The epidemiology of chronic critical illness is not well characterized. We sought to determine the prevalence, outcomes, and associated costs of chronic critical illness in the United States.
...Population-based cohort study using data from the United States Healthcare Costs and Utilization Project from 2004 to 2009.
Acute care hospitals in Massachusetts, North Carolina, Nebraska, New York, and Washington.
Adult and pediatric patients meeting a consensus-derived definition for chronic critical illness, which included one of six eligible clinical conditions (prolonged acute mechanical ventilation, tracheotomy, stroke, traumatic brain injury, sepsis, or severe wounds) plus at least 8 days in an ICU.
None.
Out of 3,235,741 admissions to an ICU during the study period, 246,151 (7.6%) met the consensus definition for chronic critical illness. The most common eligibility conditions were prolonged acute mechanical ventilation (72.0% of eligible admissions) and sepsis (63.7% of eligible admissions). Among patients meeting chronic critical illness criteria through sepsis, the infections were community acquired in 48.5% and hospital acquired in 51.5%. In-hospital mortality was 30.9% with little change over the study period. The overall population-based prevalence was 34.4 per 100,000. The prevalence varied substantially with age, peaking at 82.1 per 100,000 individuals 75-79 years old but then declining coincident with a rise in mortality before day 8 in otherwise eligible patients. Extrapolating to the entire United States, for 2009, we estimated a total of 380,001 cases; 107,880 in-hospital deaths and $26 billion in hospital-related costs.
Using a consensus-based definition, the prevalence, hospital mortality, and costs of chronic critical illness are substantial. Chronic critical illness is particularly common in the elderly although in very old patients the prevalence declines, in part because of an increase in early mortality among potentially eligible patients.
Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and ...preferences into treatment decisions.
To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients.
A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included.
Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning.
Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%).
Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.
Family caregivers of patients with chronic critical illness experience significant psychological distress.
To determine whether family informational and emotional support meetings led by palliative ...care clinicians improve family anxiety and depression.
A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes.
At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group.
The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 best to 42 worst; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 best to 88 worst), discussion of patient preferences, hospital length of stay, and 90-day survival.
Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 95% CI, -0.9 to 2.6; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 95% CI, 0.01 to 9.10; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 95% CI, 0.34 to 1.16; P = .14). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days 95% CI, -6 to 3 days; P = .51) and 90-day survival (hazard ratio, 0.95 95% CI, 0.65 to 1.38, P = .96) were not significantly different.
Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.
clinicaltrials.gov Identifier: NCT01230099.
Physician burnout associated with EHRs is a major concern in health care. A comprehensive assessment of differences among physicians in the areas of EHR performance, efficiency, and satisfaction has ...not been conducted. The study sought to study relationships among physicians' performance, efficiency, perceived workload, satisfaction, and usability in using the electronic health record (EHR) with comparisons by age, gender, professional role, and years of experience with the EHR.
Mixed-methods assessments of the medical intensivists' EHR use and perceptions. Using simulated cases, we employed standardized scales, performance measures, and extensive interviews. NASA Task Load Index (TLX), System Usability Scale (SUS), and Questionnaire on User Interface Satisfaction surveys were deployed.
The study enrolled 25 intensive care unit (ICU) physicians (11 residents, 9 fellows, 5 attendings); 12 (48%) were men, with a mean age of 33 (range, 28-55) years and a mean of 4 (interquartile range, 2.0-5.5) years of Epic experience. Overall task performance scores were similar for men (90% ± 9.3%) and women (92% ± 4.4%), with no statistically significant differences (P = .374). However, female physicians demonstrated higher efficiency in completion time (difference = 7.1 minutes; P = .207) and mouse clicks (difference = 54; P = .13). Overall, men reported significantly higher perceived EHR workload stress compared with women (difference = 17.5; P < .001). Men reported significantly higher levels of frustration with the EHR compared with women (difference = 33.15; P < .001). Women reported significantly higher satisfaction with the ease of use of the EHR interface than men (difference = 0.66; P =.03). The women's perceived overall usability of the EHR is marginally higher than that of the men (difference = 10.31; P =.06).
Among ICU physicians, we measured significant gender-based differences in perceived EHR workload stress, satisfaction, and usability-corresponding to objective patterns in EHR efficiency. Understanding the reasons for these differences may help reduce burnout and guide improvements to physician performance, efficiency, and satisfaction with EHR use.
Mixed-methods assessments of the medical intensivists' EHR use and perceptions. Using simulated cases, we employed standardized scales, performance measures, and extensive interviews.
Patients who are chronically critically ill constitute 5-10% of patients with acute respiratory failure but demand a disproportionate share of ICU resources. Epidemiologic studies and clinical trials ...require definitions for enrollment, and a uniform definition would be ideal to allow comparisons between studies. While a consensus definition exists (≥ 21 consecutive days of mechanical ventilation for ≥ 6 h/d), many study designs have required alternative definitions that include requirement for a tracheostomy, a different period of mechanical ventilation, or admission to a weaning facility. Regardless of definition, studies have indicated that the incidence of chronic critical illness has doubled in recent decades and may double again in the next decade. The overall 1-year survival for chronically critically ill patients is between 40% and 50%, depending on the cohort studied. New clinical prediction rules have been developed to better identify patients who are at high risk and low risk of death. These models could be enhanced by data on functional outcomes for survivors. The healthcare system has been adapting to the increase in chronic critical illness by increasing critical beds in short-term and long-term acute care hospitals, but continued monitoring of resources will be necessary, since the prevalence of chronic critical illness is expected to increase further.
Costs of care in the intensive care unit are a frequent area of concern in our current health care system. Utilization of critical care services in the United States, particularly near the end of ...life, has been steadily increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently experience prolonged hospitalizations and consume significant health care resources. Many patients are discharged with functional limitations and require significant postdischarge services. These patients have a high susceptibility to new complications which require significant additional health care resources. There is a slowly growing literature on the cost-effectiveness of the treatment of ARDS; despite its high costs, treatment remains a cost-effective intervention by most societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment may become less cost-effective. In addition, the provision of extracorporeal life support adds another layer of complexity to these cases. Small reductions in intensive care unit length of stay may benefit patients, but they do not lead to significant reductions in overall hospital costs. Early discharge to postacute care facilities can reduce hospital costs but is unlikely to significantly decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes. However, the most significant cost-saving interventions are early recognition and treatment of conditions to potentially prevent the development of this serious complication.
Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle ...performance and patient-centered outcomes in critical care.
Prospective, multicenter, cohort study from a national quality improvement collaborative.
68 academic, community, and federal ICUs collected data during a 20-month period.
15,226 adults with at least one ICU day.
We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.
Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio AOR, 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).
ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
Communication between families and providers in the ICU affects patient and family outcomes and use of health-care resources. Recent research studies have tested interventions designed to improve ...communication quality and outcomes between providers and families of patients in the ICU. We conducted a systematic review of these studies.
We searched the MEDLINE, PsychInfo, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from 1995 to July 2010. We included studies that reported controlled clinical interventions designed to improve communication between providers and families of patients in the ICU aged 18 years or older. We abstracted all selected studies to a standardized data collection instrument and completed a quality checklist based on recommendations from the Consolidated Standards for Reporting Trials (CONSORT) investigators.
In all, 2,841 articles were identified. Of those articles, 180 met the criteria for full review, and 21 articles of 16 distinct interventions met the full inclusion criteria, of which five were randomized. Interventions studied included printed information or structured family conferences, with or without additional family support. Conferences aimed to communicate the diagnosis and prognosis, elicit patient values, assess family understanding, and clarify the goals of treatment. Printed information, palliative care or ethics consultation, or regular, structured communication by the usual ICU team reduced family distress, improved comprehension, and decreased the use of intensive treatments.
The evidence supports the use of printed information and structured communication by the usual ICU team, ethics consultation, or palliative care consultation to improve family emotional outcomes and to reduce ICU length of stay and treatment intensity. Evidence that these interventions reduce total costs is inconclusive. A comprehensive research agenda should ensure the future study of a full range of patient-centered outcomes.
Long-term acute care hospitals have emerged as a novel approach for the care of patients recovering from severe acute illness, but the extent and increases in their activity at the national level are ...unknown.
To examine temporal trends in long-term acute care hospital utilization after an episode of critical illness among fee-for-service Medicare beneficiaries aged 65 years or older.
Retrospective cohort study using the Medicare Provider Analysis and Review files from 1997 to 2006. We included all Medicare hospitalizations involving admission to an intensive care unit of an acute care, nonfederal hospital within the continental United States.
Overall long-term acute care utilization, associated costs, and survival following transfer.
The number of long-term acute care hospitals in the United States increased at a mean rate of 8.8% per year, from 192 in 1997 to 408 in 2006. During that time, the annual number of long-term acute care admissions after critical illness increased from 13,732 to 40,353, with annual costs increasing from $484 million to $1.325 billion. The age-standardized population incidence of long-term acute care utilization after critical illness increased from 38.1 per 100,000 in 1997 to 99.7 per 100,000 in 2006, with greater use among male individuals and black individuals in all periods. Over time, transferred patients had higher numbers of comorbidities (5.0 in 1997-2000 vs 5.8 in 2004-2006, P < .001) and were more likely to receive mechanical ventilation at the long-term acute care hospital (16.4% in 1997-2000 vs 29.8% in 2004-2006, P < .001). One-year mortality after long-term acute care hospital admission was high throughout the study period: 50.7% in 1997-2000 and 52.2% in 2004-2006.
Long-term acute care hospital utilization after critical illness is common and increasing. Survival among Medicare beneficiaries transferred to long-term acute care after critical illness is poor.
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