Diane Dennis

The incidence of falls in intensive care survivors

BACKGROUND Falling among adults in acute care is an important problem with falls rates in tertiary hospitals ranging from 2% to 5%. Factors that increase the risk of falling, such as advanced age, altered mental status, medications that act on the central nervous system and poor mobility, often characterise individuals who survive a prolonged intensive care unit (ICU) admission. PURPOSE To measure the incidence of falls and describe the characteristics of fallers among intensive care survivors. METHODS A comprehensive retrospective chart review was undertaken of 190 adults who were intubated and ventilated for ≥ 168 h and survived their acute care stay. Using a standardised form, several variables were extracted including falls during hospitalisation and risk factors such as age, severity of illness, and length of stay in intensive care and hospital. FINDINGS Thirty-two (17%, 95% confidence interval 11.5-22.2%) patients fell at least once on the in-patient wards following their ICU stay. Compared with non-fallers, fallers were younger (53.2 ± 17.9 vs. 44.1 ± 18.3 years; p=0.009) and had a shorter duration of inotropic support in ICU (84 ± 112 vs. 56 ± 100 h; p=0.040). The majority of fallers were aged less than 65 years (84%). Both fallers and non-fallers had similar APACHE II scores (20 ± 8 vs. 21 ± 7; p=0.673), length of stay in intensive care (14.2 ± 8.7 vs. 14.0 ± 9.7 days; p=0.667) and hospital length of stay (43.9 ± 33.1 vs. 41.0 ± 38.8 days; p=0.533). CONCLUSION Falling during hospitalisation is common in intensive care survivors. Compared with non-fallers, fallers were younger and required inotropes for a shorter duration. Those who survive a prolonged admission to an ICU may benefit from specific assessment of balance and falls risk by the multidisciplinary team.

Relationships between mortality, morbidity, and physical function in adults who survived a period of prolonged mechanical ventilation ☆ ☆☆ ★

PURPOSE This study aimed to report mortality, morbidity, and the relationship between these outcomes with physical function in patients who survived prolonged mechanical ventilation during an intensive care unit (ICU) admission. METHODS AND MATERIALS Records were reviewed for Western Australian residents admitted to an ICU in 2007 or 2008 who were ventilated for 7 days or longer and survived their acute care stay. Records were linked with data maintained by the Department of Health. RESULTS A total of 181 patients (aged 52 ± 19 years) were included in this study. In the 12 months after discharge, 159 (88%) survived and 148 (82%) had been hospitalized. Compared with those who were ambulating independently when discharged from acute care, those who were not had more admissions (incident rate ratio, 1.81; 95% confidence interval, 1.28-2.57) and a greater cumulative length of hospital stay (10 [37] vs 57 [115] days, P < .001) over the first 12 months after discharge. Time between admission to ICU and when the patient first stood correlated with the number of admissions (Rs = 0.320, P < .001) and cumulative length of stay (Rs = 0.426, P < .001) in the 12 months after discharge. CONCLUSIONS For survivors of prolonged mechanical ventilation, physical function during acute care was associated with hospitalization over the following 12 months.

Exploring the capacity to ambulate after a period of prolonged mechanical ventilation.

PURPOSE The purposes were to assess the functional recovery of those who survived a prolonged intensive care unit (ICU) stay by reporting the proportion who were able to ambulate independently at hospital discharge and also to examine if the time duration between admission and when the patient first stood impacted on their capacity to ambulate at discharge. MATERIALS AND METHODS A retrospective review was conducted of medical records of ICU patients in 2007 to 2008, who were mechanically ventilated for 168 hours or more, and survived their acute care stay. Main outcome measures were (1) ambulation status before admission and at time of hospital discharge and (2) time between admission to the ICU and when the patient first stood. RESULTS A total of 190 patients were included. Before admission, 189 (99%; 95% confidence interval [CI], 98%-100%) were ambulating independently, of whom 180 (95%) did not require a gait aid. On discharge from acute care, 89 (47%; 95% CI, 40%-54%) were ambulating independently, of whom 54 (61%) did not require a gait aid. Compared with those who stood within 30 days of ICU admission, a delay in standing of between 30 and 60 days increased the odds 5-fold (95% CI, 2-11) of being unable to ambulate independently at the time of discharge. CONCLUSIONS After a prolonged ICU admission, more than 50% of patients were unable to ambulate independently by hospital discharge, with the time between admission and first stand, being an important predictor of this outcome.

Prevalence of obesity in an intensive care unit patient population

BACKGROUND The Australian health survey (2011-2012) reported that 63.4% of Australian adults were overweight or obese. Critical care medicine is expensive, with intensive care unit (ICU) services accounting for a substantial proportion of total hospital costs. These costs may be multiplied in the overweight cohort. OBJECTIVES The primary aim was to compare the body mass index (BMI) of a critically ill ICU patient cohort to Australian population norms in order to see if overweight people were over-represented. The secondary aim was to identify if any medical specialty was associated with overweight patients. METHODS A retrospective observational case note audit of 230 ICU patients between November 2012 and August 2013, with BMI as the primary outcome measure. RESULTS Approximately 75% of the cohort were overweight or obese (median BMI 28.7; IQR 25.0-32.7) representing a rate 12% higher than Australian normative data. Based on population, this equates to an estimated additional 5279 unanticipated overweight or obese ICU patients at our facility during 2013. CONCLUSIONS This study has shown that Australian ICU patients may have higher BMI than those of the general Australian population, and therefore there may be unanticipated costs associated with their care. No medical specialty was associated with higher BMI than another.

Prevalence of obesity and the effect on length of mechanical ventilation and length of stay in intensive care patients: A single site observational study

OBJECTIVES To provide a snapshot of the prevalence of abnormal body mass index (BMI) in a sample of intensive care unit (ICU) patients; to identify if any medical specialty was associated with abnormal BMI and to explore associations between BMI and ICU-related outcomes. BACKGROUND Obesity is an escalating public health issue across developed nations but there is little data pertaining to critically ill patients who require care that is expensive. METHODS Retrospective observational audit of 735 adult patients (median age 58 years) admitted to the Sir Charles Gairdner Hospital 23 bed tertiary ICU between November 2012 and June 2014. Primary outcome measure was patient BMI: underweight (<18.5kg/m2), normal weight (18.5-24.99kg/m2), overweight (25-29.99kg/m2), obese (30-39.99kg/m2) or extreme obese (40kg/m2 or above). Other measures included gender, acute physiology and chronic health evaluation II score, admission specialty, length of mechanical ventilation (MV), length of stay (LOS) and mortality. RESULTS Compared to the general population there was a higher proportion of obese patients within the cohort with the majority of patients overweight (33.9%) or obese (36.5%) and median BMI of 27.9 (IQR 7.9). There were no significant differences between specialties for BMI (p=0.103) and abnormal BMI was not found to impact negatively on mortality (ICU, p=0.373; hospital, p=0.330). Normal BMI patients had shorter length of MV than other BMI categories and the impact of BMI on ICU LOS was dependent on length of MV. Overweight patients ventilated for five days or more had a shorter LOS, and extremely obese non-ventilated patients had a longer LOS, compared to normal weight patients. CONCLUSIONS Although the obesity-disease relationship is increasingly complex and data presented reflects categorical BMI for patients admitted to a single ICU site it may be important to consider the cost implications of caring for this cohort especially with regard to MV and LOS.