Can patient-reported outcome measures change delivery of intensive care?

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Can patient-reported outcome measures change
delivery of intensive care?

• Cristina Granja
• Emergency and Intensive Medicine Department
• Hospital Pedro Hispano
• Biostatistics and Medical Informatics Department
• Faculty of Medicine of Porto
• Portugal

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Can patient-reported outcome measures change
delivery of intensive care?

• 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?

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Follow up clinic from real patients to outcome
studies
ICU Follow-up Clinic Hospital Pedro Hispano
Begin in 1997
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Follow up clinic from real patients to outcome
studies
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Outcomes after critical care
Follow up clinic from real patients to outcome
studies
Ridley Young, Intensive Care After
Care, Butterworth Heinemann,2002
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What have we learned Consequences of critical
illness and critical care
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What have we learned Consequences of critical
illness and critical care

• Ongoing increased mortality
• Physical Disability
• Neuropsychological Disability
• Health-Related Quality of Life

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Consequences of critical illness and critical care

• Ongoing increased mortality

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Consequences of critical illness and critical care

• Physical Disability
• Pulmonary
• Lung function impairments
• Extra-Pulmonary
• Weight loss/ICU- acquired weakness
• Critical illness polyneuropathy

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Consequences of critical illness and critical care

• Lung function impairments

Granja et al, Intensive Care Med 2003
Herridge M et al , NEJM 2003
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Consequences of critical illness and critical care

• Weight loss/ICU-acquired weakness

Herridge M et al , NEJM 2003
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Consequences of critical illness and critical care

• Weight loss/ICU-acquired weakness

Griffiths Jones, Intensive Care After Care, 2002
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Consequences of critical illness and critical care

• Critical illness polyneuropathy

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Consequences of critical illness and critical care

• Neuropsychological Disability
• Cognitive impairment
• Delirium
• Anxiety, Depression
• PTSD/PTSS

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Consequences of critical illness and critical care

• Cognitive impairment

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• Delirium

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Consequences of critical illness and critical care

• Anxiety, Depression

BDI-II - Beck Depression Inventory II 41
moderate/severe depression (BDI-II gt20)
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Consequences of critical illness and critical care

• PTSD/PTSS

Schelling et al, Crit Care Med 1998
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Consequences of critical illness and critical care

• Health-Related Quality of Life

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• 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.

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Consequences of critical illness and critical care

• Health-Related Quality of Life studies with
  EQ-5D

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Health-Related Quality of Life studies with
EQ-5D

• 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.

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Premorbid Status Age Gender Pre-existing medical
disease Prior psychopathology. Family history of
psychiatric disease Cognitive impairment ,
dementia, previous TBI or anoxic brain
injury Genetic predisposition Social support
network
Pain Altered sensorium
ICU LOS Hospital LOS
Duration of MV
ALI/ARDS and its treatment
Steroids Neuroendocrine Stress
Frightening Memories Delirium
Bed rest Immobility
Sedation Medications
Hypoxia Hypotension
Cognitive Dysfunction
Caregiver burden
Psychiatric or Mood disorders
Poor HRQOL
Financial Loss
Physical Impairment
Reduction in Employment
Wilcox et al, Semin Resp Crit Care Med 2010
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Consequences of critical illness and critical care
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Recollection of stressful experiences lived in
the ICU
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Have you had many dreams and nightmares during
ICU stay? (n 352)
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Report of No problems
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Outcome Studies
Clinical Interventions in the ICU
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Can patient-reported outcome measures change
delivery of intensive care? 1 Muscle
weakness 2 Cognitive dysfunction /Delirium 3
PTSD/PTSS 4 HRQOL
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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
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1 - Muscle weakness
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1 - Muscle weakness
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2 Brain Dysfunction/Delirium
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3 PTSD/PTSS
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4 HRQOL
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Recollection of stressful experiences lived in
the ICU
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• 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

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What was changed at the Follow-Up Clinic
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
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4 HRQOL
Follow-up was changed from 6 months to 6 days -
6 weeks - 6 months
Before Follow up at 6 months
After Follow up at 6 days, 6 weeks and 6 months
Earlier follow up and earlier interventions
Reduction in extreme problems at 6 months
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Thank You