated with severity of illness, number of comorbidities, or length of hospital stay. For more than 20 years, researchers have published an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services.

Purpose

To describe the impact of and potential interventions for cognitive decline at intensive care unit discharge and discharge readiness on 30-day readmission rates.

Content Covered

Assessing the patient’s functional cognition assessment and advocating for appropriate resources are needed to improve patient and clinical outcomes.

Evaluation of a health and social care programme to improve outcomes following critical illness: a multicentre study

RATIONALE

At present, clinicians aiming to support patients through the challenges after critical care have limited evidence to base interventions.

OBJECTIVES

Evaluate a multicentre integrated health and social care intervention for critical care survivors. A process evaluation assessed factors influencing the programme implementation.

METHODS

This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme. We compared patients who attended this programme with a usual care cohort from the same time period across nine hospital sites in Scotland. The primary outcome was health-related quality of life (HRQoL) measured via the EuroQol 5-dimension 5-level instrument, at 12 months post hospital discharge. Secondary outcome measures included self-efficacy, depression, anxiety and pain.

RESULTS

137 patients who received the InS:PIRE intervention completed outcome measures at 12 months. In the usual care cohort, 115 patients completed the measures. The two cohorts had similar baseline demographics. After adjustment, there was a significant absolute increase in HRQoL in the intervention cohort in relation to the usual care cohort (0.12, 95% CI 0.04 to 0.20, p=0.01). Patients in the InS:PIRE cohort also reported self-efficacy scores that were 7.7% higher (2.32 points higher, 95% CI 0.32 to 4.31, p=0.02), fewer symptoms of depression (OR 0.38, 95% CI 0.19 to 0.76, p=0.01) and similar symptoms of anxiety (OR 0.58, 95% CI 0.30 to 1.13, p=0.11). There was no significant difference in overall pain experience. Key facilitators for implementation were: integration with inpatient care, organisational engagement, flexibility to service inclusion; key barriers were: funding, staff availability and venue availability.

CONCLUSIONS

This multicentre evaluation of a health and social care programme designed for survivors of critical illness appears to show benefit at 12 months following hospital discharge.

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.

Survivorship After Critical Illness and Post-Intensive Care Syndrome

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

Minimizing Post-Intensive Care Syndrome to Improve Outcomes for Intensive Care Unit Survivors

TOPIC

Post-intensive care syndrome is a collection of symptoms that more than half of patients who survive a critical illness, and their family caregivers, experience after the illness. Those symptoms include weakness/ fatigue, sleep disturbances/insomnia, cognitive dysfunction, posttraumatic stress disorder, other mental health conditions, and a lack of effective coping strategies.

CLINICAL RELEVANCE

To minimize the risk of a patient developing post-intensive care syndrome, intensive care unit nurses must adopt practices that reduce the severity of disability and optimize patient outcomes. They must also advocate for patients who need additional expert care.

PURPOSE

To describe interventions that critical care nurses can implement to minimize a patient's risk for post-intensive care syndrome.

CONTENT COVERED

This article describes patients who have a high risk of developing post-intensive care syndrome and interventions that are within nurses' purview.

A multicentre evaluation exploring the impact of an integrated health and social care intervention for the caregivers of ICU survivors

Background

Caregivers and family members of Intensive Care Unit (ICU) survivors can face emotional problems following patient discharge from hospital. We aimed to evaluate the impact of a multi-centre integrated health and social care intervention, on caregiver and family member outcomes.

Methods

This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme across 9 sites in Scotland. InS:PIRE is an integrated health and social care intervention. We compared caregivers who attended this programme with a contemporary control group of ICU caregivers (usual care cohort), who did not attend.

Results

The primary outcome was anxiety measured via the Hospital Anxiety and Depression Scale at 12 months post-hospital discharge. Secondary outcome measures included depression, carer strain and clinical insomnia. A total of 170 caregivers had data available at 12 months for inclusion in this study; 81 caregivers attended the InS:PIRE intervention and completed outcome measures at 12 months post-hospital discharge. In the usual care cohort of caregivers, 89 completed measures. The two cohorts had similar baseline demographics. After adjustment, those caregivers who attended InS:PIRE demonstrated a significant improvement in symptoms of anxiety (OR: 0.42, 95% CI: 0.20–0.89, p = 0.02), carer strain (OR: 0.39; 95% CI: 0.16–0.98 p = 0.04) and clinical insomnia (OR: 0.40; 95% CI: 0.17–0.77 p < 0.001). There was no significant difference in symptoms of depression at 12 months.

Conclusions

This multicentre evaluation has shown that caregivers who attended an integrated health and social care intervention reported improved emotional health and less symptoms of insomnia, 12 months after the delivery of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04014-z.

Association of imbalance between job workload and functional ability with return to work in ARDS survivors

BACKGROUND

Inability to return to work (RTW) is common after acute respiratory distress syndrome (ARDS). Mismatch in an individual's job workload and his or her functional ability, termed work ability imbalance, is negatively associated with RTW, but has not been evaluated in ARDS survivors.

OBJECT

We examine associations between work ability imbalance at 6 months and RTW at 6 months and 12 months, as well as the ability to sustain employment in ARDS survivors.

METHODS

Previously employed participants from the ARDS Network Long-Term Outcomes Study (N=341) were evaluated. Pre-ARDS workload was determined based on the US Occupational Information Network classification. Post-ARDS functional ability was assessed using self-reported 36-Item Short Form Health Survey (SF-36) physical functioning, social functioning and mental health subscales, and Mini-Mental State Examination. ARDS survivors were categorised into four work ability imbalance categories: none, psychosocial, physical, and both psychosocial and physical.

RESULTS

Almost 90% of ARDS survivors had a physical and/or psychosocial work ability imbalance at both 6-month and 12-month follow-up. Compared with survivors with no imbalance at 6 months, those with both physical and psychosocial imbalance had lower odds of RTW (6 months: OR=0.33, 95% CI=0.13 to 0.82; 12 months: OR=0.22, 95% CI=0.07 to 0.65). Thirty-eight (19%) of those who ever RTW were subsequently jobless at 12 months.

CONCLUSION

Interventions aimed at rebalancing ARDS survivors' work ability by addressing physical and psychosocial aspects of their functional ability and workload should be explored as part of efforts to improve RTW, maintain employment and reduce the financial impact of joblessness.

Using long-term predicted Quality of Life in ICU clinical practice to prepare patients for life post-ICU: A feasibility study

PURPOSE

To examine the feasibility of using the PREdicting PAtients' long-term outcome for Recovery (PREPARE) prediction model for Quality of Life (QoL) 1 year after ICU admission in ICU practice to prepare expected ICU survivors and their relatives for life post-ICU.

MATERIALS AND METHODS

Between June 2020 and February 2021, the predicted change in QoL after 1 year was discussed in 25 family conferences in the ICU. 13 physicians, 10 nurses and 19 patients and/or family members were interviewed to evaluate intervention feasibility in ICU practice. Interviews were analysed qualitatively using thematic coding.

RESULTS

Patients' median age was 68.0 years, five patients (20.0%) were female and seven patients (28.0%) died during ICU stay. Generally, study participants thought the intervention, which clarified the concept of QoL through visualization and served as a reminder to discuss QoL and expectations for life post-ICU, had merit. However, some participants, especially physicians, thought the prediction model needed more data on more severely ill ICU patients to curb uncertainty.

CONCLUSIONS

Using predicted QoL scores in ICU practice to prepare patients and family members for life after ICU discharge is feasible. After optimising the model and implementation strategy, its effectiveness can be evaluated in a larger trial.

Características del síndrome post cuidado intensivo: revisión de alcance

Objetivo: identificar la evidencia disponible de las características del síndrome post unidad de cuidado intensivo en el paciente que egresa de la unidad de cuidado intensivo. Método: revisión de alcance con la metodología del Joanna Briggs Institut, en cinco bases de datos con la estrategia de búsqueda ([PostIntensive AND Care AND Syndrome] [Nursing AND Care AND PICS]). Se incluyeron estudios primarios publicados entre los años 2010 y 2020, disponibles en texto completo. Resultados: después del análisis de los 48 estudios primarios se extrajeron seis categorías temáticas así: aspecto cognitivo en el síndrome post UCI, osteomusculares, psicoemocionales, estrategias de prevención con modelos de sobrevivientes de UCI, síndrome post unidad cuidado intensivo en la familia y herramientas de evaluación. Conclusiones: mejorar la calidad de atención de los pacientes que presentan este síndrome, prevenir la aparición y aumentar la calidad de vida prestada a los sobrevivientes de UCI y sus familias. La evidencia reporta que entre los cuidadores se pueden desencadenar distintos trastornos que disminuyen su calidad de vida. La enfermería juega un papel crucial en la prevención de la aparición del síndrome mediante estrategias en la UCI e interdisciplinares; los planes de egreso y seguimiento a los pacientes pueden lograr que estos se rehabiliten más rápido y eviten discapacidades o secuelas a largo plazo.

Prominent Cognitive Impairment Sequelae in Adult Survivors of Acute Respiratory Distress Syndrome

PURPOSE

The primary objective of this scoping review was to identify prominent cognitive impairment sequelae in adult survivors of an intensive care unit admission for acute respiratory distress syndrome (ARDS).

DESIGN

A scoping review was performed.

METHODS

Search terms were entered into multiple EBSCOhost databases. Articles pertaining to pediatric survivors, not in English, lacking cognitive impairment sequelae, or focused on a single sequela were excluded; 12 articles remained.

RESULTS

Cognitive impairment developed in 83.5% of patients with ARDS prior to discharge and persisted in 51.3% (n = 300/585) of survivors at the 1 year mark after discharge (range: 16.7%-100% across studies). Prominent sequelae included impairments in executive function, mental processing speed, immediate memory, and attention/concentration.

CONCLUSIONS

Survivors of an intensive care unit stay for ARDS often develop cognitive impairment persisting long after their admission. Clinicians in rehabilitation facilities should screen for these sequelae and connect survivors with treatment to improve cognitive outcomes.

CLINICAL RELEVANCE

Early recognition of prominent cognitive impairment sequelae by rehabilitation clinicians and referrals to neuropsychologists by providers are critical to limiting the severity of impairment.

Development of a practically usable prediction model for quality of life of ICU survivors: A sub-analysis of the MONITOR-IC prospective cohort study

PURPOSE

As the goal of ICU treatment is survival in good health, we aimed to develop a prediction model for ICU survivors' change in quality of life (QoL) one year after ICU admission.

MATERIALS & METHODS

This is a sub-study of the prospective cohort MONITOR-IC study. Adults admitted ≥12 h to the ICU of a university hospital between July 2016-January 2019 were included. Moribund patients were excluded. Change in QoL one year after ICU admission was quantified using the EuroQol five-dimensional (EQ-5D-5L) questionnaire, and Short-Form 36 (SF-36). Multivariable linear regression analysis and best subsets regression analysis (SRA) were used. Models were internally validated by bootstrapping.

RESULTS

The PREdicting PAtients' long-term outcome for Recovery (PREPARE) model was developed (n = 1308 ICU survivors). The EQ-5D-models had better predictive performance than the SF-36-models. Explained variance (adjusted R²) of the best model (33 predictors) was 58.0%. SRA reduced the number of predictors to 5 (adjusted R² = 55.3%, SE = 0.3), including QoL, diagnosis of a Cardiovascular Incident and frailty before admission, sex, and ICU-admission following planned surgery.

CONCLUSIONS

Though more long-term data are needed to ascertain model accuracy, in future, the PREPARE model may be used to better inform and prepare patients and their families for ICU recovery.

Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness

BACKGROUND

After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear.

OBJECTIVES

Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments.

PARTICIPANTS

Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers.

DESIGN

Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews.

MEETING OUTCOMES

We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function).

CONCLUSIONS

Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2-4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Factors associated with employment outcome after critical illness: Systematic review, meta-analysis, and meta-regression

AIMS

To synthesize data on prevalence and risk factors for return to work (RTW) in ICU survivors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PUBMED, CINAHL, EMBASE and PsycINFO databases were searched from 2000-Feb 2020.

REVIEW METHODS

Peer-reviewed articles that included adult ICU survivors and employment outcomes. Two investigators independently reviewed articles following the PRISMA protocol. Pooled prevalence for RTW was calculated. Meta-regression analyses were performed to assess the association between disability policies, temporal factors and RTW following ICU.

RESULTS

Twenty-eight studies (N = 8,168) met the inclusion criteria. All studies were scored as 'low risk of bias'. Using meta-analysis, the proportion (95% CI) of RTW following ICU was 29% (0.20,0.42), 59% (0.50,0.70), 56% (0.50,0.62), 63% (0.54,0.72), 58% (0.37,0.91), 58% (0.42,0.81), and 44% (0.25,0.76) at 3, 4-6, 7-12, 13-24, 25-36, 37-48, and 49-60 months, respectively. Time and disability policy support are factors associated with the proportion of ICU survivors who RTW. Through meta-regression, there is a 20% increase (95% CI: 0.06, 0.33) in the proportion of individuals who RTW per year. However, the average rate of increase slows by 4% (-0.07, -0.1) per year. In countries with high support policies, the proportion of RTW is 32% higher compared with countries with low support policies (0.08, 0.24). However, as subsequent years pass, the additional proportion of individuals RTW in high support countries declines (β = -0.06, CI: -0.1, -0.02).

CONCLUSIONS

Unemployment is common in ICU survivors. Countries with policies that give higher support for disabled workers have a higher RTW proportion to 3 years following ICU admission. However, from 3-5 years, there is a shift to countries with lower support policies having better employment outcomes.

IMPACT

Health care policies have an impact on RTW rate in survivors of ICU. Healthcare providers, including nurses, can function as public advocates to facilitate policy change.

Patients' experiences of recovery: Beyond the intensive care unit and into the community

AIMS

To understand barriers and facilitators of recovery for critical illness survivors', who are discharged home from the hospital and do not have access to dedicated outpatient care.

DESIGN

Multi-site descriptive study guided by interpretive phenomenology using semi-structured interviews.

METHODS

Interviews were conducted between December 2017 -July 2018. Eighteen participants were included. Data were collected from interview recordings, transcripts, field notes, and a retrospective chart review for sample demographics. Analysis was completed using Interpretive Phenomenological Analysis which provided a unique view of recovery through the survivors' personal experiences and perception of those experiences.

RESULTS

Participants encountered several barriers to their recovery; however, they were resilient and initiated ways to overcome these barriers and assist with their recovery. Facilitators of recovery experienced by survivors included seeking support from family and friends, lifestyle adaptations, and creative management of their multiple medical needs. Barriers included unmet needs experienced by survivors such as mental health issues, coordination of care, and spiritual needs. These unmet needs left participants feeling unsupported from healthcare providers during their recovery.

CONCLUSION

This study highlights important barriers and facilitators experienced by critical illness survivors during recovery that need be addressed by healthcare providers. New ways to support critical illness survivors, that can reach a broader population, must be developed and evaluated to support survivors during their recovery in the community.

IMPACT

This study addressed ICU survivors' barriers and facilitators to recovery. Participants encountered several barriers to recovery at home, such as physical, cognitive, psychosocial, financial, and transportation barriers, however, these survivors were also resilient and resourceful in the development of strategies to try to manage their recovery at home. These results will help healthcare providers develop interventions to better support ICU survivors in the community.

Supporting recovery from COVID-19

COVID-19 is a new disease. Most research into the disease has focused on prevention of viral spread and treatment, but little is known about how patients recover. Nurses, whether in hospital, the community or in primary care, have a key role in supporting recovery from COVID-19. In this article, direct evidence from studies of COVID-19, and indirect evidence from studies of infections caused by other coronaviruses (eg SARS, MERS) and of the ICU experience are explored to identify the potential course of recovery and areas where nurses can help. Most people will have an uncomplicated recovery. However, it appears that a more complicated recovery is likely to be associated with severe disease. A minority, possibly those needing hospitalisation, and/or with pre-existing physical or psychological comorbidities, may experience long-term physical effects, fatigue and mental health difficulties. The support that nurses, as part of a multidisciplinary team, can provide to facilitate recovery is discussed.

Prediction Models for Physical, Cognitive, and Mental Health Impairments After Critical Illness: A Systematic Review and Critical Appraisal

OBJECTIVES

Improved ability to predict impairments after critical illness could guide clinical decision-making, inform trial enrollment, and facilitate comprehensive patient recovery. A systematic review of the literature was conducted to investigate whether physical, cognitive, and mental health impairments could be predicted in adult survivors of critical illness.

DATA SOURCES

A systematic search of PubMed and the Cochrane Library (Prospective Register of Systematic Reviews ID: CRD42018117255) was undertaken on December 8, 2018, and the final searches updated on January 20, 2019.

STUDY SELECTION

Four independent reviewers assessed titles and abstracts against study eligibility criteria. Studies were eligible if a prediction model was developed, validated, or updated for impairments after critical illness in adult patients. Discrepancies were resolved by consensus or an independent adjudicator.

DATA EXTRACTION

Data on study characteristics, timing of outcome measurement, candidate predictors, and analytic strategies used were extracted. Risk of bias was assessed using the Prediction model Risk Of Bias Assessment Tool.

DATA SYNTHESIS

Of 8,549 screened studies, three studies met inclusion. All three studies focused on the development of a prediction model to predict (1) a mental health composite outcome at 3 months post discharge, (2) return-to-pre-ICU functioning and residence at 6 months post discharge, and (3) physical function 2 months post discharge. Only one model had been externally validated. All studies had a high risk of bias, primarily due to the sample size, and statistical methods used to develop and select the predictors for the prediction published model.

CONCLUSIONS

We only found three studies that developed a prediction model of any post-ICU impairment. There are several opportunities for improvement for future prediction model development, including the use of standardized outcomes and time horizons, and improved study design and statistical methodology.

Patients' and Their Caregivers' Interest in Learning About Post-ICU Syndrome and Seeking Help for It

Critical Illness Recovery Programs report low attendance. We aimed to provide information about postintensive care syndrome and to learn which patients would pursue help in a Critical Illness Recovery Clinic.

All patients who checked in to our Lung Center were given a survey regarding their ICU experience and offered information about postintensive care syndrome and an appointment in the clinic.

Nine hundred and twenty respondents reported having had an ICU experience: 37% of former ICU patients reported difficulty returning to their normal lives afterward compared with 21% who were family or close friends of a former ICU patient. Only 5% requested information and less than 1% requested a dedicated appointment.

More than one of three former ICU patients and one in five close friends or relatives of former ICU patients reported difficulty returning to their normal lives after their ICU experience. Very few pursued the opportunity to learn more about it or seek help.

Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.

An online healthy relationship tool and safety decision aid for women experiencing intimate partner violence (I-DECIDE): a randomised controlled trial

BACKGROUND

Evidence for online interventions to help women experiencing intimate partner violence is scarce. We assessed whether an online interactive healthy relationship tool and safety decision aid (I-DECIDE) would increase women's self-efficacy and improve depressive symptoms compared with an intimate partner violence information website.

METHODS

In this two-group pragmatic randomised controlled trial, we enrolled women who had screened positive for any form of intimate partner violence or fear of a partner in the 6 months before recruitment. Women aged 16-50 years currently residing in Australia, who had safe access to a computer and an internet connection, and who answered positively to one of the screening questions in English were eligible for inclusion. Participants were randomly assigned (1:1) by computer to receive either the intervention or control website. The intervention website consisted of modules on healthy relationships, abuse and safety, and relationship priority setting, and a tailored action plan. The control website was a static intimate partner violence information website. As the initial portion of the website containing the baseline questions was identical for both groups, there was no way for women to tell which group they had been allocated to, and the research team were also masked to participant allocation until after analysis of the 12-month data. Data were collected at baseline, immediately after completion of the website, at 6 months, and 12 months. Primary outcomes were mean general self-efficacy score (immediately after website completion, and at 6 months and 12 months) and mean depression score (at 6 months and 12 months). Data analyses were done according to intention-to-treat principles, accounting for missing data, and adjusted for outcome baseline scores. This trial was registered with the Australian New Zealand Clinical Trials Registry, ACTRN 12614001306606.

FINDINGS

Between Jan 16, and Aug 28, 2015, 584 patients registered for the study and were assessed for eligibility. 422 eligible participants were randomly allocated to the intervention group (227 patients) or control group (195 patients). 179 (79%) participants in the intervention group and 156 (80%) participants in the control group completed 12-month follow-up. Mean self-efficacy at 6 months and 12 months was lower for participants in the intervention group than for participants in the control group, although this did not meet the prespecified mean difference (6 months: 27·5 [SD 5·1] vs 28·1 [4·4], imputed mean difference 1·3 [95% CI 0·3 to 2·3]; 12 months: 27·8 [SD 5·4] vs 29·0 [5·0], imputed mean difference 1·6 [95% CI 0·5 to 2·7]). We found no difference between groups in depressive symptoms at 6 months or 12 months (6 months: 22·5 [SD 17·1] vs 24·2 [17·2], imputed mean difference -0·3 [95% CI -3·5 to 3·0]; 12 months: 21·9 [SD 19·3] vs 21·5 [19·3], imputed mean difference -1·9 [95% CI -5·6 to 1·7]). Qualitative findings indicated that participants found the intervention supportive and a motivation for action.

INTERPRETATION

Our findings highlight the need for further research, development, and refinement of online interventions for women experiencing intimate partner violence, particularly into the duration needed for interventions. Although we detected no meaningful differences between groups, our qualitative results indicated that some women find an online tool a helpful source of motivation and support.

FUNDING

Australian Research Council.

Impact of Critical Illness on Resource Utilization: A Comparison of Use in the Year Before and After ICU Admission

Supplemental Digital Content is available in the text.

Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual’s resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission.

A national survey of intensive care follow-up clinics in Australia

BACKGROUND

Intensive care follow-up clinics (ICFCs) have been implemented internationally with the aim to address the growing number of patients living with sequalae of critical illness and intensive care. However, data on Australian intensive care follow-up practice are rare.

OBJECTIVES

The primary objective was to determine the proportion of Australian intensive care units (ICUs) that offer a dedicated ICFC to ICU survivors, with the intention of improving long-term outcomes of critical illness. Secondary objectives were to identify models of ICU follow-up and barriers to the implementation of ICFCs.

METHODS

A custom-designed, pilot-tested 12-question online survey was sent to the nurse unit managers and medical directors of all 167 Australian ICUs listed in the database of the Australian and New Zealand Intensive Care Society. Outcome measures included proportion of ICUs offering ICFCs, details on types of follow-up services with staffing, funding source, and reasons for not providing ICU follow-up.

RESULTS

One hundred seven of the 167 ICUs contacted responded to the survey. Of these, two (2%) operated a dedicated ICFC. Both ICFCs were nursing-led, with one receiving dedicated funding and the other being unfunded. Three units (3%) conducted routine outpatient follow-up by telephone; one of these services was doctor-led, and two were nurse-led. Four units (4%) were performing outpatient follow-up as part of research studies only. Among the units not operating an ICFC, the main reason given for not doing so were financial constraints (58%), followed by lack of clinical need (19%) and perceived lack of evidence (11%).

CONCLUSION

In Australia, only two ICUs operated an ICFC. Only one outpatient follow-up service received dedicated funding, and financial constraints were the main reason given for units not offering outpatient follow-up services.

Key Components of ICU Recovery Programs: What Did Patients Report Provided Benefit?

Supplemental Digital Content is available in the text.

To understand from the perspective of patients who did, and did not attend ICU recovery programs, what were the most important components of successful programs and how should they be organized.

Return to work after critical illness: a systematic review and meta-analysis

BACKGROUND

Survivors of critical illness often experience poor outcomes after hospitalisation, including delayed return to work, which carries substantial economic consequences.

OBJECTIVE

To conduct a systematic review and meta-analysis of return to work after critical illness.

METHODS

We searched PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from 1970 to February 2018. Data were extracted, in duplicate, and random-effects meta-regression used to obtain pooled estimates.

RESULTS

Fifty-two studies evaluated return to work in 10 015 previously employed survivors of critical illness, over a median (IQR) follow-up of 12 (6.25-38.5) months. By 1-3, 12 and 42-60 months' follow-up, pooled return to work prevalence (95% CI) was 36% (23% to 49%), 60% (50% to 69%) and 68% (51% to 85%), respectively (τ2=0.55, I2=87%, p=0.03). No significant difference was observed based on diagnosis (acute respiratory distress syndrome (ARDS) vs non-ARDS) or region (Europe vs North America vs Australia/New Zealand), but was observed when comparing mode of employment evaluation (in-person vs telephone vs mail). Following return to work, 20%-36% of survivors experienced job loss, 17%-66% occupation change and 5%-84% worsening employment status (eg, fewer work hours). Potential risk factors for delayed return to work include pre-existing comorbidities and post-hospital impairments (eg, mental health).

CONCLUSION

Approximately two-thirds, two-fifths and one-third of previously employed intensive care unit survivors are jobless up to 3, 12 and 60 months following hospital discharge. Survivors returning to work often experience job loss, occupation change or worse employment status. Interventions should be designed and evaluated to reduce the burden of this common and important problem for survivors of critical illness.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018093135.

Impact of a pharmacist intervention at an intensive care rehabilitation clinic

Objective

While disruptions in medications are common among patients who survive critical illness, there is limited information about specific medication-related problems among survivors of critical care. This study sought to determine the prevalence of specific medication-related problems detected in patients, seen after critical care discharge.

Design

Consecutive patients attending an intensive care unit (ICU) follow-up programme were included in this single-centre service evaluation.

Setting

Tertiary care regional centre in Scotland (UK).

Participants

47 patients reviewed after critical care discharge at an ICU follow-up programme.

Interventions

Pharmacists conducted a full medication review, including: medicines reconciliation, assessing the appropriateness of each prescribed medication, identification of any medication-related problems and checking adherence.

Measurements

Medication-related problems in patients following critical care discharge. Interventions and medication-related problems were systematically graded and risk factors were identified using an adapted version of the National Patient Safety Agency Risk Matrix.

Main results

69 medication-related problems were identified in 38 (81%) of the 47 patients. The most common documented problem was drug omission (29%). 64% of the medication-related problems identified were classified as either moderate or major. The number of pain medications prescribed at discharge from intensive care was predictive of medication-related problems (OR 2.02, 95% CI 1.14 to 4.26, p=0.03).

Conclusions

Medication problems are common following critical care. Better communication of medication changes both to patients and their ongoing care providers may be beneficial following a critical care admission. In the absence of highly effective communication, a pharmacy intervention may contribute substantially to an intensive care rehabilitation or recovery programme.

Supporting the Geriatric Critical Care Patient: Decision Making, Understanding Outcomes, and the Role of Palliative Care

Geriatric admissions to the intensive care unit (ICU) are common and require unique considerations for ICU clinicians. Admission to the ICU should be considered on an individual-patient basis. It is reasonable to consider a "trial of critical care" for many patients, even those who have uncertain chances of meaningful recovery. Quality of life and functional independence are especially important to older adults, and these outcomes should be considered when weighing the risks and benefits of admission or continuing ICU care.