Chris Joyce

A multicenter randomized trial of atorvastatin therapy in intensive care patients with severe sepsis

RATIONALE Observational studies link statin therapy with improved outcomes in patients with severe sepsis. OBJECTIVES To test whether atorvastatin therapy affects biologic and clinical outcomes in critically ill patients with severe sepsis. METHODS Phase II, multicenter, prospective, randomized, double-blind, placebo-controlled trial stratified by site and prior statin use. A cohort of 250 critically ill patients (123 statins, 127 placebo) with severe sepsis were administrated either atorvastatin (20 mg daily) or matched placebo. MEASUREMENTS AND MAIN RESULTS There was no difference in IL-6 concentrations (primary end point) between the atorvastatin and placebo groups (P = 0.76) and no interaction between treatment group and time to suggest that the groups behaved differently over time (P = 0.26). Baseline plasma IL-6 was lower among previous statin users (129 [87-191] vs. 244 [187-317] pg/ml; P = 0.01). There was no difference in length of stay, change in Sequential Organ Failure Assessment scores or mortality at intensive care unit discharge, hospital discharge, 28- or 90-day (15% vs. 19%), or adverse effects between the two groups. Cholesterol was lower in patients treated with atorvastatin (2.4 [0.07] vs. 2.6 [0.06] mmol/L; P = 0.006). In the predefined group of 77 prior statin users, those randomized to placebo had a greater 28-day mortality (28% vs. 5%; P = 0.01) compared with those who received atorvastatin. The difference was not statistically significant at 90 days (28% vs. 11%; P = 0.06). CONCLUSIONS Atorvastatin therapy in severe sepsis did not affect IL-6 levels. Prior statin use was associated with a lower baseline IL-6 concentration and continuation of atorvastatin in this cohort was associated with improved survival. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12607000028404).

Continuation of statin therapy in patients with presumed infection: A randomized controlled trial

RATIONALE In patients on prior statin therapy who are hospitalized for acute infections, current literature is unclear on whether statins should be continued during their hospitalization. OBJECTIVES To test the hypothesis that continuation of therapy with statins influences the inflammatory response to infection and that cessation may cause an inflammatory rebound. METHODS Prospective randomized double-blind placebo-controlled trial of atorvastatin (20 mg) or matched placebo in 150 patients on preexisting statin therapy requiring hospitalization for infection. MEASUREMENTS AND MAIN RESULTS The primary end point was progression of sepsis during hospitalization. At baseline, the rate of severe sepsis was 32% in both groups. Compared with baseline, the odds ratio for severe sepsis declined in both groups: 0.43 placebo and 0.5 statins (Day 3) versus 0.14 placebo and 0.12 statins (Day 14). The rate of decline of severe sepsis was similar between the groups (odds ratio 1.17 [0.56-2.47], P = 0.7 Day 3; 0.85 [0.21-3.34], P = 0.8 Day 14). IL-6 and C-reactive protein declined in both groups with no statistically significant difference (P = 0.7 and P = 0.2, respectively). An increase in cholesterol occurred in the placebo group (P < 0.0001). Most patients were not critically ill. Hospital mortality was 6.6%, with no difference between the groups (6 [8%] of 75 statin group; 4 [5.3%] of 75 placebo group; P = 0.75). CONCLUSIONS This study does not support a beneficial role of continuing preexisting statin therapy on sepsis and inflammatory parameters. Cessation of established statin therapy was not associated with an inflammatory rebound. Clinical trial registered at the Australian New Zealand Clinical Trials Registry (ACTRN 12605000756628).

Health status of critically ill trauma patients

AIMS AND OBJECTIVES To describe the recovery of trauma intensive care patients up to six months posthospital discharge. BACKGROUND Injury is a leading cause of preventable mortality and morbidity worldwide, with approximately 10% of hospitalised trauma patients being admitted to intensive care. Intensive care patients experience significant ongoing physical and psychological burden after discharge; however, the patterns of recovery and the subgroups of intensive care patients who experience the greatest burden are not described. DESIGN This prospective cohort study was conducted in one tertiary referral hospital in south-east Queensland, Australia. METHODS Following ethics approval, injured patients who required admission to intensive care provided consent. Participants completed questionnaires prior to hospital discharge (n = 123) and one (n = 93) and six months (n = 88) later. Data included demographic and socioeconomic details, pre-injury health, injury characteristics, acute care factors, postacute factors [self-efficacy, illness perception, perceived social support and psychological status as measured by the Kessler Psychological Distress Scale (K10) and the PTSD Civilian Checklist] and health status (SF-36). RESULTS All participants required ongoing support from healthcare providers in the six months after discharge from hospital, and approximately half required support services such as accommodation and home modifications. Approximately 20% of participants reported post-traumatic stress symptoms, while approximately half the participants reported psychological distress. Average quality of life scores were significantly below the Australian norms both one and six months postdischarge. CONCLUSIONS Trauma intensive care patients rely on ongoing healthcare professional and social support services. Compromised health-related quality of life and psychological health persists at six months. RELEVANCE TO CLINICAL PRACTICE Effective discharge planning and communication across the care continuum is essential to facilitate access to healthcare providers and other support services in the community setting.

Physical Function and Mental Health in Trauma Intensive Care Patients: A 2-Year Cohort Study.

Objectives:This study was designed to examine changes in function over time after injury and to identify factors associated with long-term recovery that may be amenable to change through intervention. Design:Prospective cohort study. Setting:Intensive care in a tertiary hospital in Queensland, Australia. Patients:Adult (n = 123) admitted to intensive care for treatment of injury. Interventions:Data were collected prior to hospital discharge and 1, 6, 12, and 24 months post injury. Data included demographics, preinjury health, injury characteristics, acute care factors, psychosocial measures, and health status. Linear mixed-effects models were used to identify factors associated with physical function and mental health over time. Measurements and Main Results:Physical function and mental health improved over time; however, the averages remained below Australian norms at 24 months. Optimistic perception of illness and greater self-efficacy were potentially modifiable factors associated with improved mental health and physical function over time. Greater perceived social support, also potentially modifiable, was associated with improved mental health. Injury insurance and income were significant nonmodifiable factors for mental health, with mental health gains associated with higher income. Hospital length of stay and injury insurance were nonmodifiable factors linked with physical function. Conclusions:Improvements in physical function and mental health are evident in the 24 months following injury, but most patients remain below Australian population norms. Factors that were associated with physical function and mental health outcomes over time that are potentially amenable to change include illness perception, self-efficacy, and perceived social support.

Patient characteristics, interventions and outcomes of 1,151 rapid response team activations in a tertiary hospital: a prospective study

The characteristics of mature contemporary rapid response systems are unclear.

Effect of a 2-tier rapid response system on patient outcome and staff satisfaction

BACKGROUND Rapid response systems (RRS) have been recommended as a strategy to prevent and treat deterioration in acute care patients. Questions regarding the most effective characteristics of RRS and strategies for implementing these systems remain. AIMS The aims of this study were to (i) describe the structures and processes used to implement a 2-tier RRS, (ii) determine the comparative prevalence of deteriorating patients and incidence of unplanned intensive care unit (ICU) admission and cardiac arrest prior to and after implementation of the RRS, and (iii) determine clinician satisfaction with the RRS. METHOD A quasi-experimental pre-test, post-test design was used to assess patient related outcomes and clinician satisfaction prior to and after implementation of a 2-tier RRS in a tertiary metropolitan hospital. Primary components of the RRS included an ICU Outreach Nurse and a Rapid Response Team. Prevalence of deteriorating patients was assessed through a point prevalence assessment and chart audit. Incidence of unplanned admission to ICU and cardiac arrests were accessed from routine hospital databases. Clinician satisfaction was measured through surveys. RESULTS Prevalence of patients who met medical emergency call criteria without current treatment reduced from 3% prior to RRS implementation to 1% after implementation; a similar reduction from 9% to 3% was identified on chart review. The number of unplanned admissions to ICU increased slightly from 17.4/month prior to RRS implementation to 18.1/month after implementation (p=0.45) while cardiac arrests reduced slightly from 7.5/month to 5.6/month (p=0.22) but neither of these changes were statistically significant. Staff satisfaction with the RRS was generally high. CONCLUSION The 2-tier RRS was accessed by staff to assist with care of deteriorating patients in a large, tertiary hospital. High levels of satisfaction have been reported by clinical staff.

Research paperEffect of a 2-tier rapid response system on patient outcome and staff satisfaction

BACKGROUND Rapid response systems (RRS) have been recommended as a strategy to prevent and treat deterioration in acute care patients. Questions regarding the most effective characteristics of RRS and strategies for implementing these systems remain. AIMS The aims of this study were to (i) describe the structures and processes used to implement a 2-tier RRS, (ii) determine the comparative prevalence of deteriorating patients and incidence of unplanned intensive care unit (ICU) admission and cardiac arrest prior to and after implementation of the RRS, and (iii) determine clinician satisfaction with the RRS. METHOD A quasi-experimental pre-test, post-test design was used to assess patient related outcomes and clinician satisfaction prior to and after implementation of a 2-tier RRS in a tertiary metropolitan hospital. Primary components of the RRS included an ICU Outreach Nurse and a Rapid Response Team. Prevalence of deteriorating patients was assessed through a point prevalence assessment and chart audit. Incidence of unplanned admission to ICU and cardiac arrests were accessed from routine hospital databases. Clinician satisfaction was measured through surveys. RESULTS Prevalence of patients who met medical emergency call criteria without current treatment reduced from 3% prior to RRS implementation to 1% after implementation; a similar reduction from 9% to 3% was identified on chart review. The number of unplanned admissions to ICU increased slightly from 17.4/month prior to RRS implementation to 18.1/month after implementation (p=0.45) while cardiac arrests reduced slightly from 7.5/month to 5.6/month (p=0.22) but neither of these changes were statistically significant. Staff satisfaction with the RRS was generally high. CONCLUSION The 2-tier RRS was accessed by staff to assist with care of deteriorating patients in a large, tertiary hospital. High levels of satisfaction have been reported by clinical staff.

Effect of a 2-tier rapid response system on patient outcome and staffsatisfaction

BACKGROUND Rapid response systems (RRS) have been recommended as a strategy to prevent and treat deterioration in acute care patients. Questions regarding the most effective characteristics of RRS and strategies for implementing these systems remain. AIMS The aims of this study were to (i) describe the structures and processes used to implement a 2-tier RRS, (ii) determine the comparative prevalence of deteriorating patients and incidence of unplanned intensive care unit (ICU) admission and cardiac arrest prior to and after implementation of the RRS, and (iii) determine clinician satisfaction with the RRS. METHOD A quasi-experimental pre-test, post-test design was used to assess patient related outcomes and clinician satisfaction prior to and after implementation of a 2-tier RRS in a tertiary metropolitan hospital. Primary components of the RRS included an ICU Outreach Nurse and a Rapid Response Team. Prevalence of deteriorating patients was assessed through a point prevalence assessment and chart audit. Incidence of unplanned admission to ICU and cardiac arrests were accessed from routine hospital databases. Clinician satisfaction was measured through surveys. RESULTS Prevalence of patients who met medical emergency call criteria without current treatment reduced from 3% prior to RRS implementation to 1% after implementation; a similar reduction from 9% to 3% was identified on chart review. The number of unplanned admissions to ICU increased slightly from 17.4/month prior to RRS implementation to 18.1/month after implementation (p=0.45) while cardiac arrests reduced slightly from 7.5/month to 5.6/month (p=0.22) but neither of these changes were statistically significant. Staff satisfaction with the RRS was generally high. CONCLUSION The 2-tier RRS was accessed by staff to assist with care of deteriorating patients in a large, tertiary hospital. High levels of satisfaction have been reported by clinical staff.