Supervised exercise rehabilitation in survivors of critical illness: A randomised controlled trial.

OBJECTIVES: To investigate the impact of a six-week supervised exercise programme on cardiopulmonary fitness, balance, muscle strength and anxiety and depression in patients who have been discharged home from hospital following an intensive care unit length of stay of greater than 48 h. To investigate patients' perceptions of a six-week supervised exercise programme delivered at three months post hospital discharge. DESIGN: A single centre parallel, randomised controlled trial. SETTING: Outpatient department of a university teaching hospital in the UK. PARTICIPANTS: Sixty adult survivors of critical illness, at three months post-hospital discharge. INTERVENTION: A six-week individually prescribed and supervised exercise program, with associated advice to home exercise modification. Twice weekly exercise sessions were individualised to participant's functional status and included cardiopulmonary, balance and strengthening exercises. Follow up at seven weeks, six months and 12 months. OUTCOME MEASURES: Six-Minute Walk Test, BERG balance test, grip strength and Hospital Anxiety and Depression Scale. A pre-designed survey was used to explore patient perceptions of the programme. RESULTS: Sixty participants (n = 30 received allocated programme in both control and treatment groups) were randomised. Loss to follow up resulted in n = 34 participants for intention to treat analysis at 12 months follow up (leaving n = 19 in control group, n = 15 in treatment group). Median participant age at enrolment was 62 years (interquartile range: 49-72), with a median intensive care unit length of stay of nine days (interquartile range: 4-17). No significant differences were found for the Six-Minute Walk Test at any time point (p > 0.05). Anxiety levels and balance were significantly improved in the treatment group at 12 months (p = 0.006 and p = 0.040, respectively). CONCLUSIONS: Further research is needed into appropriate interventions and outcome measures, target patient populations and timing of such intervention post-hospital discharge.

12-Hour nursing shifts in critical care: A service evaluation.

The aim of this single-centre study was to investigate the impact of the introduction of 12-h critical care nursing shifts on healthcare provider and patient care outcomes. A single-centre, prospective service evaluation was completed over a two-year period, comparing the 8-h and 12-h shifts. Outcomes included number of clinical incidents, levels of burn-out, sick rates, personal injuries and training. There were no significant differences between the clinical incidents, sickness rates, personal injuries and staff training between the two data collection periods. The results of the burn-out analysis demonstrate that emotional exhaustion and depersonalisation improved, from the 8-h to 12-h shifts (both p < 0.05). In conclusion, the results of this service evaluation have demonstrated that 12-h nursing shifts can be introduced safely into the critical care environment, without any detriment to patient or healthcare provider outcomes.

Predictors of post-traumatic stress disorder following critical illness: A mixed methods study.

PURPOSE: Post-traumatic stress disorder has been reported in survivors of critical illness. The aim of this study was to investigate the predictors of post-traumatic stress disorder in survivors of critical illness. MATERIALS AND METHODS: Patients attending the intensive care unit (ICU) follow-up clinic completed the UK-Post-Traumatic Stress Syndrome 14-Questions Inventory and data was collected from their medical records. Predictors investigated included age, gender, Apache II score, ICU length of stay, pre-illness psychopathology; delirium and benzodiazepine administration during ICU stay and delusional memories of the ICU stay following discharge. RESULTS: A total of 198 patients participated, with 54 (27%) patients suffering with post-traumatic stress disorder. On multivariable logistic regression, the significant predictors of post-traumatic stress disorder were younger age, lower Apache II score, pre-illness psychopathology and delirium during the ICU stay. CONCLUSIONS: The predictors of post-traumatic stress disorder in this study concur with previous research however a lower Apache II score has not been previously reported.

Depression following critical illness: Analysis of incidence and risk factors.

PURPOSE: Depression is common in ICU survivors and is known to negatively affect health-related quality of life. The reported risk factors for depression include increasing age, gender and hospital and ICU length of stay. The aim of this study was to investigate the risk factors for depression in survivors of critical illness. MATERIALS AND METHODS: Patients attending the ICU Follow-up Clinic completed the Hospital Anxiety and Depression Scale and data were also collected from their medical records. Risk factors investigated included age, gender, Apache II score, ICU length of stay and a diagnosis of sepsis during ICU admission. RESULTS: A total of 63 patients participated, with 29 (46%) patients suffering with depression. On multivariable logistic regression, the only significant risk factor for depression was sepsis (p < 0.05, odds ratio: 6.8; 95% CI: 1.8-25.8). Age, gender and ICU length of stay were not found to be risk factors for depression. CONCLUSIONS: There are a number of potential causative factors as to why sepsis would cause long-term depression and this needs further investigation.

'Do not attempt resuscitation'--do standardised order forms make a clinical difference above hand-written note entries?

AIM: To quantify any effect of Standardised Order Forms (SOFs), versus hand-written note entries for 'Do Not Attempt Resuscitation'--on the selection and survival of remaining cardiopulmonary resuscitation (CPR) attempts. METHODS: A prospective, observational study in two UK Hospitals, comparing numbers, demographics and survival rates from CPR attempts for 2 years prior to and 2 years after the introduction of SOFs (the only change in DNAR policy). RESULTS: There were 133 CPR attempts, representing 0.30% of the 44,792 admissions, pre SOFs and 147 CPR attempts representing 0.32% of the 45,340 admissions following the SOFs (p=0.46). The median duration of a CPR attempt was 11min prior to and 15min following the SOFs (p=0.02). Of the CPR attempts, there was no change in mean age (p=0.34), proportions occurring outside working hours (p=0.70) or proportions presenting with an initial shockable rhythm (p=0.30). Survival to discharge following CPR was unchanged (p=0.23). CONCLUSIONS: The introduction of SOFs for DNAR orders was associated with a significantly longer duration of CPR (on average by 3-4min) but no difference in overall number, demographics or type of arrest or survival in the remaining CPR attempts.