Frailty trajectories in ICU survivors: A comparison between the clinical frailty scale and the Tilburg frailty Indicator and association with 1 year mortality.

PURPOSE: To test the agreement of the Clinical Frailty Scale (CFS) and the Tilburg Frailty Indicator (TFI), their association with 3, 6 months and 1-year mortality and the trajectory of frailty in a mixed population of ICU survivors. MATERIAL AND METHODS: This is a prospective, multicenter, longitudinal study on ICU survivors ≥18 years old with an ICU stay >72 h. For each patient, sociodemographic and clinical data were collected. Frailty was assessed during ICU stay and at 3, 6, 12 months after ICU discharge, through both CFS and TFI. RESULTS: 124 patients with a mean age of 66 years old were enrolled. The baseline prevalence of frailty was 15.3% by CFS and 44.4% by TFI. Baseline CFS and TFI correlated but showed low agreement (Cohen's K = 0.23, p < 0.001). Baseline CFS score, but not TFI, was significantly associated to 1 year mortality. Moreover, CFS score during the follow-up was independently associated 1-year mortality (OR = 1.43; 95% CI: 1.18-1.73). CONCLUSIONS: CFS and TFI identify different populations of frail ICU survivors. Frail patients before ICU according to CFS have a significantly higher mortality after ICU discharge. The CFS during follow-up is an independent negative prognostic factor of long-term mortality in the ICU population.

Validation of the cross-cultural adapted Italian version of the Oxford Elbow Score.

BACKGROUND: The Oxford Elbow Score (OES) is an English-language questionnaire specifically designed to evaluate surgical elbow outcomes. This scoring system has been translated into other languages. Given the lack of an Italian version of the OES, the present study was designed to establish, culturally adapt, and validate the Italian version. METHODS: The OES questionnaire was culturally adapted to Italian patients in accordance with the literature guidelines with a pilot phase including seven patients with elbow problems and seven healthy subjects. The study includes 110 participants from three hospitals, who underwent elbow surgery for acute (70%) or chronic diseases. At least one month after elbow surgery, at the "index visit", the physician completed the Mayo Elbow Performance Index and patients completed the following questionnaires: the Italian OES, the shortened version of the Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) and the Short-Form 36 Health Survey. Internal consistency was evaluated using Cronbach's alpha. Reproducibility was assessed using the intraclass correlation coefficient in ten patients who completed the OES again two-three days after the index visit. Construct validity was assessed using Spearman correlation coefficients. Responsiveness was evaluated in 68 patients who answered the questionnaires four months after the index visit, using the Wilcoxon signed-rank test, the effect size and the standardized response mean calculation. RESULTS: Cronbach's alpha was excellent: 0.86 (0.82-0.90) for OES pain, 0.92 (0.90-0.94) for OES function, and 0.90 (0.87-0.93) for OES social/psychological. The intraclass correlation coefficient was 0.94 (0.78-0.98) for OES pain, 0.91 (0.71-0.97) for OES function, 0.95 (0.83-0.98) for OES social-psychological and 0.93 (0.76-0.98) for OES total. The Spearman ρ was >0.7 for OES pain and QuickDASH, for OES function and both QuickDASH and Mayo Elbow Performance Index, and for OES social-psychological and QuickDASH. Regarding responsiveness, the mean of the changes between the two visits ranged from 33.9 for OES pain, to 44 points for OES function and OES social/psychological. The effect size and the standardized response mean were >0.8 for all OES domains. CONCLUSION: This study demonstrates that the Italian version of the OES, translated in accordance with the international standardized guidelines, is reliable, valid, and responsive in patients who have undergone elbow surgery.

Determinants of the calibration of SAPS II and SAPS 3 mortality scores in intensive care: a European multicenter study.

BACKGROUND: The aim of the Simplified Acute Physiology Score (SAPS) II and SAPS 3 is to predict the mortality of patients admitted to intensive care units (ICUs). Previous studies have suggested that the calibration of these scores may vary across countries, centers, and/or characteristics of patients. In the present study, we aimed to assess determinants of the calibration of these scores. METHODS: We assessed the calibration of the SAPS II and SAPS 3 scores among 5266 patients admitted to ICUs during a 4-week period at 120 centers in 17 European countries. We obtained calibration curves, Brier scores, and standardized mortality ratios. Points attributed to SAPS items were reevaluated and compared with those of the original scores. Finally, we tested associations between the calibration and center characteristics. RESULTS: The mortality was overestimated by both scores: The standardized mortality ratios were 0.75 (95% CI 0.71-0.79) for the SAPS II score and 0.91 (95% CI 0.86-0.96) for the SAPS 3 score. This overestimation was partially explained by changes in associations between some items of the scores and mortality, especially the heart rate, Glasgow Coma Scale score, and diagnosis of AIDS for SAPS II. The calibration of both scores was better in countries with low health expenditures. The between-center variability in calibration curves was much greater than expected by chance. CONCLUSIONS: Both scores overestimate current mortality among European ICU patients. The magnitude of the miscalibration of SAPS II and SAPS 3 scores depends not only on patient characteristics but also on center characteristics. Furthermore, much between-center variability in calibration remains unexplained by these factors. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01422070 . Registered 19 August 2011.

Fatigue in intensive care survivors one year after discharge.

BACKGROUND: Fatigue has not been investigated in long-term Intensive Care Unit (ICU) survivors. This study aimed to assess fatigue through a specific instrument, namely the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scale, in ICU survivors one year after hospital discharge. A secondary aim was to compare the findings of FACIT-F with those of the Vitality domain (VT) of the 36-item Short-Form Health Survey (SF-36). METHODS: This prospective cohort study was performed on 56 adult patients with a Length Of Stay (LOS) in ICU longer than 72 h. At one year after hospital discharge, FACIT-F and SF-36 questionnaires were administered to consenting patients by direct interview. FACIT-F was measured as raw (range 0-52), and FACIT-F-trans value (range 0-100). Past medical history, and demographic and clinical ICU-related variables were collected. RESULTS: The patients' median age was 67.5, Simplified Acute Physiology Score II 31, and LOS in ICU 5 days. The median raw FACIT-F of the patients was 41, and Cronbach's α was 0.937. The correlation coefficient between FACIT-F-trans and VT of SF-36 was 0.660 (p < 0.001). Both FACIT-F and VT were related to dyspnoea scale (p = 0.01). A Bland-Altman plot of VT vs FACIT-F-trans showed a bias of -0.8 with 95 % limits of agreement from 35.7 to -34.1. The linear regression between differences and means was 0.639, suggesting a significant proportional bias. CONCLUSIONS: The 13-item FACIT-F questionnaire is valid to assess fatigue of long-term ICU survivors. VT of SF-36 relates to FACIT-F, but consists of only four items assessing two positive and two negative aspects. FACIT-F grasps the negative aspects of fatigue better than VT. Specific tools assess specific conditions better that general tools. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02684877 .

Evaluation of a protocol for vancomycin administration in critically patients with and without kidney dysfunction.

BACKGROUND: Administration of vancomycin in critically ill patients needs close regulation. While subtherapeutical vancomycin serum concentration (VSC) is associated with increased mortality, accumulation is responsible for nephrotoxicity. Our study aimed to estimate the efficacy of a vancomycin-dosing protocol in reaching appropriate serum concentration in patients with and without kidney dysfunction. METHODS: This was a retrospective study in critically ill patients treated with continuous infusion of vancomycin. Patients with creatinine clearance > 50 ml/min (Group A) were compared to those with creatinine clearance ≤ 50 ml/min (Group B). RESULTS: 348 patients were enrolled (210 in Group A, 138 in Group B). At first determination, patients with kidney dysfunction (Group B) had a statistically higher percentage of vancomycin in target range, while the percentage of patients with a VSC under the range was almost equal. These percentages differed at the subsequent measurements. The number of patients with low vancomycin concentration progressively decreased, except in those with augmented renal clearance; the percentage of patients with VSC over 30 mg/L was about 28 %, irrespective of the presence or absence of kidney dysfunction. Patients who reached a subtherapeutic level at the first VSC measurement had a significant correlation with in-hospital mortality. CONCLUSIONS: Our protocol seems to allow a rapid achievement of a target VSC particularly in patients with kidney dysfunction. In order to avoid subtherapeutical VSC, our algorithm should be implemented by the estimation of the presence of an augmented renal clearance.

Our paper 20 years later: 1-year survival and 6-month quality of life after intensive care.

INTRODUCTION: In the early 1990s, the in-hospital mortality rate of intensive care unit (ICU) patients dropped, and interest in the quality of life (QOL) of ICU survivors increased. In 1996, we published a study to investigate 1-year survival after hospital discharge and 6-month QOL after intensive care. Now, we compare our previous results with those reported in the recent literature to appraise any changes, and new knowledge in the area. RESULTS: The 1-year survival of ICU patients after hospital discharge is substantial, lower than in the general population, and different among subgroups. Some studies showed a reduction in QOL at 6 months, as in our study, while others showed an improvement. Different results seem to be related mainly to the case mix. Studies on different types of patients found long-term cognitive impairment in ICU survivors, possibly not disease specific. The proportions of patients with neuropsychological morbidities such as posttraumatic stress disorder, anxiety, and depression, described after our study, did not show any change over time. CONCLUSIONS: Differences between studies on long-term survival and QOL do not allow conclusions to be drawn about change over time. No change was found in neuropsychological morbidities. However, a lack of change may not be viewed negatively, because critically ill patients who survive ICU today may be at higher risk for poor long-term outcome than in the past due to the higher severity of their illness and the more aggressive treatments received. Future studies may provide understanding of the relationships between psychiatric symptoms, cognitive impairment, functional disability, and QOL.

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study.

INTRODUCTION: The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU. METHODS: An observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days). RESULTS: One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002). CONCLUSIONS: The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment. TRIAL REGISTRATION: Clinicaltrials.gov NCT01422070. Registered 19 August 2011.

Hospital staff education on severe sepsis/septic shock and hospital mortality: an original hypothesis.

BACKGROUND: Signs of serious clinical events overlap with those of sepsis. We hypothesised that any education on severe sepsis/septic shock may affect the outcome of all hospital patients. We designed this study to assess the trend of the mortality rate of adults admitted to hospital for at least one night in relationship with a hospital staff educational program dedicated to severe sepsis/septic shock. METHODS: This study was performed in six Italian hospitals in the same region. Multidisciplinary Sepsis Teams members were selected by each hospital management among senior staff. The education included the following steps: i) the Teams were taught about adult learning, problem based learning, and Surviving Sepsis guidelines, and provided with educational material (literature, electronic presentations, scenarios of clinical cases for training and booklets); ii) they started delivering courses and seminars each to their own hospital staff in the last quarter of 2007.To analyse mortality, we selected adult patients, admitted for at least one night to the wards or units present in all the study hospitals and responsible for 80% of hospital deaths. We fitted a Poisson model with monthly hospital mortality rates from December 2003 to August 2009 as dependent variable. The effect of the educational program on hospital mortality was measured as two dummy variables identifying a first (November 2007 to December 2008) and a second (January to August 2009) education period. The analysis was adjusted for a linear time trend, seasonality and monthly average values of age, Charlson score, length of stay in hospital and urgent/non-urgent admission. RESULTS: The hospital staff educated reached 30.6% at the end of June 2009. In comparison with the pre-education period, the Relative Risk of death of the patient population considered was 0.93 (95% confidence interval [CI] 0.87-0.99; p 0.025) for in-patients in the first, and 0.89 (95% CI 0.81-0.98; p 0.012) for those in the second period after education. CONCLUSION: Our hypothesis that a program educating hospital staff to early detection and treatment of severe sepsis/septic shock may affect the outcome of all hospital patients is original, but it has to be corroborated by other experiences.

Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial.

INTRODUCTION: Patients recovering from critical illness have been shown to be at risk of developing Post Traumatic Stress disorder (PTSD). This study was to evaluate whether a prospectively collected diary of a patient's intensive care unit (ICU) stay when used during convalescence following critical illness will reduce the development of new onset PTSD. METHODS: Intensive care patients with an ICU stay of more than 72 hours were recruited to a randomised controlled trial examining the effect of a diary outlining the details of the patients ICU stay on the development of acute PTSD. The intervention patients received their ICU diary at 1 month following critical care discharge and the final assessment of the development of acute PTSD was made at 3 months. RESULTS: 352 patients were randomised to the study at 1 month. The incidence of new cases of PTSD was reduced in the intervention group compared to the control patients (5% versus 13%, P = 0.02). CONCLUSIONS: The provision of an ICU diary is effective in aiding psychological recovery and reducing the incidence of new PTSD. TRIAL REGISTRATION: NCT00912613.

Health-related quality of life before planned admission to intensive care: memory over three and six months.

BACKGROUND: The validity of Health-Related Quality of Life (HRQOL) recalled by ICU admitted patients have not been published. The aim of this study was to compare the baseline HRQOL measured before surgery and ICU admission with that recalled at 3 and 6 months in a population of patients with planned ICU admission after surgery. METHODS: This prospective study was performed in three Italian centres on patients who had undergone General, Orthopaedic or Urologic surgery. All adult patients with planned ICU admission between October 2007 and July 2008 were considered for enrolment. At hospital admission, the Mini Mental Status Examination and EuroQoL (EQ) questionnaire (referring to the last two weeks) were administered to the patients who consented. Three and six months after ICU admission, the researchers administered by phone the EQ questionnaire and Post-Traumatic Stress Syndrome 14 questions Inventory, asking the patients to rate their HRQOL before surgery and ICU admission. Past medical history demographic and clinical ICU-related variables were collected. STATISTICAL ANALYSIS: Chi-square test and non parametric statistics were used to compare groups of patients. The EQ-5D was transformed in the time trade-off (TTO) to obtain a continuous variable, subsequently analysed using the Intraclass Correlation Coefficient (ICC). RESULTS: Of the 104 patients assessed at baseline and discharged from the hospital, 93 had the EQ administered at 3 months, and 89 at 6 months. The ICC for TTO recalled at 3 months vs pre-ICU TTO was 0.851, and that for TTO recalled at 6 months vs pre-ICU TTO was 0.833. The ICC for the EQ-VAS recalled at 3 months vs pre-ICU EQ-VAS was 0.648, and that for the EQ-VAS recalled at 6 months vs pre-ICU EQ-VAS was 0.580. Forty-two (45%) patients assessed at 3 months gave the same score in all EQ-5D items as at baseline. They underwent mainly orthopaedic surgery (p 0.011), and perceived the severity of their illness as lower (p 0.009) than patients scoring differently at 3 months in comparison with baseline. CONCLUSIONS: The patients with planned ICU admission have a good memory of their health status as measured by EQ-5D in the period preceding surgery and ICU admission, especially at three months.

Admission and discharge of critically ill patients.

PURPOSE OF REVIEW: The intensive care unit (ICU) provides continuous surveillance and specialized care to acutely ill patients. The decisions on patient admission and discharge should be based on common clinical criteria in order to guarantee equity. RECENT FINDINGS: The survival benefit of early admission to intensive care has been demonstrated recently. Sometimes, the number of potential patients may exceed the available beds making triage of the patients necessary. The prioritization model based on the benefit that the patient can have from the admission is the most used. In the case of the outbreak peak of pandemic A H1N1 flu, a triage plan using Sequential Organ Failure Assessment score combined with inclusion and exclusion criteria to complement clinical judgment has been recommended. Nevertheless, studies have shown that this triage could lead to withdrawal of life support in patients who survive. Triage implies refusal of some patients, and refusal rates vary greatly even across the same country. Policies for discharge from intensive care show wide variability influenced by the availability of step-down facilities. SUMMARY: The decisions to admit and discharge patients depend on patient, structure and physician-related variables. Early ICU admission of the critically ill patient is beneficial. Future analysis should also investigate economic parameters.

Intensive care reimbursement practices: results from the ICUFUND survey.

OBJECTIVE: To assess patterns of intensive care reimbursement practices. METHODS: A detailed questionnaire about basic intensive care unit (ICU) characteristics and ICU reimbursement practices was created, and then members of the European Society of Intensive Care (ESICM) were asked by e-mail to participate in the survey and complete the web-based questionnaire. RESULTS: There were a total of 447 responses analyzed. Of respondents, 51.5% stated that their ICU received detailed financial information; however, only 15.4% of respondents could identify each cost item for each patient. A majority of respondents (77.6%) stated that their unit's reimbursement system was included in the hospital reimbursement. ICU reimbursement systems were most commonly based on previous year's ICU expenditure (51.0%) and diagnosis-related group weights (36%). Selecting European respondents (n = 306) showed that supplying detailed financial information makes ICU doctors significantly more satisfied (p = 0.019) with their reimbursement system. Regarding ICU funding elements, the most satisfied with their ICU reimbursement system were those respondents from ICUs where nursing workload score was used (p = 0.018). CONCLUSIONS: Our result indicates that ICU physicians who receive detailed financial information about their units are more satisfied with their reimbursement system than those not receiving this information. Nursing workload score may have advantage over other forms of reimbursement practices. ICU physicians would like to be more involved in their unit's financial aspects and would prefer separate funding from hospital.

Errors in administration of parenteral drugs in intensive care units: multinational prospective study.

OBJECTIVE: To assess on a multinational level the frequency, characteristics, contributing factors, and preventive measures of administration errors in parenteral medication in intensive care units. DESIGN: Observational, prospective, 24 hour cross sectional study with self reporting by staff. SETTING: 113 intensive care units in 27 countries. PARTICIPANTS: 1328 adults in intensive care. MAIN OUTCOME MEASURES: Number of errors; impact of errors; distribution of error characteristics; distribution of contributing and preventive factors. RESULTS: 861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage. In a multiple logistic regression with patients as the unit of analysis, odds ratios for the occurrence of at least one parenteral medication error were raised for number of organ failures (odds ratio per increase of one organ failure: 1.19, 95% confidence interval 1.05 to 1.34); use of any intravenous medication (yes v no: 2.73, 1.39 to 5.36); number of parenteral administrations (per increase of one parenteral administration: 1.06, 1.04 to 1.08); typical interventions in patients in intensive care (yes v no: 1.50, 1.14 to 1.96); larger intensive care unit (per increase of one bed: 1.01, 1.00 to 1.02); number of patients per nurse (per increase of one patient: 1.30, 1.03 to 1.64); and occupancy rate (per 10% increase: 1.03, 1.00 to 1.05). Odds ratios for the occurrence of parenteral medication errors were decreased for presence of basic monitoring (yes v no: 0.19, 0.07 to 0.49); an existing critical incident reporting system (yes v no: 0.69, 0.53 to 0.90); an established routine of checks at nurses' shift change (yes v no: 0.68, 0.52 to 0.90); and an increased ratio of patient turnover to the size of the unit (per increase of one patient: 0.73, 0.57 to 0.93). CONCLUSIONS: Parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.