Joanne McPeake

Assessment and management of alcohol-related admissions to UK intensive care units

BACKGROUND The critical care environment has felt the overwhelming impact of the growing problem of alcohol abuse. However, there is ambiguity concerning the assessment and management of this patient group. AIM The aim of this study was to explore current practice in the use of assessment and management tools for alcohol-related admissions in UK intensive care units (ICU). METHODS Two hundred and forty-eight lead consultants across England, Scotland, Northern Ireland and Wales were sent an electronic survey using the SurveyMonkey(®) ( www.surveymonkey.com) website. RESULTS A total of 103 (41·05%) lead consultants responded to the survey. Most units (67%) utilized the volume of alcohol consumed per week to assess patient alcohol use. Furthermore, 12 units (11%) used the Clinical Institute Withdrawal Assessment tool, 5 units (5%) used the Glasgow Modified Alcohol Withdrawal Scale and 79 units (73%) used no tool for the management of alcohol withdrawal syndrome. CONCLUSION There appears to be a diverse approach to the assessment and management of alcohol-related admissions in UK ICUs. Further research is required in this area to identify the most effective way to assess and manage alcohol-related admissions within intensive care. RELEVANCE TO CLINICAL PRACTICE Under recognition and poor assessment of alcohol use can have major implications for critically ill patients.

Validation and analysis of prognostic scoring systems for critically ill patients with cirrhosis admitted to ICU

IntroductionThe number of patients admitted to ICU who have liver cirrhosis is rising. Current prognostic scoring tools to predict ICU mortality have performed poorly in this group. In previous research from a single centre, a novel scoring tool which modifies the Child-Turcotte Pugh score by adding Lactate concentration, the CTP + L score, is strongly associated with mortality. This study aims to validate the use of the CTP + L scoring tool for predicting ICU mortality in patients admitted to a general ICU with cirrhosis, and to determine significant predictive factors for mortality with this group of patients. This study will also explore the use of the Royal Free Hospital (RFH) score in this cohort.MethodsA total of 84 patients admitted to the Glasgow Royal Infirmary ICU between June 2012 and Dec 2013 with cirrhosis were included. An additional cohort of 115 patients was obtained from two ICUs in London (St George’s and St Thomas’) collected between October 2007 and July 2009. Liver specific and general ICU scoring tools were calculated for both cohorts, and compared using area under the receiver operating characteristic (ROC) curves. Independent predictors of ICU mortality were identified by univariate analysis. Multivariate analysis was utilised to determine the most predictive factors affecting mortality within these patient groups.ResultsWithin the Glasgow cohort, independent predictors of ICU mortality were identified as Lactate (p < 0.001), Bilirubin (p = 0.0048), PaO2/FiO2 Ratio (p = 0.032) and PT ratio (p = 0.012). Within the London cohort, independent predictors of ICU mortality were Lactate (p < 0.001), PT ratio (p < 0.001), Bilirubin (p = 0.027), PaO2/FiO2 Ratio (p = 0.0011) and Ascites (p = 0.023). The CTP + L and RFH scoring tools had the highest ROC value in both cohorts examined.ConclusionThe CTP + L and RFH scoring tool are validated prognostic scoring tools for predicting ICU mortality in patients admitted to a general ICU with cirrhosis.

Do alcohol use disorders impact on long term outcomes from intensive care

IntroductionThere is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge.MethodThis was an 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency.Results34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001).ConclusionAlcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

PURPOSE This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting. METHODS This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed. RESULTS Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86). CONCLUSIONS This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores.

Caregiver strain following critical care discharge: An exploratory evaluation

OBJECTIVE The objective of this exploratory evaluation was to understand the impact of critical care survivorship on caregivers. DESIGN Family members who attended a quality improvement initiative within our critical care unit were asked to complete 4 questionnaires. SETTING The setting for this study was a 20-bedded mixed critical care unit in a large teaching hospital in Scotland. Data were collected as a part of an evaluation of a quality improvement initiative. PARTICIPANTS Thirty-six carers completed the questionnaire set. MEASUREMENTS AND MAIN RESULTS A total of 53% of caregivers suffered significant strain. Poor quality of life in the patient was significantly associated with higher caregiver strain (P= .006). Anxiety was present in 69% of caregivers. Depression was present in 56% of caregivers, with a significant association between carer strain and depression (P< .001). Those caregivers who were defined as being strained also had significantly higher Insomnia Severity Index scores than those without carers strain (P= .007). CONCLUSION This evaluation has demonstrated that there is a significant burden for caregivers of critical care survivors. Furthermore, they reported high levels of posttraumatic stress disorder, anxiety, depression, and insomnia. Future work on rehabilitation from critical care should focus on the inclusion of caregivers.

Health and social consequences of an alcohol-related admission to critical care: a qualitative study

Objective To examine the impact of critical care on future alcohol-related behaviour. Further, it aimed to explore patterns of recovery for patients with and without alcohol use disorders beyond the hospital environment. Design In-depth, semistructured interviews with participants (patients) 3–7 months post intensive care discharge. Setting The setting for this study was a 20-bedded mixed intensive care unit (ICU), in a large teaching hospital in Scotland. On admission, patients were allocated to one of the three alcohol groups: low risk, harmful/hazardous and alcohol dependency. Participants 21 participants who received mechanical ventilation for greater than 3 days were interviewed between March 2013 and June 2014. Interventions None. Measurements and main results Four themes which impacted on recovery from ICU were identified in this patient group: psychological resilience, support for activities of daily living, social support and cohesion and the impact of alcohol use disorders on recovery. Participants also discussed the importance of personalised goal setting and appropriate and timely rehabilitation for alcohol-related behaviours during the critical care recovery period. Conclusions There is a significant interplay between alcohol misuse and recovery from critical illness. This study has demonstrated that at present, there is a haphazard approach to rehabilitation for patients after ICU. A more targeted rehabilitation pathway for patients leaving critical care, with specific emphasis on alcohol misuse if appropriate, requires to be generated.

Peer support to improve recovery following critical care discharge: a case-based discussion

We report the case of a self-employed builder aged 58-years, with a medical history of ischaemic heart disease and type II diabetes. He was transferred to our intensive care unit (ICU) from another local hospital for treatment of gallstone pancreatitis. He stayed in critical care for 19 days, with a total hospital stay of 9 weeks. He and his wife have consented to the presentation of their case. This patient required level three care (ICU care) for 3 days. He required level two care (high dependency care) for a further 16 days due to complications related to his acute kidney injury and pancreatitis. He was mechanically ventilated for 3 days with a worst P/F ratio of 150 mmHg and underwent renal replacement therapy for 8 days. As per standard practice in the ICU at the time, he was visited by physical therapy on 17 of his 19 ICU days. This patient has two children and a wife who works as a Nursery Teacher. After discharge from hospital, he returned to his own home. At discharge from hospital, aerobic capacity was assessed using the incremental shuttle walk test. The patient scored a metabolic equivalent of 2.4 on this test (this represents an ability to undertake a low intensity exercise programme).1 Grip strength measurements were obtained and were 16 kg (right hand) and 12 kg (left hand), less than half of expected when compared with the population norm.2 At home, further nutritional support from a nasogastric tube (NGT) was required. The patient also had significant fatigue, limb weakness, lethargy, decreased balance and shortness of breath. At 2 months post-discharge from hospital, neither he nor his wife had returned to work. In light of these problems, at 2 months post-ICU discharge, both the patient and his wife were invited to participate in Intensive Care Syndrome: Promoting Independence and Return to Employment …

Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE). Early evaluation of a complex intervention

Background Many patients suffer significant physical, social and psychological problems in the months and years following critical care discharge. At present, there is minimal evidence of any effective interventions to support this patient group following hospital discharge. The aim of this project was to understand the impact of a complex intervention for ICU survivors. Methods Quality improvement project conducted between September 2014 and June 2016, enrolling 49 selected patients from one ICU in Scotland. To evaluate the impact of this programme outcomes were compared to an existing cohort of patients from the same ICU from 2008–2009. Patients attended a five week peer supported rehabilitation programme. This multidisciplinary programme included pharmacy, physiotherapy, nursing, medical, and psychology input. The primary outcome in this evaluation was the EQ-5D, a validated measure of health-related quality of life. The minimally clinically important difference (MCID) in the EQ-5D is 0.08. We also measured change in self-efficacy over the programme duration. Based on previous research, this study utilised a 2.4 (6%) point change in self-efficacy scores as a MCID. Results 40 patients (82%) completed follow-up surveys at 12 months. After regression adjustment for those factors known to impact recovery from critical care, there was a 0.07–0.16 point improvement in quality of life for those patients who took part in the intervention compared to historical controls from the same institution, depending on specific regression strategy used. Self-efficacy scores increased by 2.5 points (6.25%) over the duration of the five week programme (p = 0.003), and was sustained at one year post intervention. In the year following ICU, 15 InS:PIRE patients returned to employment or volunteering roles (88%) compared with 11 (46%) in the historical control group (p = 0.15). Conclusions and relevance This historical control study suggests that a complex intervention may improve quality of life and self-efficacy in survivors of ICU. A larger, multi-centre study is needed to investigate this intervention further.

Validation of a prognostic scoring system for critically ill patients with cirrhosis admitted to ICU

Introduction: The number of patients admitted to ICU who have liver cirrhosis is rising. Current prognostic scoring tools to predict ICU mortality have performed poorly in this group. In previous research from a single centre, a novel scoring tool which modifies the Child-Turcotte Pugh score by adding Lactate concentration, the CTP + L score, is strongly associated with mortality. This study aims to validate the use of the CTP + L scoring tool for predicting ICU mortality in patients admitted to a general ICU with cirrhosis, and to determine significant predictive factors for mortality with this group of patients. This study will also explore the use of the Royal Free Hospital (RFH) score in this cohort. Methods: A total of 84 patients admitted to the Glasgow Royal Infirmary ICU between June 2012 and Dec 2013 with cirrhosis were included. An additional cohort of 115 patients was obtained from two ICUs in London (St George’s and St Thomas’) collected between October 2007 and July 2009. Liver specific and general ICU scoring tools were calculated for both cohorts, and compared using area under the receiver operating characteristic (ROC) curves. Independent predictors of ICU mortality were identified by univariate analysis. Multivariate analysis was utilised to determine the most predictive factors affecting mortality within these patient groups. Results: Within the Glasgow cohort, independent predictors of ICU mortality were identified as Lactate (p <0.001), Bilirubin (p = 0.0048), PaO 2 /FiO 2 Ratio (p = 0.032) and PT ratio (p = 0.012). Within the London cohort, independent predictors of ICU mortality were Lactate (p <0.001), PT ratio (p < 0.001), Bilirubin (p = 0.027), PaO 2 /FiO 2 Ratio (p = 0.0011) and Ascites (p = 0.023). The CTP + L and RFH scoring tools had the highest ROC value in both cohorts examined. Conclusion: The CTP + L and RFH scoring tool are validated prognostic scoring tools for predicting ICU mortality in patients admitted to a general ICU with cirrhosis.

896: The Creation Of The First Icu Patient And Family Advisory Council In The Uk

Learning Objectives: The creation of person centred care is central to national and international policy. One way of achieving person centred care within the critical care environment is to ensure that patients and family members co-produce healthcare services and are involved in the quality improvement agenda. This can be achieved through the use of a Patient and Family Advisory Council (PFAC). Methods: We invited 12 patient and family members to our first PFAC. We recruited a variety of participants including those who had made a complaint about aspects of our service and those from different backgrounds and specialities. The PFAC met bimonthly in a room off of the ICU. The PFAC was co-chaired by a patient or carer. The agenda for each meeting was also co-produced by the Council. Results: The PFAC identified five main stages of the critical care journey for patient and carers: arrival in ICU, the ICU stay, discharge to the ward, discharge home and ongoing recovery. This led to significant changes within our ICU including: improvements in the provision of information for relatives and patients, improved signage to the ICU and the creation of an information leaflet for ward staff. The PFAC has also helped design our current ICU rehabilitation program. Changes to the downstream ward areas are an ongoing area of work but will include patient volunteers. The PFAC will approve a final report which will be sent to the Chief Executive of our organization. This ICU PFAC Framework will be used for future Councils in our hospital to shape improvements in care. Conclusions: The creation of a PFAC is feasible and appropriate in the ICU environment. Our PFAC has helped established meaningful change in both our ICU and hospital.