Persistent Critical Illness · • Persistent critical illness can be defined and is probably not...

Persistent Critical Illness

Theodore J. Iwashyna, MD, PhDUniversity of Michigan

Ann Arbor VA Center for Clinical Management Researchwhile on sabbatical at ANZIC-RC at Monash University

1 November 2016 -- CCCF

This is joint work with:

• Carol Hodgson

• David Pilcher

• Michael Bailey

• Allison van Lint

• Shaila Chavan

• Neil Orford

• John Santamaria

• Rinaldo Bellomo

• Liz Viglianti

• Kyle Kepreos

• Brenda Vincent

• Wyndy Wiitala

• Joanne McPeake

• Tara Quasim

• Martin Shaw

It is our hypothesis that

there exists a substantial and growing group of patients

who are ICU-dependent, in the sense that they are are unable to

live for more than a few days outside of intensive-care-like services

whose current problems are driven by their ongoing cascading

critical illnesses rather than their original ICU admitting diagnosis

who account for a substantial portion of our bed-days

for whom we have little specific expertise in promoting their

recovery (as opposed to continuing their resuscitation)

but who are not immutably fated to such limbo, but rather whose

care we could improve both via improved ICU patient selection but

also by changing care & communication practices in the ICU

Iwashyna, Hodgson, Pilcher, Orford, Santamaria, Bailey, Bellomo (2015) Crit Care & Resusc 17:215.

Persistent Critical Illness:

“those patients whose reason for

being in the ICU is now more related

to their ongoing critical illness than

their original reason for admission to

the ICU”

A novel concept in the family of

“Chronic Critical Illness”

• Persistent critical illness (as defined

here)

• Chronic Critical Illness / Medically

Complex patients

• Diseases with long intrinsic

recovery times

• Prolonged weaning

• Prolonged ICU length of stay

Iwashyna, Hodgson, Pilcher, Orford, Santamaria, Bailey, Bellomo (2015) Crit Care & Resusc 17:215.

Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation 17:153.

Role N=101

Relative

Distribution

ICU Consultant 59 70 %

Research Coordinator 10 12 %

Nurse 14 17 %

Project Manager 1 1 %

Dietitian 11 13 %

Physiotherapist 4 5 %

Other 2 2 %

Persistent Critical Illness, as Characterized by Australian and New

Zealand ICU Clinicians

Aim: determine, via websurvey, the perspectives of members of the

ANZICS CTG regarding patients with persistent critical illness.

Time to Onset of Persistent Critical Illness: 10 days (IQR: 7-14)

Incidence Estimate: 10% (IQR: 5%-15%) of all ICU Patients

Fraction of Prolonged ICU Length of Stay that is Due to

Persistent Critical Illness: 50% (IQR: 20% - 60%)


Typical Problems of the

Persistently Critically Ill0% 25% 50% 75% 100%

Respiratory Insufficiency

Delirium

Acquired Neuromuscular…

Sepsis

Kidney Injury

Malnutrition

Skin Breakdown and…

Traumatic Brain Injury

Severe Wounds

Pancreatitis

Heart Failure

Liver Failure

Gastrointestinal Bleeding

Severe Burns

Stroke

Endocrinopathies

Percent of Respondents (n=78)

90% identified ongoing

mechanical ventilation

as the typical need


Not Persistently Critically Ill:

Diseases with Long Intrinsic

Recovery Times0% 25% 50% 75% 100%

Neuromuscular Disease

Head Trauma

Pancreatitis

Intracranial Haemorrhage

Neurologic Infection

Hepatic Failure

Multiple Trauma Excluding…

Isolated Cervical Spine…

Cardiogenic Shock

Pneumonia

Cardiac Arrest

Intestinal Surgery

Ischemic Stroke

Seizure

Percent of Respondents (n=78)

Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.

Timing of Onset and Burden of Persistent Critical Illness

Aim 1: Test the “persistent critical illness” hypothesis that there

is a point in the ICU stay beyond which ICU-admission

diagnosis and severity of illness in the first 24 hours no longer

differentiates patients regarding their probability of in-hospital

death.

Aim 2: Measure the timing of such a population-level transition.

Aim 3: Characterize the utilization of such persistently critically

ill patients.


Characteristic All Patients

Median Age (IQR) – yr 65 (51–75)

Mean Age (SD) – yr 61∙5 (17∙7)

Male sex – no. (%) 602,455 (58∙6)

APACHE III Score on Admission 49∙1 (26∙6)

Median risk of death on admission

(ANZROD) (IQR) – %2∙2 (0∙5–6∙9)

Mean risk of death on admission

(ANZROD) (SD) – %10∙0 (18∙3%)

Median duration of ICU stay (IQR) – days 1∙7 (0∙9–3∙0)

Median duration of hospital stay (IQR) –

days8∙4 (4∙6–15∙6)

Major Diagnostic Category – no. (%)

Cardiovascular (CABG/Valve) 162,858 (15∙8)

Other cardiovascular 137,445 (13∙4)

Respiratory 155,376 (15∙1)

Gastrointestinal 180,351 (17∙5)

Neurological 110,270 (10∙7)

Trauma 46,304 (4∙5)

Sepsis 52,066 (5∙1)

Other 183,565 (17∙9)

Characteristic All Patients

Hospital Outcome – no. (%)

Death 102,948 (10∙0)

Discharge to

Home 782,520 (76∙1)

Rehabilitation or Long-term Care 77,418 (7∙5)

Other Hospital 65,349 (6∙3)


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0 10 20 30ICU Days Completed


Reason for ICU Admission

Number in Validation

Cohort

Day on which Acute

Characteristics are No

Longer More Predictive

than Antecedent

Characteristics Alone

Day on which Acute

Characteristics are No

Longer Statistically

Significantly More

Predictive than Antecedent

Characteristics Alone

Cardiac Surgical 75,340 22 6

Cardiovascular 64,716 11 9

Respiratory 74,213 9 7

Gastrointestinal 86,722 12 8

Neurologic 51,453 9 7

Trauma 22,108 17 9

Sepsis 24,977 7 6


Hospital Outcome 10 or Fewer Days More Than 10 Days

Death 90,323 (9∙2) 12,625 (24∙4)

Discharge

to home 758,552 (77∙7) 23,698 (49∙9)

to Rehabilitation or

Long-term Care

68,584 (7∙0) 8,834 (17∙2)

to Other Hospital 59,627 (6∙1) 6,082 (11∙8)

The 51,509 patients who stayed 10 days or more accounted for:

5.0% of all ICU patients in Australia and New Zealand;

32.8% of all ICU bed-days (1,029,354 ICU bed days); and

14.6% of all hospital-bed-days by ICU patients (2,197,108 hospital bed days).

Interim Conclusions

• Persistent critical illness can be defined and is probably not just relabelling

currently described syndromes of chronic critical illness.

• Many ANZ clinicians identify consistent features of persistent critical illness

and have concerns about these patients.

• The “persistent critical illness” hypothesis that there is a point in the ICU

stay beyond which ICU-admission diagnosis and severity of illness in the

first 24 hours no longer differentiates patients regarding their probability of

in-hospital death is supported, with onset somewhere during the second

week.

Interim Conclusions

• The “persistent critical illness” hypothesis that there is a point in the ICU

stay beyond which ICU-admission diagnosis and severity of illness in the

first 24 hours no longer differentiates patients regarding their probability of

in-hospital death is supported, with onset somewhere during the second

week in both ANZ and VA2014.

• Next steps include:

• Patterns post-discharge mortality and healthcare utilization

• Detailed examination of the evolution of ICU patients in this time frame

• Understanding the relative importance of non-resolution; cascading new

problems; complications of care; and iatrogenesis in mechanisms

Please email me at [email protected] or tweet me @iwashyna for copies of

slides or to continue the conversation

mailto:[email protected]

ExploratoryEmpirical Work

Articulate theConcept

ConsensusConference

Workable Case Definition& Admin Operationalization

Validation

MeasureBurden

Prognostication &Risk Stratification

Interventions

Critical Care & Resuscitation “Point of View” published

Presentations to Assorted Bodies done

Survey of ANZ Clinicians published

Timing of Onset and Burden under review

Criterion Validation 1: Do case def pts meet clinician judgement gold standar d?

Predictive Validation 2: Do case def pts have higher subsequent mortality , readmits?

Replications of Timing Analysis: VA and ICNARC

Goal: Define a clear, clinically relevant case definition

First round convened, consensus 2/3 drafted

Second round February - March 2016

Cascades of Primary Problems possible VA MERIT

ANZ Time Course of Complications & Hospital-Acquir ed Conditions data being obtained

Survey respondents offered 188

recommendations for possible

interventions to improve care.

Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2015) under review

Thank you for your attention.

Email me at [email protected] or

tweet me @iwashyna for copies of slides

or to continue the conversation.

Van den Berge (1998) Verhandelingen - Koninklijke Academie voor Geneeskunde van Belgie 60:487.

http://innovation.cms.gov/Files/reports/ChronicallyCriticallyIllPopulation-Report.pdf;Kahn et al (2010) JAMA 303:2253.; Kahn et al (2015) Crit Care Med 43:282.

Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation forthcoming.

0 10 20 30 40

Die before leaving the hospital?

Die in the 6 months afterdischarge from hospital?

Survive 6 months after dischargewith high level support in a…

Survive 6 months after dischargewith significant assistance at…

Be alive and well at 6 monthsafter discharge?

0 10 20 30 40

Die before leaving the hospital?

Die in the 6 months afterdischarge from hospital?

Survive 6 months after dischargewith high level support in a…

Survive 6 months after dischargewith significant assistance at…

Be alive and well at 6 monthsafter discharge?

Persistently Critically Ill:

Prolonged ICU Length of Stay

Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation forthcoming.

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Quality of Care for Persistently Critically Ill

Poor Care Excellent CareExcellent Care

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Care is Stressful for Team

Very Stressful Not Stressful

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Care is Cost Effective

Not At All VeryVery Cost Effective

Persistent Critical Illness · • Persistent critical illness can be defined and is probably not...

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