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