Brief description of media:

Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post–intensive care syndrome, functional limitations, and high costs. Early mobility–based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility–based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility–based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.

Brief description of media:

Background: Psychological morbidity in both patients and family members related to the intensive care unit (ICU) experience is an often overlooked, and potentially persistent, healthcare problem recognized by the Society of Critical Care Medicine as Post-intensive Care Syndrome (PICS). ICU diaries are an intervention increasingly under study with potential to mitigate ICU-related psychological morbidity, including ICU-related post-traumatic stress disorder (PTSD), depression and anxiety. As we encounter a growing number of ICU survivors, in particular in the wake of the coronavirus pandemic, clinicians must be equipped to understand the severity and prevalence of significant psychiatric complications of critical illness.

Methods: We compared the efficacy of the ICU diary, written by family and healthcare workers during the patient's intensive care course, versus education alone in reducing acute PTSD symptoms after discharge. Patients with an ICU stay >72 h, who were intubated and mechanically ventilated over 24 h, were recruited and randomized to either receive a diary at bedside with psycho education or psycho education alone. Intervention patients received their ICU diary within the first week of admission into the intensive care unit. Psychological symptom screening with IES-R, PHQ-8, HADS and GAD-7 was conducted at baseline within 1 week of ICU discharge and at weeks 4, 12, and 24 after ICU discharge. Change from baseline in these scores was assessed using Wilcoxon rank sum tests.

Results: From September 26, 2017 to September 25, 2018, our team screened 265 patients from the surgical and medical ICUs at a single large academic urban hospital. 60 patients were enrolled and randomized, of which 35 patients completed post-discharge follow-up, (n = 18) in the diary intervention group and (n = 17) in the education-only control group. The control group had a significantly greater decrease in PTSD, hyperarousal, and depression symptoms at week 4 compared to the intervention group. There were no significant differences in other measures, or at other follow-up intervals. Both study groups exhibited clinically significant PTSD symptoms at all timepoints after ICU discharge. Follow-up phone interviews with patients revealed that while many were interested in getting follow-up for their symptoms, there were many barriers to accessing appropriate therapy and clinical attention.

Conclusions: Results from psychological screening tools demonstrate no benefit of ICU diaries versus bedside education-alone in reducing PTSD symptoms related to the intensive care stay. However, our study finds an important gap in clinical practice – patients at high risk for PICS are infrequently connected to appropriate follow-up care. Perhaps ICU diaries would prove beneficial if utilized to support the work within a program providing wrap-around services and close psychiatric follow up for PICS patients. This study demonstrates the high prevalence of ICU-related PTSD in our cohort of survivors, the high barrier to accessing care for appropriate treatment of PICS, and the consequence of that barrier—prolonged psychological morbidity.

Brief description of media:

Research has shown an increased prevalence of psychological distress and acute cognitive impairment in patients who have experienced hospitalization within the intensive care setting (Myers, Smith, Allen, & Kaplan, 2016; Pandharipande et al., 2013). Periods of mechanical ventilation, sensory deprivation, presence of noxious stimuli, and using sedation medication increase a patient’s risk of developing delirium and may result in hallucinations, traumatic memories of medical events, or the absence or fragmentation of memories throughout their intensive care experience (Myers et al., 2016).

In 2010, stakeholders from the Society of Critical Care Medicine identified this phenomenon as Post Intensive Care Syndrome (PICS) characterized by new or worsening physical, cognitive, or mental health problems after critical illness (Needham et al., 2012). PICS manifests in numerous ways, including anxiety, depression, and post-traumatic stress disorder (PTSD), as well as impaired global cognition and executive function (Myers et al., 2016).

Current literature regarding intensive care survivors indicates that 30% of patients will experience depression and 70% will experience anxiety after discharge from the intensive care unit (ICU), with one third of patients developing PTSD symptoms in the first 2 years after critical illness (Bienvenu et al., 2013; Myers et al., 2016). Additionally, the duration of delirium can be an independent risk factor for below-baseline global cognition, as well as for impairment in executive functioning after discharge from the ICU (Pandharipande et al., 2013). In an effort to reduce the occurrence of PICS, health care professionals have used numerous non-pharmacological interventions, including early mobilization, environmental modifications, and the ICU diary (Álvarez et al., 2017; Garrouste-Orgeas et al., 2012; Schweickert et al., 2009).

Brief description of media:

Background: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. Conclusions: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Brief description of media:

Background: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge.
Conclusions: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Brief description of media:

Survivors of critical illness often experience new or worsening impairments of physical, cognitive, and/or mental health, referred to as Post-Intensive Care Syndrome (PICS). Such impairments can be long-lasting and negatively affect survivors’ quality of life. Early rehabilitation in the intensive care unit (ICU), while patients remain on life-support therapy, may reduce the complications associated with PICS. This article addresses evidence-based rehabilitation interventions to reduce the physical and mental health impairments associated with PICS. Implementation of effective early rehabilitation interventions targeting physical impairment requires consideration of five factors: barriers, benefits, feasibility, safety, and resources. Mental health impairments may be addressed by use of the following interventions: use of ICU diaries, early in-ICU psychological interventions, and post-ICU coping skills training. In both cases, a multidisciplinary team-based approach is paramount to successful incorporation of early rehabilitation into routine practice in the ICU.

Brief description of media:

Introduction: We examined the effectiveness of early rehabilitation for the prevention of post intensive care syndrome (PICS), characterized by an impaired physical, cognitive, or mental health status, among survivors of critical illness.

Methods: We performed a systematic literature search of several databases (Medline, Embase and Cochrane Central Register of Controlled Trials) and a manual search to identify randomized controlled trials (RCTs) comparing the effectiveness of early rehabilitation versus no early rehabilitation or standard care for the prevention of PICS. The primary outcomes were short-term physical-related, cognitive-related, and mental health-related outcomes assessed during hospitalization. The secondary outcomes were the standardized, long-term health-related quality of life scores (EuroQol 5 Dimension (EQ5D) and the Medical Outcomes Study 36-Item Short Form Health Survey Physical Function Scale (SF-36 PF)). We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the quality of evidence (QoE).

Results: Six RCTs selected from 5105 screened abstracts were included. Early rehabilitation significantly improved short-term physical-related outcomes, as indicated by an increased Medical Research Council scale score (standardized mean difference (SMD): 0.38, 95% CI 0.10 to 0.66, p=0.009) (QoE: low) and a decreased incidence of intensive care unit-acquired weakness (OR 0.42, 95% CI 0.22 to 0.82, p=0.01, QoE: low), compared with standard care or no early rehabilitation. However, the two groups did not differ in terms of cognitive-related delirium-free days (SMD: −0.02, 95% CI −0.23 to 0.20, QoE: low) and the mental health-related Hospital Anxiety and Depression Scale score (OR: 0.79, 95% CI 0.29 to 2.12, QoE: low). Early rehabilitation did not improve the long-term outcomes of PICS as characterized by EQ5D and SF-36 PF.

Conclusions: Early rehabilitation improved only short-term physical-related outcomes in patients with critical illness. Additional large RCTs are needed.

Brief description of media:

This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.

Brief description of media:

• BACKGROUND Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients’ satisfaction and quality of care.

• OBJECTIVE To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.

• METHODS During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit, nurses, biannually.

• RESULTS Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P< .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P< .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P=.006). Nurses in both groups reported similar levels of communication (P= .59) and collaboration (P= .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P<.001).

• CONCLUSIONS The multidisciplinary intervention resulted in better communication and collaboration among the participants. (American Journal of Critical Care. 2005;14:71-77)

Brief description of media:

Importance: A meta-analysis of outcomes during the 6 months after intensive care unit (ICU) discharge indicate a prevalence for clinically important posttraumatic stress disorder (PTSD) symptoms of 25%.

Objective: To determine whether a nurse-led preventive, complex psychological intervention, initiated in the ICU, reduces patient-reported PTSD symptom severity at 6 months.

Design, Setting, and Participants: A multicenter, parallel-group, cluster-randomized clinical trial with integrated economic and process evaluations conducted in 24 ICUs in the United Kingdom. Participants were critically ill patients who regained mental capacity following receipt of level 3 (intensive) care. A total of 2961 eligible patients were identified from September 2015 to January 2017. A total of 2048 were approached for participation in the ICU, of which 1458 provided informed consent. Follow-up was completed December 2017.

Interventions: Twenty-four ICUs were randomized 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period. The preventive, complex psychological intervention comprised promotion of a therapeutic ICU environment plus 3 stress support sessions and a relaxation and recovery program delivered by trained ICU nurses to high-risk (acutely stressed) patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods.

Main Outcomes and Measures: The primary clinical outcome was PTSD symptom severity among survivors at 6 months measured using the PTSD Symptom Scale–Self-Report questionnaire (score range, 0-51, with higher scores indicating greater symptom severity; the minimal clinically important difference was considered to be 4.2 points).

Results: Among 1458 enrolled patients (mean [SD] age, 58 [16] years; 599 women [41%]), 1353 (93%) completed the study and were included in the final analysis. At 6 months, the mean PTSD Symptom Scale–Self Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period) (difference, −0.40 [95% CI, −2.46 to 1.67]) and in control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) (difference, 0.06 [95% CI, −1.74 to 1.85]) between periods. There was no significant difference in PTSD symptom severity at 6 months (treatment effect estimate [difference in differences] of −0.03 [95% CI, −2.58 to 2.52]; P = .98).

Conclusions and Relevance: Among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported PTSD symptom severity at 6 months. These findings do not support the use of this psychological intervention.

Brief description of media:

Each year, millions of patients throughout the world survive a hospitalization that included a stay in an intensive care unit (ICU). ICU survivors can experience a variety of physical, cognitive, and emotional sequelae. In particular, mental health disorders associated with an ICU stay include anxiety, depression symptoms, post-traumatic stress disorder (PTSD) symptoms, and complicated grief for families.

It is possible that impaired recall of the ICU stay, potentially accompanied by hallucinations or delusions, contributes to the post-traumatic stress. Thus, use of an ICU diary given to the patient at discharge to consult at will could offer benefit. By providing objective information to patients, which could help fill in memory gaps, ICU diaries have allowed them to abandon unrealistic experiences, reconstruct their experience, gain a sense of reality, and resolve differences in experience with their families. However, studies exploring the usefulness of ICU diaries in preventing psychological post–intensive care syndrome were often conducted with small numbers of patients or select samples or with various design characteristics, outcome measures, and length of follow-up that compromised comparison. This multicenter study was designed to assess the effect of an ICU diary on the occurrence of mental health consequences in patients and their families in the ICU setting.

Brief description of media:

Background
Critical illness leading to prolonged length of stay (LOS) in an intensive care unit (ICU) is associated with significant mortality and resource utilization. This study assessed the independent effect of ICU LOS on in-hospital and long-term mortality after hospital discharge.
Methods
Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox's regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and long-term mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson's co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the χ2 statistic contribution to the total χ2 statistic.
Results
Most hospital deaths occurred within the first few days of ICU admission. Increasing LOS in ICU was not associated with an increased risk of in-hospital mortality after adjusting for other covariates, but was associated with an increased risk of long-term mortality after hospital discharge. The variability on the long-term mortality effect associated with ICU LOS (2.3%) appeared to reach a plateau after the first 10 days in ICU and was not as important as age (35.8%), co-morbidities (18.6%), diagnosis (10.9%), and APS (3.6%).
Conclusions
LOS in ICU was not an independent risk factor for in-hospital mortality, but it had a small effect on long-term mortality after hospital discharge after adjustment for other risk factors.