Can patient-reported outcome measures change delivery of intensive care?
Cristina Granja
Emergency and Intensive Medicine DepartmentHospital Pedro Hispano
Biostatistics and Medical Informatics DepartmentFaculty of Medicine of Porto
Portugal
, epe Unidade Local de Saúde de Matosinhos
• Follow up clinic: from real patients to outcome studies
• What we have learned: Consequences of critical illness and critical
care
• From outcome studies to clinical interventions
• Can patient-reported outcome measures change delivery of
intensive care?
Can patient-reported outcome measures change delivery of intensive care?
Begin in 1997
ICU Follow-up Clinic
Hospital Pedro Hispano
Follow up clinic: from real patients to outcome studies
Follow up clinic: from real patients to outcome studies
Ridley & Young, Intensive Care After Care,Butterworth Heinemann,2002
Outcomes after critical care
Follow up clinic: from real patients to outcome studies
What have we learned: Consequences of critical illness and critical care
• Ongoing increased mortality
• Physical Disability
• Neuropsychological Disability
• Health-Related Quality of Life
What have we learned: Consequences of critical illness and critical care
Consequences of critical illness and critical care
• Ongoing increased mortality
• Physical Disability:
– Pulmonary
• Lung function impairments
– Extra-Pulmonary
• Weight loss/ICU- acquired weakness
• Critical illness polyneuropathy
Consequences of critical illness and critical care
• Lung function impairments
Consequences of critical illness and critical care
Granja et al, Intensive Care Med 2003Herridge M et al , NEJM 2003
• Weight loss/ICU-acquired weakness
Consequences of critical illness and critical care
Herridge M et al , NEJM 2003
• Weight loss/ICU-acquired weakness
Consequences of critical illness and critical care
Griffiths & Jones, Intensive Care After Care, 2002
• Critical illness polyneuropathy
Consequences of critical illness and critical care
• Neuropsychological Disability:
– Cognitive impairment
– Delirium
– Anxiety, Depression
– PTSD/PTSS
Consequences of critical illness and critical care
• Cognitive impairment
Consequences of critical illness and critical care
• Delirium
BDI-II - Beck Depression Inventory II
41% moderate/severe depression (BDI-II >20)
• Anxiety, Depression
Consequences of critical illness and critical care
• PTSD/PTSS
Consequences of critical illness and critical care
Schelling et al, Crit Care Med 1998
• Health-Related Quality of Life
Consequences of critical illness and critical care
Report of moderate and extreme problems (%)
37%
22%
46% 45%54%
0%
20%
40%
60%
80%
100%
• 21 independent studies with 7320 patients were reviewed
• SF-36, EuroQol-5D, Sickness Impact Profile or Nottingham Health Profile in
representative populations of adult ICU survivors
• Compared with the general population ICU survivors report lower HRQOL prior to
ICU admission
• After hospital discharge, HRQOL in ICU survivors improves but remains lower than
general population levels.
• Age and severity of illness were predictors of physical functioning: Physical
functioning showed rapid improvement and was associated with age and severity of
illness, whereas mental health shows no improvement and was independent of
baseline characteristics.
• Health-Related Quality of Life – studies with EQ-5D
Consequences of critical illness and critical care
• In all ICU survivors Granja et al, Intensive Care Med 2002
• In cardiac arrest ICU survivors Granja et al, Resuscitation 2002
• In ARDS ICU survivors Granja et al, Intensive Care Med 2003
• In severe sepsis ICU survivors Granja et al, Crit Care 2004
No significant differences in HRQOL,
when compared with other ICU survivors
with similar age, gender, previous health
state and severity of disease at admission.
HRQOL of ICU survivors seems depend less on specific diagnosis, and more on the typical residual of any severe, critical illness.
Health-Related Quality of Life – studies with EQ-5D
ALI/ARDS and its treatment
Premorbid StatusAge
GenderPre-existing medical disease
Prior psychopathology. Family history of psychiatric diseaseCognitive impairment , dementia, previous TBI or anoxic brain injury
Genetic predispositionSocial support network
Poor HRQOL
PainAltered sensorium
Duration of MVICU LOSHospital LOS
SteroidsNeuroendocrine Stress
Frightening MemoriesDelirium
Sedation Medications
HypoxiaHypotension
Bed restImmobility
Caregiver burden CognitiveDysfunction
Financial Loss
Reduction inEmployment
Physical Impairment
Psychiatric orMood disorders
Wilcox et al, Semin Resp Crit Care Med 2010
Consequences of critical illness and critical care
Recollection of stressful experiences lived in the ICU
Remember
With Stress
n (%) Without Stress
n (%) Tracheal tube aspiration 113 (81) 26 (19) Nose tube 127 (75) 42 (25) Family worries 129 (71) 53 (29) Pain 121 (64) 69 (36) Bedridden 129 (64) 73 (36) Fear of dying, uncertain in the future 110 (64) 62 (36) Daily needle punctures 114 (61) 72 (39) Communication difficulties 111 (59) 78 (41) Ventilator dependence 93 (58) 68 (42) General discomfort 98 (58) 71 (42) Bladder tube 90 (56) 72 (44) Noisy and bad sleeping nights 83 (54) 71 (46)
Have you had many dreams and nightmares during ICU stay? (n= 352)
No49%
Yes51%
No
Yes
Currently, do you think that those dreams and nigthmares disturb your daily life?
0%
20%
40%
60%
80%
100%
Mobility Self-Care Usual Activities Pain/Disconfort Anxiety/Depression
No (n=146) Yes (n=23)
p=0.042p=0.084
p=0.183p<0.001 p=0.009
Report of No problems
Outcome Studies
Clinical Interventions in the ICU
Can patient-reported outcome measures change delivery of intensive care?
1 – Muscle weakness
2 – Cognitive dysfunction /Delirium
3 – PTSD/PTSS
4 – HRQOL
1 - Muscle weakness
Intervention – early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation
Vs
Control – daily interruption of sedation with therapy as ordered by the primary care team
1 - Muscle weakness
1 - Muscle weakness
2 – Brain Dysfunction/Delirium
3 – PTSD/PTSS
4 – HRQOL
Recollection of stressful experiences lived in the ICU
Remember
With Stress
n (%) Without Stress
n (%) Tracheal tube aspiration 113 (81) 26 (19) Nose tube 127 (75) 42 (25) Family worries 129 (71) 53 (29) Pain 121 (64) 69 (36) Bedridden 129 (64) 73 (36) Fear of dying, uncertain in the future 110 (64) 62 (36) Daily needle punctures 114 (61) 72 (39) Communication difficulties 111 (59) 78 (41) Ventilator dependence 93 (58) 68 (42) General discomfort 98 (58) 71 (42) Bladder tube 90 (56) 72 (44) Noisy and bad sleeping nights 83 (54) 71 (46)
• What was changed inside the ICU (2007)– Tracheal aspiration technique was improved
– Set of letters and pictures for patients to facilitate communication
– More time for relatives to be inside the ICU, improvement in communication with
relatives (66% of relatives did not understood the information provided by physicians)
– Analgesia (epidural)
– Early evaluation and treatment of delirium (CAM-ICU)
– Daily reduction of sedation
– Earlier rehabilitation inside the ICU
– Keeping the cycle day/night inside the ICU
– …
Follow-up: ward (first week) - 6 weeks - 6 months
• Functional Sequelae: N - Critical illness polyneuropathy rehabilitation - Respiratory evaluation rehabilitation - Neurologic evaluation rehabilitation - Other sequelae:
weight loss; nutritional status; joint stiffness; decubitus ulcer
• Psychological Sequelae: Psicologia - PTSD/PTSS ICU diaries - Anxiety/depression (HAD) psychological/psichiatric follow-up; early medication
What was changed at the Follow-Up Clinic :
4 – HRQOL
Follow-up was changed from 6 months to: 6 days - 6 weeks - 6 months
Earlier follow up and earlier interventions Reduction in extreme problems at 6 months
Before : Follow up at 6 months
After: Follow up at 6 days, 6 weeks and 6 months
Thank You