Janete Maria da Silva

Decline in functional status after intensive care unit discharge is associated with ICU readmission: a prospective cohort study

OBJECTIVES To compare the functional status at intensive care unit (ICU) discharge of patients who were later readmitted to the ICU and patients discharged home and to verify whether a decline in functional status is associated with ICU readmission. DESIGN Prospective cohort study. SETTING ICU at a tertiary teaching hospital. PARTICIPANTS Patients admitted to the ICU, ≥18 years old, submitted to invasive mechanical ventilation (IMV), and discharged to the ward. INTERVENTIONS Functional assessment at ICU discharge. Discharge Group (DG) (patients discharged home) and Readmission Group (RG) (patients who returned to the ICU) were compared with Mann-Whitney and Chi-square or Exact Fisher tests. Multiple logistic regression verified association. MAIN OUTCOME MEASURES Barthel Index, key pinch strength, clinical and demographic data. RESULTS Patients in the readmission group presented lower Barthel Index [Median 40 (IQR 20-75) vs 60 (33-83), P=0.033], greater relative variation (pre and post ICU) of the Barthel Index (P=0.04), lower key pinch strength [3.4 (1.8-4.5) vs 4.5 (2.7-6.8)kg·f, P=0.006] and higher APACHE II [18 (12-22) vs 15 (11-20), P=0.027]. Multiple regression found that the relative variation of the Barthel Index was independently associated with ICU readmission (P<0.001), as well as higher APACHE II (P=0.020), shorter IMV duration (P<0.001) and ICU admission without clear diagnosis (P=0.020). The Hosmer-Lemeshow test indicated good adjustment of the model (P=0.99). CONCLUSION Readmitted patients presented poorer functional status and lower pinch strength. Relative variation of the Barthel Index was associated with ICU readmission despite other factors, as was higher APACHE II, shorter IMV duration and admission without clear diagnosis. TRIAL REGISTRATION NUMBER Not applicable.

Assessing functional status after intensive care unit stay: the Barthel Index and the Katz Index

Objective To assess the functional status of post-ICU patients using the Barthel Index (BI) and the Katz Index (KI) and to assess which is more suitable for this population. Design Retrospective longitudinal study. Setting Public tertiary hospital in São Paulo (Brazil). Participants Patients aged ≥18 years old, admitted to ICU, who were treated with mechanical ventilation (MV) ≥ 24 h and were discharged to ward. Exclusion criteria Inability to answer the BI and the KI; limiting neurological or orthopaedic conditions; ICU stay ≥90 days. Patients transferred to or from other hospitals or who died in the wards were not analysed. Intervention BI and KI were scored pre-ICU and post-ICU and the variation was calculated. Main Outcome Measures BI and KI scores were compared using analysis based on item response theory (IRT), using degree of difficulty and discriminating items as parameters. Results Median age was 52 years old, median APACHE II score was 15. Median ICU stay was 11 days and median MV duration was 4 days. BI variation was 44% and KI variation was 55%. In IRT analysis, BI considered a larger number of items with different levels of difficulty. Conclusion Both the BI and the KI revealed significant deterioration of functional status after ICU discharge. The IRT analysis suggested that the Barthel Index might be a better scale than the Katz Index for the assessment of functional status of patients discharged from ICU, since it presented better discrimination of the ability to carry out the tasks.

Fisioterapia nos pacientes politraumatizados graves: modelo de assistência terapêutica

Objetivo: Conhecendo-se o alto grau de complexidade que o paciente politraumatizado representa a equipe multiprofissional na elaboracao e execucao do seu plano assistencial na unidade de terapia intensiva (UTI), aliado a carencia de evidencias sobre o tema, o presente estudo sugere um modelo de assistencia fisioterapeutica precoce aos pacientes criticos politraumatizados com base na experiencia clinica dos ultimos anos. Metodo: O modelo foi elaborado a partir das praticas verificadas nos registros de 6388 sessoes de fisioterapia realizadas em 198 pacientes internados entre dezembro de 2009 e setembro de 2011 em UTI especializada em politrauma. As atividades/ cuidados foram inseridas no modelo apos aprovadas em discussao com a equipe multiprofissional. Todos os pacientes atendidos tinham idade igual ou maior que 18 anos e eram vitimas de trauma grave de acordo com o Injury Severity Score (ISS). Resultados: O modelo proposto foi estruturado de forma que as atividades/cuidados da assistencia fisioterapeutica fossem organizadas de acordo com a regiao corporea lesada do paciente (traumatismo cranioencefalico, fraturas de face, fraturas de coluna, trauma toracico, trauma abdominal, fratura de pelve e fraturas de extremidades). A rotina da unidade apregoava discussoes diarias com a equipe medica para se conhecer as particularidades de cada caso clinico, estabelecer meta terapeutica e tracar o programa de reabilitacao. Conclusao: O modelo proposto se tornou rotina e consolidou a atuacao fisioterapeutica na respectiva unidade assistencial. A equipe de fisioterapia passou a atuar 24 horas por dia. O modelo possibilitou padronizacao da assistencia fisioterapeutica e maior seguranca para o paciente politraumatizado grave.

Quality of life of critically ill patients in a developing country: a prospective longitudinal study

[Purpose] To evaluate the quality of life of critical illness survivors in a developing country over the time after hospital discharge and to assess the influence of clinical variables on quality of life. [Subjects and Methods] A prospective longitudinal study was conducted in a large, tertiary, public hospital in Sao Paulo, Brazil. We included patients ≥18 years old, hospitalized in the intensive care unit with ≥24 hours of invasive mechanical ventilation. Quality of life was assessed using the Medical Outcomes Study 36-Item Short Form Health Survey, which was applied by telephone interview at the first, third and sixth months after hospital discharge. [Results] 75 patients were included in the study. Quality of life improved progressively after hospital discharge; role-physical was the most compromised domain. The physical component was influenced by the age. Quality of life was not influenced by Apache II categorization, length of invasive mechanical ventilation, intensive care unit stay or hospital stay. [Conclusion] Survivors of critical illness in a developing country present poor quality of life, which improves over time. Age influenced the physical component of quality of life.

Recovery of functional capacity in severe trauma victims at one year after injury: association with trauma-related and hospital stay aspects

[Purpose] The aim of this study was to investigate the functional capacity of trauma survivors one year after hospital discharge and to identify associations with trauma- and hospital stay-related aspects in a developing country. [Subjects and Methods] This study included severe trauma patients (Injury Severity Score ≥16; ≥18 years old) who were admitted to an intensive care unit in Sao Paulo, Brazil. Hospital stay data were collected from the patients’ records. Functional capacity was assessed using the Glasgow Outcome Scale and Lawton Instrumental Activities of Daily Living Scale one year after hospital discharge. Patients were asked if they had returned to work/school. [Results] Forty-nine patients completed follow-up. According to the Glasgow Outcome Scale data, most patients had moderate or mild/no dysfunction. The Lawton Instrumental Activities of Daily Living Scale showed that 60–70% of the subjects performed most activities independently. Multiple linear regression of the Glasgow score, Acute Physiology and Chronic Health Disease Classification System II score, length of mechanical ventilation, and hospital length of stay revealed an association between the Lawton Instrumental Activities of Daily Living Scale and hospital length of stay. Overall, 32.6% of the subjects had returned to work/school. [Conclusion] Most severe trauma patients experienced functional recovery, although only one-third had returned to work/school one year after hospital discharge. Hospital length of stay was identified as a significant predictor of functional recovery.

Declínio de atividades instrumentais de vida diária associado à perda de força de preensão palmar em idosos internados em enfermaria geriátrica

OBJECTIVE: To verify the association between the ability to perform instrumental activities of daily living (IADL) and handgrip strength in hospitalized geriatric patients without cognitive impairment. METHODS: Cross-sectional study. Elderly patients aged over 60 years of both genders admitted to geriatric patients ward were included. On the other hand, elderly with neurological, musculoskeletal and respiratory acute exacerbated diseases; individuals with medical indication of rest or use of clinical apparatus, cognitive impairment and/or delirium were excluded. Data were collected from medical records. The ability to perform IADL was assessed by Lawton Scale and the handgrip strength was measured using handheld dynamometry on the dominant upper limb. A descriptive analysis with mean and standard deviation was carried out. The Pearson correlation test was applied to verify association between the total score of Lawton Scale and handgrip strength. RESULTS: The study included 12 patients (75% women) whose mean age were 80.67±6.35 years. The mean of handgrip strength and total Lawton Scale score were 11.96±6.71 Kgf and 22.58±1.67 points, respectively. A moderate positive association between handgrip strength and Lawton Scale score (r=0.640; p=0.025) was found. CONCLUSION: The handgrip strength and IADLs were associated in this study population.