Dutch ICU survivors have more consultations with general practitioners before and after ICU admission compared to a matched control group from the general population

Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention

Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It significantly impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources. Therefore, early intervention and assessment of PICS is crucial. This paper aims to provide clinical professionals with a reference base by focusing on the clinical symptoms, diagnostic assessment, and preventative measures of PICS.

Prevalence of and predictive factors associated with high levels of post-traumatic stress symptoms 3 months after intensive care unit admission: A prospective study

BACKGROUND

Post-traumatic stress symptoms (PTSS) following intensive care unit (ICU) treatment may increase morbidity and mortality. Therefore, it is important to identify patients at risk of suffering from such symptoms.

OBJECTIVES

The objective of this study was to describe the prevalence and identify possible predictive factors associated with high levels of PTSS 3 months after ICU admission.

METHODS

A multicentre, observational study was carried out in six ICUs in Norway. Patients aged ≥18 years were included. The Impact of Event Scale-Revised measured PTSS 3 months after ICU admission. The impacts of pre-ICU measures; demographic and clinical measures; and daily measures of pain, agitation, and delirium were analysed using univariate and multivariate logistic regression models.

RESULTS

In total, of the 273 patients included, the prevalence rate of high levels of PTSS was 19.8% (n = 54) 3 months after ICU admission (95% confidence interval [CI]: [15.2, 25.0]). Female gender, age, pre-ICU unemployment, a minimum of one episode of agitation or delirium, and pre-ICU level of functioning in daily living were all significantly associated with high levels of PTSS in univariate logistic analyses. In the multivariate logistic regression, two models were analysed. In model 1, episodes of agitation during ICU stay (odds ratio [OR] = 4.73; 95% CI: [1.17, 19.0]), pre-ICU unemployment (OR = 3.33; 95% CI: [1.26, 8.81]), and pre-ICU level of functioning in daily living (OR = 0.78; 95% CI: [0.63, 0.96]) (implying lower level) increased the odds of reporting high levels of PTSS. In model 2, pre-ICU unemployment (OR = 2.70; 95% CI: [1.05, 6.93]) and pre-ICU level of functioning in daily living (OR = 0.77; 95% CI: [0.62, 0.95]) (implying lower level) increased the odds of reporting high levels of PTSS.

CONCLUSIONS

Healthcare personnel are suggested to be aware of ICU patients' pre-ICU employment status, pre-ICU functioning in daily living, and agitation during ICU stay to identify those at risk of PTSS after discharge.

Low prevalence of communication between intensive care unit medical staff and general practitioners: A single-centre retrospective study

BACKGROUND

General practitioners (GPs) have a central role in delivering care to the Australian community, which includes coordinating management of chronic diseases and treatment of patients after admission to intensive care units (ICUs). Consultations between ICUs and GPs may become increasingly relevant as patients of advancing age and chronic disease burden are admitted to ICUs. However, how frequently and for what reason such consultations occur remain unclear.

OBJECTIVES

The objective of this study was to determine the prevalence and themes of consultations between ICU medical staff and GPs.

METHODS

Ten years of electronic medical records in the ICU of a regional Australian hospital were searched for patient admissions documenting the terms "gp", "general p∗", or "primary care∗" anywhere throughout the record. The proportion of ICU admissions in which a consultation between ICU staff members and GPs was documented was recorded along with the reason/s for the consultation and designation (resident, registrar, consultant) of those who communicated with the GP.

MAIN OUTCOME MEASURES

Main outcome measures included the proportion of ICU admissions with a documented consultation between ICU staff and GPs, theme of the consultation, and designation (resident, registrar, consultant) of those who communicated with the GP.

RESULTS

Of 13 402 admissions to the ICU, 137 (1.02%) had a documented consultation between ICU medical staff and GPs. Most consultations (n = 116, 85%) were initiated by junior ICU medical staff members seeking clinical information from the GPs. Few consultations were to discuss goals of care (n = 10, 7.3%) or care following ICU discharge (n = 15, 11%).

CONCLUSIONS

Consultations between ICU medical staff and GPs were infrequent. Further research is required on how best to integrate the health care provided by ICUs and GPs.

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.

The impact of an intensive care unit admission on the health status of relatives of intensive care survivors: A prospective cohort study in primary care

Background

Relatives of intensive care unit (ICU) survivors may suffer from various symptoms after ICU admittance of their relative, known as post-intensive care syndrome-family (PICS-F). Studies regarding PICS-F have been performed but its impact in primary care is unknown.

Objectives

To explore health problems of relatives of ICU survivors in primary care.

Methods

This is an exploratory prospective cohort study in which we combined data from two hospitals and a primary care research network in the Netherlands. ICU survivors who had been admitted between January 2005 and July 2017 were identified and matched by sex and age with up to four chronically ill (e.g. COPD, cardiovascular disease) patients. In both groups, relatives living in the same household were identified and included in this study. Primary outcome was the number of new episodes of care (International Classification of Primary Care-2) for up to five years. Hazard ratios (HRs) for the total number of new episodes were calculated.

Results

Relatives of ICU survivors (n = 267, mean age 38.1 years, 41.0% male) had significantly more new care episodes compared to the reference group (n = 705, mean age 36.3 years, 41.1% male) 1–2 years (median 0.11 vs. 0.08, HR 1.26; 95% confidence interval (CI) 1.03–1.54) and 2–5 years (median 0.18 vs. 0.13, HR 1.28; 95%CI 1.06–1.56) after ICU discharge. No differences were found in the period before ICU admission.

Conclusion

Relatives of ICU survivors present more morbidity in primary care than relatives of chronically ill patients up to five years after ICU discharge.

MiCare study, an evaluation of structured, multidisciplinary and personalised post-ICU care on physical and psychological functioning, and quality of life of former ICU patients: a study protocol of a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Over 70% of the intensive care unit (ICU) survivors suffer from long-lasting physical, mental and cognitive problems after hospital discharge. Post-ICU care is recommended by international guidelines, but evidence for cost-effectiveness lacks. The aim of this study is to evaluate the clinical effectiveness and cost-effectiveness of structured, multidisciplinary and personalised post-ICU care versus usual care on physical and psychological functioning and health-related quality of life (HRQoL) of ICU survivors, 1- and 2-year post-ICU discharge.

METHODS AND ANALYSIS

The MONITOR-IC post-ICU care study (MiCare study) is a multicentre stepped-wedge randomised controlled trial conducted in five hospitals. Adult patients at high risk for critical illness-associated morbidity post-ICU will be selected and receive post-ICU care, including an invitation to the post-ICU clinic 3 months after ICU discharge. A personalised long-term recovery plan tailored to patients' reported outcome measures will be made. 770 (intervention) and 1480 (control) patients will be included. Outcomes are 1- and 2-year HRQoL (EuroQol Instrument (EQ-5D-5L)), physical (fatigue and new physical problems), mental (anxiety, depression and post-traumatic stress disorder), and cognitive symptoms and cost-effectiveness. Medical data will be retrieved from patient records and cost data from health insurance companies.

ETHICS AND DISSEMINATION

Due to the lack of evidence, Dutch healthcare insurers do not reimburse post-ICU care. Therefore, evaluation of cost-effectiveness and integration in guidelines supports the evidence. Participation of several societies for physicians, nurses, paramedics, and patients and relatives in the project team increases the support for implementation of the intervention in clinical practice. Patients and relatives will be informed by the patient associations, hospitals and professional associations. Informing healthcare insurers about this project's results is important for the consideration for inclusion of post-ICU care in Dutch standard health insurance. The study is approved by the Radboud University Medical Centre research ethics committee (2021-13125).

TRIAL REGISTRATION NUMBER

NCT05066984.

The Potential Cost-Effectiveness of a Machine Learning Tool That Can Prevent Untimely Intensive Care Unit Discharge

OBJECTIVES

The machine learning prediction model Pacmed Critical (PC), currently under development, may guide intensivists in their decision-making process on the most appropriate time to discharge a patient from the intensive care unit (ICU). Given the financial pressure on healthcare budgets, this study assessed whether PC has the potential to be cost-effective compared with standard care, without the use of PC, for Dutch patients in the ICU from a societal perspective.

METHODS

A 1-year, 7-state Markov model reflecting the ICU care pathway and incorporating the PC decision tool was developed. A hypothetical cohort of 1000 adult Dutch patients admitted in the ICU was entered in the model. We used the literature, expert opinion, and data from Amsterdam University Medical Center for model parameters. The uncertainty surrounding the incremental cost-effectiveness ratio was assessed using deterministic and probabilistic sensitivity analyses and scenario analyses.

RESULTS

PC was a cost-effective strategy with an incremental cost-effectiveness ratio of €18 507 per quality-adjusted life-year. PC remained cost-effective over standard care in multiple scenarios and sensitivity analyses. The likelihood that PC will be cost-effective was 71% at a willingness-to-pay threshold of €30 000 per quality-adjusted life-year. The key driver of the results was the parameter "reduction in ICU length of stay."

CONCLUSIONS

We showed that PC has the potential to be cost-effective for Dutch ICUs in a time horizon of 1 year. This study is one of the first cost-effectiveness analyses of a machine learning device. Further research is needed to validate the effectiveness of PC, thereby focusing on the key parameter "reduction in ICU length of stay" and potential spill-over effects.

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.

Can a Dyadic Resiliency Program Improve Quality of Life in Cognitively Intact Dyads of Neuro-ICU Survivors and Informal Caregivers? Results from a Pilot RCT

BACKGROUND

Neuro-ICU hospitalization for an acute neurological illness is often traumatic and associated with heightened emotional distress and reduced quality of life (QoL) for both survivors and their informal caregivers (i.e., family and friends providing unpaid care). In a pilot study, we previously showed that a dyadic (survivor and caregiver together) resiliency intervention (Recovering Together [RT]) was feasible and associated with sustained improvement in emotional distress when compared with an attention placebo educational control. Here we report on changes in secondary outcomes assessing QoL.

METHODS

Survivors (n = 58) and informal caregivers (n = 58) completed assessments at bedside and were randomly assigned to participate together as a dyad in the RT or control intervention (both 6 weeks, two in-person sessions at bedside and four sessions via live video post discharge). We measured QoL domain scores (physical health, psychological, social relations, and environmental), general QoL, and QoL satisfaction using the World Health Organization Quality of Life Abbreviated Instrument at baseline, post treatment, and 3 months' follow-up. We conducted mixed model analyses of variance with linear contrasts to estimate (1) within-group changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up and (2) between-group differences in changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up.

RESULTS

We found significant within-group improvements from baseline to post treatment among RT survivors for physical health QoL (mean difference 1.73; 95% confidence interval [CI] 0.39-3.06; p = 0.012), environmental QoL (mean difference 1.29; 95% CI 0.21-2.36; p = 0.020), general QoL (mean difference 0.55; 95% CI 0.13-0.973; p = 0.011), and QoL satisfaction (mean difference 0.87; 95% CI 0.36-1.37; p = 0.001), and those improvements sustained through the 3-month follow-up. We found no significant between-group improvements for survivors or caregivers from baseline to post treatment or from post treatment to 3 months' follow-up for any QoL variables (i.e., domains, general QoL, and QoL satisfaction together).

CONCLUSIONS

In this pilot study, we found improved QoL among survivors, but not in caregivers, who received RT and improvements sustained over time. These RT-related improvements were not significantly greater than those observed in the control. Results support a fully powered randomized controlled trial to allow for a definitive evaluation of RT-related effects among dyads of survivors of acute brain injury and their caregivers.

Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies

INTRODUCTION

Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery.

AREAS COVERED

First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families.

EXPERT OPINION

PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

OBJECTIVE

To identify views, experiences and needs for shared decision-making (SDM) in the intensive care unit (ICU) according to ICU physicians, ICU nurses and former ICU patients and their close family members.

DESIGN

Qualitative study.

SETTING

Two Dutch tertiary centres.

PARTICIPANTS

19 interviews were held with 29 participants: seven with ICU physicians from two tertiary centres, five with ICU nurses from one tertiary centre and nine with former ICU patients, of whom seven brought one or two of their close family members who had been involved in the ICU stay.

RESULTS

Three themes, encompassing a total of 16 categories, were identified pertaining to struggles of ICU physicians, needs of former ICU patients and their family members and the preferred role of ICU nurses. The main struggles ICU physicians encountered with SDM include uncertainty about long-term health outcomes, time constraints, feeling pressure because of having final responsibility and a fear of losing control. Former patients and family members mainly expressed aspects they missed, such as not feeling included in ICU treatment decisions and a lack of information about long-term outcomes and recovery. ICU nurses reported mainly opportunities to strengthen their role in incorporating non-medical information in the ICU decision-making process and as liaison between physicians and patients and family.

CONCLUSIONS

Interviewed stakeholders reported struggles, needs and an elucidation of their current and preferred role in the SDM process in the ICU. This study signals an essential need for more long-term outcome information, a more informal inclusion of patients and their family members in decision-making processes and a more substantial role for ICU nurses to integrate patients' values and needs in the decision-making process.

A Call for the World Health Organization to Create International Classification of Disease Diagnostic Codes for Post-Intensive Care Syndrome in the Age of COVID-19

Post‐intensive care syndrome (PICS), a condition found in survivors of critical illness, is characterized by persistent physical, cognitive, and psychological sequelae that impact the quality of life after discharge from an intensive care unit (ICU). At present, there are no International Classification of Disease (ICD) billing codes for this condition. Without financial alignment, clinicians cannot diagnose PICS, hindering tracking of its prevalence and impeding policy development for this condition. Clinicians should be screening for PICS in all survivors of critical illness, particularly those with acute respiratory distress syndrome (ARDS). Results from single‐center studies suggest over 75 percent of ARDS survivors develop PICS. With nearly 5 percent of patients with COVID‐19 requiring ICU admission for ARDS, it is important for clinicians to be able to diagnose PICS in survivors, and researchers to be able to track it. Member states should impress upon the World Health Organization to create ICD‐10 codes for PICS.

General practitioners' views and experiences in caring for patients after sepsis: a qualitative interview study

BACKGROUND

Patients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.

OBJECTIVES

The aim of this study is to describe GPs' views and experiences of caring for postsepsis patients and of participating a specific outreach training.

DESIGN

Semistructured qualitative interviews.

SETTING

14 primary care practices in the metropolitan area of Berlin, Germany.

PARTICIPANTS

14 GPs who had participated in a structured sepsis aftercare programme in primary care.

RESULTS

Themes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP's experiences during their patient's critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.

CONCLUSIONS

GPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit-GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.

TRIAL REGISTRATION NUMBER

ISRCTN61744782.