A Survey of Implementation of ABCDE Protocols.

BACKGROUND: Spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), delirium assessment/management, early mobility have been termed the ABCDE bundle. The ABCDE bundle has been proven to improve patient outcomes. However, there is often a long gap in dissemination and implementation of evidence-based medicine. OBJECTIVES: To determine the prevalent implementation of and determinants for ABCDE protocol adoption in Pennsylvania. METHODS: We developed a survey of ABCDE bundle protocols. We surveyed factors around implementation including written protocol presence, standardized assessments to guide protocols, timing of creation of protocols, and estimated adherence to protocols. We also collected data on factors that might be determinants for protocol adoption including ICU staffing models, hospital and ICU level factors. We validated the survey tool using the Michigan Health and Hospital Association Keystone ICU collaborative. We then administered the validated survey to a leader of the medical ICU or mixed medical-surgical ICU of all Pennsylvania Hospitals. Multivariable logistic and ordinal regression were used to determine associations between ICU staffing models and hospital and ICU level factors with the presence of ABCDE bundle protocols. RESULTS: In the study cohort of Pennsylvania ICUs (n = 144), we had 100 respondents (69% response). The median number of hospital beds among the respondents was 185 (IQR 111-355) with a median of 14 ICU beds (IQR 10-20). 86% reported spontaneous awakening trial protocols, 60% reported spontaneous breathing trial protocols, 43% reported delirium assessment/management protocols, and 27% reported early mobility protocols. Being a medical ICU compared to a mixed medical-surgical ICU (OR 3.48, 95% CI 1.19-10.21, P = .02) and presence of multidisciplinary rounds (OR 4.97, 95% CI 2.07-11.94, P < .001) were associated with increasing number of ABCDE bundle protocol components. CONCLUSIONS: Variable implementation of ABCDE bundle protocols was present across Pennsylvania. Team communication is important to implementation of these protocols.

A Survey to Assess Primary Care Physician Awareness of Complications Following Critical Illness.

Background: Survivors of critical illness are at risk for post-intensive care syndrome (PICS, comprised of physical dysfunction, cognitive impairment, and neuropsychiatric disorders including anxiety, depression, and post-traumatic stress). Their family members and caregivers are at risk for PICS-F (PICS-family, comprised of anxiety, depression, post-traumatic stress). PICS and PICS-F are increasingly recognized in critical care; however, the awareness among primary providers of the domains and the terms of PICS/PICS-F is unknown. Objectives: To determine current practice patterns and knowledge among primary care physicians in regards to patients recovering from critical illness; to determine barriers to care of post-critically ill patients. Methods: A paper and electronic survey were developed and randomly distributed to a subset of North Carolina primary care physicians. Survey questions consisted of the following domains: demographics, current practice, barriers to providing care, knowledge of common issues/complications following critical illness, and interest in changing care for survivors of critical illness. Results: One hundred and ninety-six surveys were delivered and 77 completed surveys (39% response rate) were analyzed. Respondents confirmed significant barriers to care of post-critically ill patients including lack of awareness of PICS/PICS-F terminology, insufficient time to spend with patients, and inadequate education of patients/families about recovery after critical illness. Fifty-seven percent of respondents thought a specialized transitional post-ICU clinic would be helpful. Sixty-two percent reported feeling comfortable caring for patients after a critical illness and 75% felt they were aware of common problems encountered after critical illness. However, 84% also thought more education about PICS/PICS-F would be helpful as would a list of common problems seen after critical illness (91%). Conclusions: Significant gaps and barriers to providing optimal post-ICU care by PCPs exist. Providers identified time constraints and educational gaps as domains needing attention. Dedicated post-ICU clinics might provide a bridge to transition care post-critical illness back to primary care providers.

Patient and Caregiver-Derived Health Service Improvements for Better Critical Care Recovery.

OBJECTIVES: To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN: End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING: The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS: Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.

Transitions of Care After Critical Illness-Challenges to Recovery and Adaptive Problem Solving.

OBJECTIVES: Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges. DESIGN: Qualitative design-data generation via interviews and data analysis via the framework analysis method. SETTING: Patients and caregivers from three continents, identified through the Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness. INTERVENTIONS: Nil. MEASUREMENTS AND MAIN RESULTS: From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients-interacting with the health system and gaps in care; managing others' expectations of illness and recovery. 2) Challenges for caregivers-health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care-personal attributes, resources, and initiative; receiving support and helping others; and acceptance. CONCLUSIONS: Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care.

A randomized pilot study of nitrate supplementation with beetroot juice in acute respiratory failure.

Nitrate rich beetroot juice (BRJ) can enhance nitric oxide signaling, leading to improved physical function in healthy and diseased populations, but its safety and biologic efficacy have not been evaluated in a critically ill population. We randomized 22 previously functional acute respiratory failure patients to either BRJ or placebo daily until day 14 or discharge. We measured blood nitrate and nitrite levels and quantified strength and physical function at intensive care unit (ICU) and hospital discharge. Participants were predominantly male (54%), aged 68.5 years with an APACHE III score of 62. BRJ increased plasma nitrate (mean 219.2 µM increase, p = 0.002) and nitrite levels (mean 0.144 µM increase, p = 0.02). We identified no adverse events. The unadjusted and adjusted effect sizes of the intervention on the short physical performance battery were small (d = 0.12 and d = 0.17, respectively). In this pilot trial, administration of BRJ was feasible and safe, increased blood nitrate and nitrate levels, but had a small effect on physical function. Future studies could evaluate the clinical efficacy of BRJ as a therapy to improve physical function in survivors of critical illness.

Association of Hyperchloremia With Unfavorable Clinical Outcomes in Adults With Diabetic Ketoacidosis.

OBJECTIVE: Hyperchloremia is associated with worsened outcomes in various clinical situations; however, data are limited in patients with diabetic ketoacidosis (DKA). The purpose of this study was to determine the effect of hyperchloremia on time to DKA resolution. METHODS: We conducted a retrospective cohort study of adult patients admitted with incident DKA from January 2013 through October 2017 and stratified by the development of hyperchloremia versus maintaining normochloremia. The primary outcome was time to final DKA resolution. Secondary outcomes included time to initial DKA resolution, incidence of acute kidney injury (AKI) on admission, in-hospital development of AKI, and hospital length of stay (LOS). RESULTS: Of the 102 patients included, 52 developed hyperchloremia. Patients with hyperchloremia had longer times to final DKA resolution compared to those with normochloremia (median 22.3 [interquartile range, IQR, 15.2-36.9] vs 14.2 [IQR 8.8-21.1] hours; P = .001). Time to initial DKA resolution was also longer in patients who developed hyperchloremia compared to those who did not (median 16.3 vs 10.9 hours; P = .024). More patients with hyperchloremia developed in-hospital AKI (26.9% vs 8.0%; P = .01). Median hospital LOS was significantly longer in the hyperchloremia cohort (P < .001). On Cox regression analysis, time to DKA resolution was significantly longer with each 1 mmol/L increase in serum chloride (HR 0.951; P < .001). CONCLUSION: The presence of hyperchloremia in patients with DKA was associated with increased time to DKA resolution, risk of in-hospital AKI, and hospital LOS. Further evaluation of the avoidance or treatment of hyperchloremia in DKA is needed.

The fear and risk of community falls in patients following an intensive care admission: An exploratory cohort study.

BACKGROUND: Muscle weakness and impairments in physical functioning are well-recognised sequelae after critical illness. Whether individuals have a higher risk of community falls and a fear of falling has not been examined amongst individuals after critical illness. OBJECTIVES: The objective of this study was to explore the prevalence of falls, fear of falling, and fall risk in intensive care unit (ICU) survivors over a 6-month period after hospital discharge. METHODS: This was a nested exploratory study within a medical ICU. Fall prevalence was measured in line with established guidelines over 6 months after ICU discharge. Fear of falling and prediction of fall risk were assessed at 2, 4, and 6 months after discharge. RESULTS: Twelve individuals were included. Half of the cohort (n = 6) had at least one fall, with one-third sustaining more than one fall. There were 17 falls reported across the six individuals. Injuries requiring medical intervention were reported with five falls. Almost one-third were classified as 'moderate' to 'severe' injurious falls. Loss of balance and fatigue were reported as the main contributors to the falls. All individuals who had a fall reported a severe fear of falling at 2 months. Individuals classified as having 'moderate' to 'high' risk of falls at 2 months were more likely to have at least one fall. CONCLUSIONS: This study suggests that ICU survivors may have a high fall risk, fear of falling, and fall prevalence, which can result in significant injury.

Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing.

OBJECTIVES: To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model. DESIGN: Prospective observational study. SETTING: Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing. PATIENTS: Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS: As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS: Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS: Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative.

OBJECTIVES: Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN: We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING: Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS: Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS: A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.

Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives.

OBJECTIVES: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS: Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.

A randomized trial of nighttime physician staffing in an intensive care unit.

BACKGROUND: Increasing numbers of intensive care units (ICUs) are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness. METHODS: We conducted a 1-year randomized trial in an academic medical ICU of the effects of nighttime staffing with in-hospital intensivists (intervention) as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone (control). We randomly assigned blocks of 7 consecutive nights to the intervention or the control strategy. The primary outcome was patients' length of stay in the ICU. Secondary outcomes were patients' length of stay in the hospital, ICU and in-hospital mortality, discharge disposition, and rates of readmission to the ICU. For length-of-stay outcomes, we performed time-to-event analyses, with data censored at the time of a patient's death or transfer to another ICU. RESULTS: A total of 1598 patients were included in the analyses. The median Acute Physiology and Chronic Health Evaluation (APACHE) III score (in which scores range from 0 to 299, with higher scores indicating more severe illness) was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P<0.001). Nonetheless, intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% confidence interval [CI], 0.88 to 1.09; P=0.72), ICU mortality (relative risk, 1.07; 95% CI, 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome. CONCLUSIONS: In an academic medical ICU in the United States, nighttime in-hospital intensivist staffing did not improve patient outcomes. (Funded by University of Pennsylvania Health System and others; ClinicalTrials.gov number, NCT01434823.).

Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

IMPORTANCE: Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure. OBJECTIVE: To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS: Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up. INTERVENTIONS: Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0). MAIN OUTCOMES AND MEASURES: Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength. RESULTS: Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, -1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, -2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, -0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, -1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, -0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02). CONCLUSIONS AND RELEVANCE: Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00976833.

An Environmental Scan for Early Mobilization Practices in U.S. ICUs.

OBJECTIVE: Early mobilization improves patient outcomes. However, diffusion of this intervention into standard ICU practice is unknown. Dissemination and implementation efforts may be guided by an environmental scan to detail readiness for early mobilization, current practice, and barriers to early mobilization. DESIGN: A telephone survey. SETTING: U.S. ICUs. SUBJECTS: Five hundred randomly selected U.S. ICUs stratified by regional hospital density and hospital size. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We surveyed 687 ICUs for a 73% response rate (500 ICUs); 99% of respondents were nursing leadership. Fifty-one percent of hospitals reported an academic affiliation. Surveyed ICUs were most often mixed medical/surgical (58%) or medical (22%) with a median of 16 beds (12-24). Thirty-four percent reported presence of a dedicated physical and/or occupational therapy team for the ICU. Overall, 45% of ICUs reported early mobilization practice; two thirds of ICUs with early mobilization practice reported using a written early mobilization protocol. In ICUs with early mobilization practice, 52% began the intervention at admission and 74% enacted early mobilization for both ventilated and nonventilated patients. Early mobilization was provided a median of 6 days per week, twice daily. Factors independently associated with early mobilization protocols include dedicated physical/occupational therapy (odds ratio, 3.34; 95% CI, 2.13-5.22; p<0.01), American Hospital Association region 2 (odds ratio, 3.33; 95% CI, 1.04-10.64; p=0.04), written sedation protocol (odds ratio, 2.36; 95% CI, 1.25-4.45; p<0.01), daily multidisciplinary rounds (odds ratio, 2.31; 95% CI, 1.29-4.15; p<0.01), and written daily goals for patients (odds ratio, 2.17; 95% CI, 1.02-4.64; p=0.04). Commonly cited barriers included equipment, staffing, patient and caregiver safety, and competing priorities. In ICUs without early mobilization adoption, 78% have considered implementation but cite barriers including competing priorities and need for further planning. CONCLUSIONS: Diffusion regarding benefits of early mobilization has occurred, but adoption into practice is lagging. Mandates for multidisciplinary rounds and formal sedation protocols may be necessary strategies to increase the likelihood of successful early mobilization implementation. Methods to accurately assess and compare institutional performance via practice audit are needed.

A Pragmatic Pilot Trial Comparing Patient-Triggered Adaptive Pressure Control to Patient-Triggered Volume Control Ventilation in Critically Ill Adults.

BACKGROUND: Patient-triggered adaptive pressure control (APC) continuous mandatory ventilation (CMV) (APC-CMV) has been widely adopted as an alternative ventilator mode to patient-triggered volume control (VC) CMV (VC-CMV). However, the comparative effectiveness of the 2 ventilator modes remains uncertain. We sought to explore clinical and implementation factors pertinent to a future definitive randomized controlled trial assessing APC-CMV versus VC-CMV as an initial ventilator mode strategy. The research objectives in our pilot trial tested clinician adherence and explored clinical outcomes. METHODS: In a single-center pragmatic sequential cluster crossover pilot trial, we enrolled all eligible adults with acute respiratory failure requiring mechanical ventilation admitted during a 9-week period to the medical ICU. Two-week time epochs were assigned a priori in which subjects received either APC-CMV or VC-CMV The primary outcome of the trial was feasibility, defined as 80% of subjects receiving the assigned mode within 1 h of initiation of ICU ventilation. The secondary outcome was proportion of the first 24 h on the assigned mode. Finally, we surveyed clinician stakeholders to understand potential facilitators and barriers to conducting a definitive randomized trial. RESULTS: We enrolled 137 subjects who received 152 discreet episodes of mechanical ventilation during time epochs assigned to APC-CMV (n = 61) and VC-CMV (n = 91). One hundred and thirty-one episodes were included in the prespecified primary outcome. One hundred and twenty-six (96%) received the assigned mode within the first hour of ICU admission (60 of 61 subjects assigned APC-CMV and 66 of 70 assigned VC-CMV). VC-CMV subjects spent a lower proportion of first 24 h (84% [95% CI 78-89]) on the assigned mode than APC-CMV recipients (95% [95% CI 91-100]). Mixed-methods analyses identified preconceived perceptions of subject comfort by clinicians and need for real-time education to address this concern. CONCLUSIONS: In this pilot pragmatic, sequential crossover trial, unit-wide allocation to a ventilator mode was feasible and acceptable to clinicians.

Modification of social determinants of health by critical illness and consequences of that modification for recovery: an international qualitative study.

OBJECTIVES: Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness. DESIGN: In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections. SETTING: 14 hospital sites in the USA, UK and Australia. PARTICIPANTS: Patients and caregivers, who had been admitted to critical care from three continents. RESULTS: 86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems. CONCLUSIONS: Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems.

The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

Activity Levels in Survivors of the Intensive Care Unit.

OBJECTIVE: Limited data exist on the quantification of activity levels and functional status in critically ill patients as they transition from the intensive care unit (ICU) to the wards and, subsequently, back into the community. The physical activity of critically ill patients from their ICU stay until 7 days after hospital discharge was characterized, as well as correlate physical activity levels with an objective measure of physical function. METHODS: This prospective observational study of previously independent adults aged 55 or older, undergoing mechanical ventilation for up to 7 days, recruited participants at the time of spontaneous breathing trials or less than 24 hours after extubation. Participants received an accelerometer at enrollment to wear until 1 week after discharge. RESULTS: Twenty-two participants received accelerometers; 15 were suitable for analysis. Participants had a mean (SD) age of 68 (9.6) years; 47% were female. Mean step counts were 95 (95% CI = 15-173) in the 3 days before ICU discharge, 257 (95% CI = 114-400) before hospital discharge, 1223 (95% CI = 376-2070) in the first 3 days at home, and 1278 (95% CI = 349-2207) between day 4 and 6 post-hospital discharge. Physical activity was significantly higher post- compared with pre-hospital discharge. Short Physical Performance Battery scores were poor at ICU and hospital discharge; however, they correlated moderately with physical activity levels immediately upon return home. CONCLUSIONS: Physical activity remained low as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. Despite poor Short Physical Performance Battery scores at both ICU and hospital discharge, participants were significantly more active immediately after discharge than in their last 3 days of hospitalization. This may represent rapid functional improvement or, conversely, constrained physical activity in hospital. IMPACT: This study highlights the need for further evaluation of physical activity constraints in hospital and ways to augment physical activity and function upon discharge. LAY SUMMARY: Physical activity (step counts) increased modestly as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. This study highlights the need for further evaluation of physical activity constraints in the hospital setting and ways to augment physical activity and function postdischarge.

Optimizing Critical Illness Recovery: Perspectives and Solutions From the Caregivers of ICU Survivors.

OBJECTIVES: To understand the unmet needs of caregivers of ICU survivors, how they accessed support post ICU, and the key components of beneficial ICU recovery support systems as identified from a caregiver perspective. DESIGN: International, qualitative study. SUBJECTS: We conducted 20 semistructured interviews with a diverse group of caregivers in the United States, the United Kingdom, and Australia, 11 of whom had interacted with an ICU recovery program. SETTING: Seven hospitals in the United States, United Kingdom, and Australia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Content analysis was used to explore prevalent themes related to unmet needs, as well as perceived strategies to improve ICU outcomes. Post-ICU care was perceived to be generally inadequate. Desired caregiver support fell into two main categories: practical support and emotional support. Successful care delivery initiatives included structured programs, such as post discharge telephone calls, home health programs, post-ICU clinics, and peer support groups, and standing information resources, such as written educational materials and online resources. CONCLUSIONS: This qualitative, multicenter, international study of caregivers of critical illness survivors identified consistently unmet needs, means by which caregivers accessed support post ICU, and several care mechanisms identified by caregivers as supporting optimal ICU recovery.

Benefits of Peer Support for Intensive Care Unit Survivors: Sharing Experiences, Care Debriefing, and Altruism.

BACKGROUND: After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues. OBJECTIVE: To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery. METHODS: In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis. RESULTS: Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism. CONCLUSION: Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.

Key Components of ICU Recovery Programs: What Did Patients Report Provided Benefit?

To understand from the perspective of patients who did, and did not attend ICU recovery programs, what were the most important components of successful programs and how should they be organized. DESIGN: International, qualitative study. SETTING: Fourteen hospitals in the United States, United Kingdom, and Australia. PATIENTS: We conducted 66 semi-structured interviews with a diverse group of patients, 52 of whom had used an ICU recovery program and 14 whom had not. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using content analysis, prevalent themes were documented to understand what improved their outcomes. Contrasting quotes from patients who had not received certain aspects of care were used to identify perceived differential effectiveness. Successful ICU recovery programs had five key components: 1) Continuity of care; 2) Improving symptom status; 3) Normalization and expectation management; 4) Internal and external validation of progress; and 5) Reducing feelings of guilt and helplessness. The delivery of care which achieved these goals was facilitated by early involvement (even before hospital discharge), direct involvement of ICU staff, and a focus on integration across traditional disease, symptom, and social welfare needs. CONCLUSIONS: In this multicenter study, conducted across three continents, patients identified specific and reproducible modes of benefit derived from ICU recovery programs, which could be the target of future intervention refinement.