Ann M. Parker

Posttraumatic stress disorder in critical illness survivors: a metaanalysis.

Objective: To conduct a systematic review and metaanalysis of the prevalence, risk factors, and prevention/treatment strategies for posttraumatic stress disorder symptoms in critical illness survivors. Data Sources: PubMed, Embase, CINAHL, PsycINFO, and Cochrane Library from inception through March 5, 2014. Study Selection: Eligible studies met the following criteria: 1) adult general/nonspecialty ICU, 2) validated posttraumatic stress disorder instrument greater than or equal to 1 month post-ICU, and 3) sample size greater than or equal to 10 patients. Data Extraction: Duplicate independent review and data abstraction from all eligible titles/abstracts/full-text articles. Data Synthesis: The search identified 2,817 titles/abstracts, with 40 eligible articles on 36 unique cohorts (n = 4,260 patients). The Impact of Event Scale was the most common posttraumatic stress disorder instrument. Between 1 and 6 months post-ICU (six studies; n = 456), the pooled mean (95% CI) Impact of Event Scale score was 20 (17–24), and the pooled prevalences of clinically important posttraumatic stress disorder symptoms (95% CI) were 25% (18–34%) and 44% (36–52%) using Impact of Event Scale thresholds greater than or equal to 35 and greater than or equal to 20, respectively. Between 7 and 12 months post-ICU (five studies; n = 698), the pooled mean Impact of Event Scale score was 17 (9–24), and pooled prevalences of posttraumatic stress disorder symptoms were 17% (10–26%) and 34% (22–50%), respectively. ICU risk factors for posttraumatic stress disorder symptoms included benzodiazepine administration and post-ICU memories of frightening ICU experiences. Posttraumatic stress disorder symptoms were associated with worse quality of life. In European-based studies: 1) an ICU diary was associated with a significant reduction in posttraumatic stress disorder symptoms, 2) a self-help rehabilitation manual was associated with significant posttraumatic stress disorder symptom reduction at 2 months, but not 6 months; and 3) a nurse-led ICU follow-up clinic did not reduce posttraumatic stress disorder symptoms. Conclusions: Clinically important posttraumatic stress disorder symptoms occurred in one fifth of critical illness survivors at 1-year follow-up, with higher prevalence in those who had comorbid psychopathology, received benzodiazepines, and had early memories of frightening ICU experiences. In European studies, ICU diaries reduced posttraumatic stress disorder symptoms.

Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions ☆

PURPOSE Critical illness survivors commonly have impaired physical functioning. Physical therapy interventions delivered in the intensive care unit can reduce these impairments, but the safety of such interventions within routine clinical practice requires greater investigation. MATERIALS AND METHODS We conducted a prospective observational study of routine physical therapy from July 2009 through December 2011 in the Johns Hopkins Hospital Medical Intensive Care Unit in Baltimore, MD. The incidence of 12 types of physiological abnormalities and potential safety events associated with physical therapy were monitored and evaluated for any additional treatment, cost, or length of stay. RESULTS Of 1787 admissions of at least 24 hours, 1110 (62%) participated in 5267 physical therapy sessions conducted by 10 different physical therapists on 4580 patient-days. A total of 34 (0.6%) sessions had a physiological abnormality or potential safety event, with the most common being arrhythmia (10 occurrences, 0.2%) and mean arterial pressure greater than 140 mm Hg (8 occurrences; 0.2%) and less than 55 mm Hg (5 occurrences; 0.1%). Only 4 occurrences (0.1%) required minimal additional treatment or cost, without additional length of stay. CONCLUSIONS In this large, single-center study, routine care physical therapy interventions were safe for critically ill patients.

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.

Psychiatric Symptoms in Acute Respiratory Distress Syndrome Survivors: A 1-Year National Multicenter Study.

Objective:To evaluate prevalence, severity, and co-occurrence of and risk factors for depression, anxiety, and posttraumatic stress disorder symptoms over the first year after acute respiratory distress syndrome. Design:Prospective longitudinal cohort study. Settings:Forty-one Acute Respiratory Distress Syndrome Network hospitals across the United States. Patients:Six hundred ninety-eight acute respiratory distress syndrome survivors. Interventions:None. Measurements and Main Results:Psychiatric symptoms were evaluated by using the Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised at 6 and 12 months. Adjusted prevalence ratios for substantial symptoms (binary outcome) and severity scores were calculated by using Poisson and linear regression, respectively. During 12 months, a total of 416 of 629 patients (66%) with at least one psychiatric outcome measure had substantial symptoms in at least one domain. There was a high and almost identical prevalence of substantial symptoms (36%, 42%, and 24% for depression, anxiety, and posttraumatic stress disorder) at 6 and 12 months. The most common pattern of co-occurrence was having symptoms of all three psychiatric domains simultaneously. Younger age, female sex, unemployment, alcohol misuse, and greater opioid use in the ICU were significantly associated with psychiatric symptoms, whereas greater severity of illness and ICU length of stay were not associated. Conclusions:Psychiatric symptoms occurred in two thirds of acute respiratory distress syndrome survivors with frequent co-occurrence. Sociodemographic characteristics and in-ICU opioid administration, rather than traditional measures of critical illness severity, should be considered in identifying the patients at highest risk for psychiatric symptoms during recovery. Given high co-occurrence, acute respiratory distress syndrome survivors should be simultaneously evaluated for a full spectrum of psychiatric sequelae to maximize recovery.

Early Rehabilitation in the Intensive Care Unit: Preventing Impairment of Physical and Mental Health

Abstract Survivors of critical illness often experience new or worsening impairments of physical, cognitive, and/or mental health, referred to as Post-Intensive Care Syndrome (PICS). Such impairments can be long-lasting and negatively affect survivors’ quality of life. Early rehabilitation in the intensive care unit (ICU), while patients remain on life-support therapy, may reduce the complications associated with PICS. This article addresses evidence-based rehabilitation interventions to reduce the physical and mental health impairments associated with PICS. Implementation of effective early rehabilitation interventions targeting physical impairment requires consideration of five factors: barriers, benefits, feasibility, safety, and resources. Mental health impairments may be addressed by use of the following interventions: use of ICU diaries, early in-ICU psychological interventions, and post-ICU coping skills training. In both cases, a multidisciplinary team-based approach is paramount to successful incorporation of early rehabilitation into routine practice in the ICU.

Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis.

PURPOSE Early rehabilitation programs in a medical intensive care unit can improve patient outcomes, but clinicians face barriers in implementing and sustaining such programs. We sought to describe a multidisciplinary team perspective regarding how to implement and sustain a successful early rehabilitation program. METHODS Semistructured interviews were conducted with 20 staff and faculty who were involved in the early rehabilitation program at the Johns Hopkins Hospital Medical Intensive Care Unit. Transcripts were evaluated using the Consolidated Framework of Implementation Research Theory. RESULTS Four major constructs emerged as important, as follows: (1) necessary components, (2) implementation strategies, (3) perceived barriers, and (4) positive outcomes. All participants reported that staff buy-in was necessary, whereas having a multidisciplinary team with good communication among team members was reported as helpful by 90% of participants. The most common barrier reported was increased staff workload (80%). All participants (100%) noted improved patient outcomes as an important benefit, and 95% reported improved job satisfaction. CONCLUSIONS This qualitative study of a successful early rehabilitation program highlights the importance of assessing and engaging a multidisciplinary team before implementation and the positive outcomes of early rehabilitation on staff by improving job satisfaction and changing the culture of a hospital unit.

Association of severity of illness and intensive care unit readmission: A systematic review

OBJECTIVES To determine whether ICU readmission is associated with higher severity of illness scores in adult patients. BACKGROUND Readmissions to the intensive care unit (ICU) are associated with increased costs, morbidity, and mortality. METHODS We performed searches of MEDLINE, EMBASE, and grey literature databases. We selected studies reporting data from adults who were hospitalized in an ICU, received severity of illness scores, and were discharged from the ICU. Characteristics of readmitted and non-readmitted patients were examined. RESULTS We screened 4766 publications and included 31 studies in our analysis. In most studies, severity of illness scores were higher in patients readmitted to the ICU. Readmission was also associated with higher mortality and longer ICU and hospital stays. Excessive heterogeneity precluded the reporting of results in the form of a meta-analysis. CONCLUSIONS ICU readmission is associated with higher severity of illness scores during the same hospitalization in adult patients.

A Quality Improvement Project Sustainably Decreased Time to Onset of Active Physical Therapy Intervention in Patients with Acute Lung Injury

RATIONALE Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI). METHODS This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU. MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]). CONCLUSIONS In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.

Ambient light levels and critical care outcomes

PURPOSE Guidelines for the construction of critical care units require windows in room design to ensure a contribution of natural sunlight to ambient lighting. However, few studies have been published with evidence assessing this recommendation. We investigated the association of ambient light levels with clinical outcomes and sedative/analgesic/neuroleptic use in a medical intensive care unit (MICU). METHODS This is a retrospective, observational study at a tertiary care facility with a 29-bed MICU. First/single MICU admissions between April 19, 2006, and June 30, 2009 (N = 3577), were analyzed with respect to clinical outcomes and sedation use according to MICU room orientation and corresponding light levels. RESULTS Light levels were low but varied among the 4 room orientations. There were no significant differences in MICU mortality (north, 14.0%; east, 13.5%; west, 16.2%; south, 15.6%; P = .451), hospital mortality (20.8%, 20.9%, 22.2%, 22.3%; P = .796), 28-day intensive care unit-free days (17.6 ± 10.2, 18.0 ± 10.1, 17.7 ± 10.5, 17.2 ± 10.4; P = .555), 28-day ventilator-free days (16.3 ± 11.1, 16.5 ± 11.1, 15.5 ± 11.5, 15.4 ± 11.4; P = .273). No clinically significant differences in intravenous sedative/analgesic use occurred across room orientations. CONCLUSIONS Despite differing ambient light, room orientation was not associated with critical care outcomes or differences in sedative/analgesic/neuroleptic use. Current guidelines positing that windows alone are necessary or sufficient for MICU room light management may require further investigation and consideration.

Increasing the dose of acute rehabilitation: is there a benefit?

Rehabilitation interventions, including physiotherapy and occupational therapy, can improve patient outcomes; however, the optimal duration and frequency of inpatient rehabilitation interventions is uncertain. In a recent randomized controlled trial published in BMC Medicine, 996 patients in two publicly-funded Australian metropolitan rehabilitation facilities were assigned to physiotherapy and occupational therapy delivered Monday through Friday (five days/week control group) versus Monday through Saturday (six days/week intervention group). This increased dose of rehabilitation in the intervention group resulted in greater functional independence and quality of life at discharge, with a trend towards significant improvement at six-month follow-up. Moreover, the length of stay for the intervention group was shorter by two days (95% CI 0 to 4, P = 0.10). Hence, in the acute inpatient rehabilitation setting, a larger dose of physiotherapy and occupational therapy, via six versus five days/week treatment, improves patient outcomes and potentially reduces overall length of stay and costs.Please see related research: http://www.biomedcentral.com/1741-7015/11/198.