Objective: The aim of the study was to assess the effectiveness of intensive care unit (ICU)–initiated transitional care interventions for patients and families on elements of post-intensive care syndrome (PICS) and/or PICS-family (PICS–F). Review method used: This is a systematic review and meta-analysis Sources: The authors searched in biomedical bibliographic databases including PubMed, Embase (OVID), CINAHL Plus (EBSCO), Web of Science, and the Cochrane Library and included studies written in English conducted up to October 8, 2020. Review methods: We included (non)randomised controlled trials focussing on ICU-initiated transitional care interventions for patients and families. Two authors conducted selection, quality assessment, and data extraction and synthesis independently. Outcomes were described using the three elements of PICS, which were categorised into (i) physical impairments (pulmonary, neuromuscular, and physical function), (ii) cognitive impairments (executive function, memory, attention, visuo-spatial and mental processing speed), and (iii) psychological health (anxiety, depression, acute stress disorder, post-traumatic stress disorder, and depression). Results: From the initially identified 5052 articles, five studies were included (i.e., two randomised controlled trials and three nonrandomised controlled trials) with varied transitional care interventions. Quality among the studies differs from moderate to high risk of bias. Evidence from the studies shows no significant differences in favour of transitional care interventions on physical or psychological aspects of PICS-(F). One study with a nurse-led structured follow-up program showed a significant difference in physical function at 3 months. Conclusions: Our review revealed that there is a paucity of research about the effectiveness of transitional care interventions for ICU patients with PICS. All, except one of the identified studies, failed to show a significant effect on the elements of PICS. However, these results should be interpreted with caution owing to variety and scarcity of data. Prospero registration: CRD42020136589 (available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020136589).
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Physiotherapy, Dietetics and Occupational Therapy have been collaborating over recent years to develop an optimal healthcare programme for patients with Post Intensive Care Syndrome (PICS). This case is an example of PICS symptomatology and focuses on the collaboration between Physiotherapy and Dietetics. What is PICS? Owing to healthcare improvements, more and more patients are surviving the intensive Care Unit (ICU), and recovery during and after ICU stay has been receiving more attention [1, 2]. Approximately 30% of the patients admitted to an ICU have persistent symptoms including muscle weakness, reduced walking ability, fatigue, concentration deficits, memory problems, malnutrition, sleep and mood disorders sometimes even years after discharge [3-8]. Since 2012, this combination of physical, cognitive and psychiatric manifestations and reduced quality of life after staying in an ICU has been recognised as Post Intensive Care Syndrome (PICS) [9]. The impact of PICS is often not limited to the patient as it may also impact the mental status of the patient’s immediate family. This is known as PICS-Family (PICS-F) [10-12]. Treatment of PICS: Approximately 80% of PICS patients need primary care physiotherapy. Physiotherapists and GPs are often the only primary care professionals involved in the recovery process of these patients after hospital discharge [13, 14]. Both patients and healthcare professionals report a number of difficulties, e.g. limited transmural continuity in healthcare, coordination of multidisciplinary activities, supportive treatment guidelines and specific knowledge of pathology, treatment and prognosis. Patients report that they are not adequately supported when resuming their professional activities and that medical and allied healthcare treatments do not fully meet their needs at that time [15-18]. The REACH project: In order to improve the situation, the REACH project (REhabilitation After Critical illness and Hospital discharge) was started in Amsterdam region in the Netherlands. Within REACH, a Community of Practice – consisting of professionals (physiotherapists, occupational therapists, dieticians), those who live or have lived with the condition and researchers – has developed a transmural rehab programme. A special attribute of this programme is the integration of the concept of “positive health”. The case in this article describes the treatment of a PICS patient treated within the REACH network.
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BackgroundSurvivors of critical illness experience long-term functional challenges, which are complex, heterogeneous, and multifactorial in nature. Although the importance of rehabilitation interventions after intensive care unit (ICU) discharge is universally recognized, evidence on feasibility and effectiveness of home-based rehabilitation programs is scarce and ambiguous. This study investigates the feasibility of an interdisciplinary rehabilitation program designed for patients with Post-Intensive Care Syndrome (PICS) who are discharged home.MethodsA mixed method, non-randomized, prospective pilot feasibility study was performed with a 6-month follow-up, comparing the intervention (REACH) with usual care. REACH was provided by trained professionals and included a patient-centered, interdisciplinary approach starting directly after hospital discharge. Primary outcomes were patient safety, satisfaction, adherence, referral need and health care usage. Secondary outcomes, measured at 3 timepoints, were functional exercise capacity, self-perceived health status, health-related quality of life (HRQoL), return to work and psychotrauma. Risk of undernutrition was assessed at baseline.Results43 patients with a median mechanical ventilation duration of 8 (IQR:10) days, were included in the study and 79.1% completed 6-month follow-up. 19 patients received the intervention, 23 received usual care. Groups were similar for gender distribution and ICU length of stay. No adverse events occurred. REACH participants showed higher satisfaction with treatment and reported more allied health professional visits, while the usual care group reported more visits to medical specialists. Qualitative analysis identified positive experiences among REACH-professionals related to providing state-of-the-art interventions and sharing knowledge and expertise within an interprofessional network. Similar recovery was seen between groups on all secondary outcomes, but neither group reached reference values for HRQoL at 6 months. Larger return to work rates were seen in the REACH group. Prevalence of undernutrition at hospital discharge was high in both groups (> 80%), warranting the need for careful tuning of physical therapy and nutritional interventions.ConclusionsThis study shows that providing early, home-based rehabilitation interventions for patients with PICS-related symptoms is feasible and perceived positively by patients and professionals. When provided in an interdisciplinary collaborative network state of the art, person-centered interventions can be tailored to individual needs potentially increasing patient satisfaction, adherence, and efficacy.Registered in the Dutch Trial register: NL7792: https://www.trialregister.nl/trial/7792, registered 7-06-2019.
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Delirium has been a recognised syndrome in the intensive care unit for some years. This systematic review reports risk factors for delirium studied in the intensive care unit. Four predisposing and 21 precipitating factors, including nine laboratory blood values and seven items relating to the use or the administration of medication, were found to influence the onset of delirium in the intensive care unit in six publications. The APACHE II score and hypertension were the only factors reported twice. Risk factors for the development of intensive care delirium were understudied and underreported in the literature.
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Background: To prevent deterioration after admission to the intensive care unit (ICU), and to improve rehabilitation, the ICU team should use digital technologies to provide comprehensive and practical information alongside personalised support for survivors and their family members. However, a knowledge gap exists on the users’ preferences for such an e-health platform in ICU follow-up services. Objectives: This study aims to explore the opinions and priorities for an e-health platform, including choices in digital elements, according to survivors of critical illness and their family members. Methods: A cross-sectional survey was used among members and other interested individuals of the Dutch volunteer organisation ‘Foundation Family- and Patient-Centred Intensive Care’. An investigator-developed questionnaire was disseminated through the newsletter and social media channels of the Foundation Family- and Patient-Centred Intensive Care. The results of this member consultation were analysed and reported as descriptive statistics on demographic variables and outcome measures in opinions and priorities of the participants. Results: Most of the 227 participants were female (76%), aged 46–55 years (33%), and completed higher education (70%). The participants reported high confidence in advice delivered through an e-health platform (72%). They prioritised the provision of a guide including relevant professionals who may support them during their recovery when using an e-health platform. Conclusions: ICU survivors prioritised the provision of relevant professionals who may support them during their recovery when using an e-health platform; however, selection bias means the population studied is likely to be more digitally connected than the general ICU population. Digital solutions could cater to their information and support needs. For family members, the highest priority reported was receiving help in managing their emotional distress. The development of an e-health platform considering the opinions and priorities of this target group could contribute to a personalised recovery trajectory promoting self-management while including digital elements addressing relevant ICU follow-up services.
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Objective:The objective of this scoping review is threefold: (1) to describe outcomes of and determinants for physical functioning in pediatric intensive care unit (PICU) survivors evaluated during and/or after their PICU stay, (2) to provide an overview how physical functioning and its associated determinants in this population are reported, measured and classified in accordance with the International classification of Functioning, Disability and Health-Children and Youth framework (ICF-CY) components and (3) to synthesize key gaps in knowledge and research and clinical recommendations related to our review questions.Introduction:Optimal physical functioning in children is of major importance in their developmental trajectories and for the prevention and recovery of health problems across lifespan. PICU children are at high risk of poor physical functioning during and after critical illness. A recent overview of the literature, concerning evaluation of physical functioning in PICU survivors according to the ICF-CY components, is lacking. Inclusion criteria:This review includes empirical studies reporting outcomes and determinants of physical functioning in PICU survivors evaluated during and/or after PICU stay. All English language studies reporting empirical data will be included with no restrictions set on the types of study designs used.Methods:This review will be conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) statement. To locate studies eligible for inclusion, the electronic databases Pubmed, EMBASE, CINAHL and Cochrane Library will be searched from the earliest records to October 2019. Study selection will be performed by two independent reviewers. Covidence software will be used to screen titles and abstracts as well as the full-text of included studies. Data extraction will be conducted using a customized form. The extracted data will be presented in diagrammatic or tabular form with an accompanying narrative summary.
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ObjectiveMany patients with coronavirus disease 2019 (COVID-19) infections were admitted to an intensive care unit (ICU). Physical impairments are common after ICU stays and are associated with clinical and patient characteristics. To date, it is unknown if physical functioning and health status are comparable between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The primary objective of this study was to compare handgrip strength, physical functioning, and health status between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The second objective was to identify factors associated with physical functioning and health status in patients in the ICU with COVID-19. Methods In this observational, retrospective chart review study, handgrip strength (handheld dynamometer), physical functioning (Patient-Reported Outcomes Measurement Information System Physical Function), and health status (EuroQol 5 Dimension 5 Level) were compared between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 using linear regression. Multilinear regression analyses were used to investigate whether age, sex, body mass index, comorbidities in medical history (Charlson Comorbidity Index), and premorbid function illness (Identification of Seniors At Risk-Hospitalized Patients) were associated with these parameters in patients in the ICU with COVID-19. Results In total, 183 patients (N = 92 with COVID-19) were included. No significant between-group differences were found in handgrip strength, physical functioning, and health status 3 months after ICU discharge. The multilinear regression analyses showed a significant association between sex and physical functioning in the COVID-19 group, with better physical functioning in men compared with women. Conclusion Current findings suggest that handgrip strength, physical functioning, and health status are comparable for patients who were in the ICU with COVID-19 and patients who were in the ICU without COVID-19 3 months after ICU discharge. Impact Aftercare in primary or secondary care in the physical domain of postintensive care syndrome after ICU discharge in patients with COVID-19 and in patients without COVID-19 who had an ICU length of stay >48 hours is recommended. Lay Summary Patients who were in the ICU with and without COVID-19 had a lower physical status and health status than healthy people, thus requiring personalized physical rehabilitation. Outpatient aftercare is recommended for patients with an ICU length of stay >48 hours, and functional assessment is recommended 3 months after hospital discharge.
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BACKGROUND: Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome have been widely investigated. However, data are lacking on prevalence and outcome in high-risk patients. Our objectives in this study were to investigate prevalence and outcome of intra-abdominal hypertension and abdominal compartment syndrome in high-risk patients in a prospective, observational, single-center cohort study.RESULTS: Between March 2014 and March 2016, we included 503 patients, 307 males (61%) and 196 females (39%). Patients admitted to the intensive care unit with a diagnosis of pancreatitis, elective or emergency open abdominal aorta surgery, orthotopic liver transplantation, other elective or emergency major abdominal surgery and trauma were enrolled. One hundred and sixty four (33%) patients developed intra-abdominal hypertension and 18 (3.6%) patients developed abdominal compartment syndrome. Highest prevalence of abdominal compartment syndrome occurred in pancreatitis (57%) followed by orthotopic liver transplantation (7%) and abdominal aorta surgery (5%). Length of intensive care stay increased by a factor 4 in patients with intra-abdominal hypertension and a factor 9 in abdominal compartment syndrome, compared to patients with normal intra-abdominal pressure. Rate of renal replacement therapy was higher in abdominal compartment syndrome (38.9%) and intra-abdominal hypertension (8.2%) compared to patients with normal intra-abdominal pressure (1.2%). Both intensive care mortality and 90-day mortality were significantly higher in intra-abdominal hypertension (4.8% and 15.2%) and abdominal compartment syndrome (16.7% and 38.9%) compared to normal intra-abdominal pressure (1.2% and 7.1%). Body mass index (odds ratio 1.08, 95% confidence interval 1.03-1.13), mechanical ventilation at admission (OR 3.52, 95% CI 2.08-5.96) and Apache IV score (OR 1.03, 95% CI 1.02-1.04) were independent risk factors for the development of intra-abdominal hypertension or abdominal compartment syndrome.CONCLUSIONS: The prevalence of abdominal compartment syndrome was 3.6% and the prevalence of intra-abdominal hypertension was 33% in this cohort of high-risk patients. Morbidity and mortality increased when intra-abdominal hypertension or abdominal compartment syndrome was present. The patient most at risk of IAH or ACS in this high-risk cohort has a BMI > 30 kg/m2 and was admitted to the ICU after emergency abdominal surgery or with a diagnosis of pancreatitis.
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OBJECTIVE: To describe the long-term functioning of patients who survived a COVID-19-related admission to the intensive care unit and their family members, in the physical, social, mental and spiritual domain.DESIGN: A single-centre, prospective cohort study with a mixed-methods design.SETTING: The intensive care unit of the University Medical Center Groningen in the Netherlands.MAIN OUTCOME MEASURES: To study functioning 12 months after intensive care discharge several measurements were used, including a standardised list of physical problems, the Clinical Frailty Scale, the Medical Outcomes Study Short-Form General Health Survey, the McMaster Family Assessment Device, the Hospital Anxiety and Depression Scale, and the Spiritual Needs Questionnaire, as well as open questions and interviews with survivors and their family members.RESULTS: A total of 56 survivors (77%) returned the 12-month questionnaire, whose median age was 62 (inter-quartile range [IQR]: 55.0-68.0). Moreover, 67 family members (66%) returned the 12-month questionnaire, whose median age was 58 (IQR: 43-66). At least one physical problem was reported by 93% of the survivors, with 22% reporting changes in their work-status. Both survivors (84%) and their family members (85%) reported at least one spiritual need. The need to feel connected with family was the strongest. The main theme was 'returning to normal' in the interviews with survivors and 'if the patient is well, I am well' in the interviews with family members.CONCLUSIONS: One year after discharge, both COVID-19 intensive care survivors and their family members positively evaluate their health-status. Survivors experience physical impairments, and their family members' well-being is strongly impacted by the health of the survivor.
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Purpose: The aim of this study was to develop practical recommendations for physiotherapy for survivors of critical illness after hospital discharge. Methods: A modified Delphi consensus study was performed. A scoping literature review formed the basis for three Delphi rounds. The first round was used to gather input from the panel to finalize the survey for the next two rounds in which the panel was asked to rank each of the statements on an ordinal scale with the objective to reach consensus. Consensus was defined as a SIQR of ≤ 0.5. Ten Dutch panelists participated in this study: three primary care physiotherapists, four intensive care physiotherapists, one occupational therapist, one ICU-nurse and one former ICU-patient. All involved professionals have treated survivors of critical illness. Our study was performed in parallel with an international Delphi study with hospital-based health-care professionals and researchers. Results: After three Delphi rounds, consensus was reached on 95.5% of the statements. This resulted in practical recommendations for physiotherapy for critical illness survivors in the primary care setting. The panel agreed that the handover should include information on 14 items. Physiotherapy treatment goals should be directed toward improvement of aerobic capacity, physical functioning, activities in daily living, muscle strength, respiratory and pulmonary function, fatigue, pain, and health-related quality of life. Physiotherapy measurements and interventions to improve these outcomes are suggested. Conclusion: This study adds to the knowledge on post-ICU physiotherapy with practical recommendations supporting clinical decision-making in the treatment of survivors of critical illness after hospital discharge.
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