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Dettling-Ihnenfeldt D.S.1, Nollet F.1, Beelen A.1, van der Schaaf M.1,2
1University of Amsterdam, Academic Medical Center, Rehabilitation Medicine, Amsterdam, Netherlands, 2Amsterdam University of Applied Sciences, ACHIEVE-Centre of Applied Research, Faculty of Health, Amsterdam, Netherlands
Background: Many intensive care unit (ICU) survivors have physical, mental and cognitive sequelae after discharge from the ICU, known as post-intensive care syndrome (PICS). These problems are associated with long-lasting restrictions in daily functioning and reduced health-related quality of life (QoL), and can also negatively affect family members (PICS-F). The nature of these restrictions require interdisciplinary rehabilitation care, but to date there is no structured pathway for the prevention and treatment of the symptoms of PICS.
Purpose: The aim of this doctoral thesis was to explore the course and prognosis of functioning in ICU survivors, and to investigate means for early identification of PICS, in order to develop an optimal care pathway for patients and their families.
Methods: We conducted 5 studies. The first study investigated the functional status and its potential determinants in ICU survivors, within the first week after ICU discharge. The next two studies investigated the impact of ICU-acquired weakness (ICU-AW) on functional outcome at 3, 6 and 12 months. The fourth study investigated the association of coping styles and quality of life (QoL). The last study evaluated the feasibility of a post-ICU clinic in different hospital settings.
Results: Within the first week after ICU discharge, the majority of patients had severe restrictions in performing activities of daily living, and were unable to walk independently. Besides physical limitations, one third had cognitive impairments. Duration of mechanical ventilation was associated with poorer functional status immediately after discharge from the ICU. ICU-AW was independently associated with higher post-ICU mortality and poorer physical functioning at 6 months. Patients with ICU-AW were less likely to be discharged home than patients without ICU-AW. At 3, 6 and 12 months after ICU discharge, physical functioning was significantly more impaired in patients with ICU-AW compared to patients without ICU-AW. Social functioning remained severely restricted in the majority of ICU survivors, independent from ICU-AW.
Regarding coping styles and QoL, we found that an emotion-oriented coping style was independently associated with reduced mental health. In order to facilitate continuity of care, post-ICU clinics could be useful to identify recovery problems in critically ill patients who are discharged to their homes. The use of validated screening instruments with pre-defined cut-off points enabled the identification of PICS in ICU survivors and their family members.
Conclusion(s): Patients with prolonged ICU-stay, longer duration of mechanical ventilation, and/or ICU-AW as well as their relatives, have a higher risk of short- and long-term functional impairments, limitations in activities and restrictions in participation. A majority does not receive adequate rehabilitation care after discharge from the hospital.
Implications: Patients and their close relatives should be closely monitored after discharge from the ICU to initiate interdisciplinary rehabilitation treatment. To improve the quality of survivorship, we propose a structured, stepped care rehabilitation pathway, consisting of clinical assessments with validated screening instruments, interdisciplinary rehabilitation interventions, tailored to the patients abilities and needs, and adequate handover in the transition of care.
Funding acknowledgements: This research was financially supported by the Academic Medical Center Amsterdam, the Netherlands.
Topic: Critical care
Ethics approval: Institutional review board of the AMC waved the need for informed consent because of the nonintrusive nature of the studies.
All authors, affiliations and abstracts have been published as submitted.
