Multiple interventions in the ICU - are they worthwhile?
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The document discusses multiple interventions in the ICU and whether they are worthwhile. It summarizes several randomized controlled trials that tested interventions like physiotherapy and recovery programs in the ICU. While some individual studies found benefits, the results were mixed overall. A qualitative study within one RCT found that patients valued the confirmation and information provided by follow-up consultations, despite the RCT finding no differences in quality of life scores between groups. There are challenges in measuring outcomes that are most important to patients, as their experiences did not always align with generic quality of life scales used.
Multiple interventions in the ICU - are they worthwhile?
- 1. Multiple interventions in the ICU - are they worthwhile? Janet Froulund Jensen, Post.doc., PHD Department of Anesthesiology Holbæk Hospital
- 2. What do we know? - Mixed results from a RCT Challenges Perspectives Presentation
- 3. What do we know Trial n Population Intervention Compari son Primary outcomes Effect Schweickert et al (2009) 104 ICU admission (Ventilatory support >72 h) Physiotherapy in the ICU SC Functional status, at hospital discharge (28 days) + Elliot et al (2011) 195 ICU admission (Ventilatory support >24 h) Physiotherapy SC Physical function, SF- 36, 6M - Denehy et al (2013) 150 ICU admission Physiotherapy SC Physical function, 6 min walk test, 12M - Moss et al (2016) 120 ICU admission (Ventilatory support, no time) Physiotherapy SC Physical function, 1M - Morris et al (2016) 300 ICU admission (Ventilatory support, No time) Physiotherapy SC LOS - Hospital - McDowell et al (2017) 60 ICU admission (ventilatory support >96 h) Physiotherapy SC Physical function, SF- 36, 2,5M - Jones et al (2010) 352 ICU admission (ventilatory support >72 h) ICU diary in the ICU SC Not reported, 3M + Cuthbertson et al (2009) 286 ICU admission (Ventilatory support, No time) Complex intervention (Physical and psychological program) SC HRQOL, SF-36, 12M - Walsh et al (2015) 240 ICU admission (Ventilatory support >48 h) Complex intervention (Rehabilitation professionals) SC Physical function, 3M - Jensen et al (2016) 386 ICU admission (Ventilatory support >48 h) Complex intervention (Recovery program) SC Mental health, SF-36, 12M -
- 4. What about patient experience Study n Population/aim Design/Data Source Themes Effectiveness Jonasdóttir at al (2016) 17 Post-ICU To synthesize the advantages of nurse-led ICU follow-up Integrative review The availability of the ICU follow-up service might be helpful <6 M ICU discharge Strong implications for patients’ satisfaction Prinhja et al (2009), UK 34 Patients Explore experiences of ICU follow-up care from the perspective of former patients Qual Interviews 1. Continuity of care 2. Receiving information 3. Importance of expert reassurance 4. Giving feedback to ICU staff Valued Without access to ICU follow-up -> often felt disappointed Harraldson et al (2015) 11 Patients Describe how ICU- patients experience a follow-up session Qual Interviews Clarified and confirmed experiences Without access to follow-up -> Some patients showed a greater need for a follow-up session Without access to ICU follow-up -> some showed a greater need Ramsay et al (2016), UK 22 14 Patients/8 carers To explore and compare patient/carer experiences of rehabilitation in both arms of the RECOVER study Mixed methods Experience questionnaire and focus group discussions (n=4) The case management approach might improve patient satisfaction by means as individualization of care Highly valued Concordance between Quan/qual data on patients’ satisfaction
- 5. RAPIT – A RCT •To test the effectiveness of a post-ICU recovery program on physical and psychological HRQOL, sense of coherence (SOC), anxiety, depression, and PTSD, and healthcare service utilization compared to SC 12 months after ICU discharge Aim •Non-blinded, two-armed, parallel-group, pragmatic randomized controlled trial •10 (level II–III) ICUs •Patients, who received mechanical ventilatory support for a minimum of 48 hours (n=386) Setting •Patients photographs during ICU-stay, three follow-up consultations •Standard careIntervention •Health-related quality of life (HRQOL) at 12 months Primary Outcome
- 6. Results primary outcomes 0 10 20 30 40 50 60 70 80 PHYSICAL FUNCTIONING SCALE ROLE PHYSICAL SCALE BODILY PAIN SCALE GENERAL HEALTH PERCEPTIONS VITALITY SCALE SOCIAL FUNCTIONING SCALE ROLE EMOTIONAL SCALE MENTAL HEALTH SCALE Complete data, ITT, HRQOL I 3M I 12M SC 3M SC 12M
- 7. Conclusion Overall, no beneficial or detrimental effectiveness were found on either primary or secondary outcomes. Danish patients surviving intensive care have a relatively decent life after 12 months with high scores on the mental component score on HRQOL, a strong SOC, and with less anxiety and depression compared with other studies
- 8. QUANTITATIVE STUDY – A RCT Design: Qualitative study embedded in RCT QUALITATIVE STUDY - A part of the RCT Aim: To describe the patient experience of ICU-recovery from a longitudinal perspective by analyzing follow-up consultations at three time-points Data collection: Patient photographs, Semi-structured Interviews in three follow-up consultations (n=12, 36 consultations)
- 9. Results
- 10. Conclusion Provides an understanding of the process of recovery after intensive care from a longitudinal patient perspective
- 11. Mixed results from RCT – The RAPIT-study RQ Quantitative Qualitative Conclusion What is the effects of the intervention? Quotes Third consultation: - All I needed was someone, who took care of me in the processes. Nobody else has contacted me. Actually I think it helped me because I had to reflect on things I would not have thought about. I've had a feeling of a caring person who took me seriously. That has been good (P1) - I have gained an insight into many things, and recognized my values that I didn’t before (P2) - I was very happy at the first consultation at the hospital when I got my pictures and all that (P6) - It was comforting and nice to know that some people do come back after such an experience (P8) - It was a strong experience to be so far out and come back again; especially when I got back so well. It's been good talking to you (P11) Quan: No difference Qual: Confirmation and information was valued Resolving the jigsaw puzzle gave a sense of coherence and understanding Beneficial to share the experience Discordance between Quan and Qual 0 10 20 30 40 50 60 70 80 AL FUNCTI ONING SCALE ROLE PHYSIC AL SCALE BODILY PAIN SCALE GENERA L HEALTH PERCEP TIONS VITALIT Y SCALE SOCIAL FUNCTI ONING SCALE ROLE EMOTIO NAL SCALE MENTA L HEALTH SCALE MI Intention-to-treat I 3M I 12M SC 3M SC 12M Preliminary analysis of a Joint display: Discordance?
- 12. Mixed results from RCT – The RAPIT-study RS Qualitative Quantitative Conclusion What is most important for patients after intensive care? Intervention: - To live and be happy for one's life, I’m alive still (P2) - When you have been seriously ill, you have some good days, and for a few days you’re all down. If you feel bad, I'm up again anyway (P12) Control: - It was close I know that. The fact that I'm sitting here today and I do have back pain, but it doesn’t matter because I'm alive - I'm happy for it - My health could be better. I was readmitted at the hospital again. Otherwise, it's very good, some days are significantly better than others. There are different days Both groups seem to appreciate life, even though some days are better than others Confirmation of “no differences between groups” But did we measure what was most important for patients in the two data sources? Discordance between patient experiences and the SF-36 scores 0 10 20 30 40 50 60 70 80 PHYSIC AL FUNCTI ONING SCALE ROLE PHYSIC AL SCALE BODILY PAIN SCALE GENER AL HEALT H PERCE PTIONS VITALI TY SCALE SOCIAL FUNCTI ONING SCALE ROLE EMOTI ONAL SCALE MENTA L HEALT H SCALE MI Intention-to-treat I 3M I 12M SC 3M Preliminary analysis of a joint display: Discordance?
- 13. Challenges - measurements OQL* Consensus Indicators Dimensions in general* General health Physical health Psychological health Sexual function Social function Indicators: Symptoms Existential questions (Why me?) Wellbeing Satisfaction ICU population in RAPIT SF-36: Two component scores Indicators: SOC Symptoms ICU population in conceptualizing HRQOL** Survivors’ health status and the impact of this on QOL Physical status Emotional/psychological status Cognitive status = life changing experience Conclusion: Significant gaps between generic measures and patient- based conceptualizing HRQOL Adapted from *Fayers, 2016 and **Lim et al. 2016
- 14. Challenges of measuring QOL Natural development? - Response shift theory Adapted from Spranger and Scwartz 1999 Catalyst Mechanism Response shift Perceived QOL Antecedent Antecedents Socio-demographics Personality Expectations Associated symptoms Catalysts Health status (progression) Events Experiences Interventions Mechanism Coping Social comparison Goal reordering Reframing expectations Adherence Response shift Changes in internal standards Values Conceptualization
- 15. - Conceptualization - Consensus on important outcomes and instruments - Development - Validation - Itembank – PROMIS (http://www.healthmeasures.net/explore- measurement-systems/promis) - Computer adaptive test - Improving long-term Outcomes (www.improvelto.com) - Core outcome measurement sets? - Specific QOL/follow-up measurement Perspectives
- 16. Multiple interventions in the ICU - are they worthwhile?
- 17. Acknowledgements Research Foundation, Nordsjællands Hospital, University of Copenhagen The Danish Nursing Organization The Novo Nordisk Foundation Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen All collaborators, The RAPIT-group and patients Graphics: Farmhouse design Photos: AV-Media, Nordsjællands Hospital, Stockphoto, and Colourbox
- 18. Thank you for your attention Contact: Jfje@regionsjaelland.dk
- 19. Looking beyond the ICU to survivorship Cost-benefits analysis Experiences from staff Telemedicine Big data –databases? Post-ICU data to direct treatment and prognosis, and inform and engage patients in establishing a choice of goals of care Optimize healthcare utilization Communication strategies Identify high-risk survivors Re-evaluate measurements/develop new Test new strategies/interventions Early ICU-based interventions Including sub-group analysis Perspectives
- 20. Health-related quality of life after Intensive care Prospective studies after 2010 have investigated HRQOL with at least three points in time using the Medical Outcome Study 36-Item Short-Form General Health Survey (SF-36) divided into the PCS and MCS after ICU discharge