Category Archives: After-care

The PARTNER trial

The PARTNER trial was presented today (published over the summer in NEJM) which is the latest in the critical care community’s attempt to support families with loved ones in ICU.

We know that its a stressful time for families (and of course patients) and we think we could do better in communication with them, and support.

The family members who are involved in the discussion around care and end of life and limitation of treatment often suffer psychological morbidity

Could these outcomes for families be improved by “reengineering” the ICU team and up-skilling them? And interestingly, might that even extend to less burden of treatment for patients?

Thats what the partner trial set out to discover and Derek Angus presented the results this morning in Paris

At its heart PARTNER was a nurse driven emotional support and relationship building intervention

The key thrust of the intervention was around 3 things

  1. Protocolled pathway of family support
  2. Advanced communication skills training for staff
  3. Intensive implementation support of the pathway

It was a stepped wedge cluster RCT in 5 different ICUs  of differing sizes and case mix.

It didn’t show a difference in its primary outcome (HADS score) but it did improve how people felt – families AND nurses! Which is promising – but the real win was reduced length of stay for me, a relatively cheap intervention that saves money, sounds good huh!

Of note there was an apparent increase in ICU mortality, as some patients had treatment limited earlier – but that disappeared at later follow up.

If you are interested in the field its worth reading this study from Curtis et al which was similar but did show a difference in depressive symptoms in families later on… Why? not sure – perhaps just the play of chance??? Perhaps difference in the way the intervention was blanket applied?

Your roving reporter, JS

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France

Hot Topics Session

It is well recognised that critically ill elderly patient have a higher mortality and therefore the beneficial effect of intensive care unit (ICU) admission variable ICU use among this population have let to significant difference in uptake.

Guidet and colleagues performed a cluster, randomised trial of admission versus standard care in 3036 elderly patients aged 75 years and above. In their multicentre randomised trail, suitable patients were allocated to routine or non-routine admission as per the following:

CONSORT Diagram

Outcome Measures

  • Primarily 6 months
  • Secondarily ICU admission rate, in-hospital death, functional status and quality of life.

 

Results

Results

 

  • Disappointingly there was no difference seen in any of the outcome measures, even after adjustment for differences in illness severity and patients admitted to ICU had an INCREASED risk of death at six months despite an increase ICU admission rates.
  • Functional status and physical quality of life at six months did not differ significantly.

 

What does this mean?

  • As our ICU population changes it may be that a systematic approach which admits all elderly patients has no effect upon outcome.
  • Further international trials are needed before we know whether this is applicable to other populations.

Clinical Trial Session 2

CAESAR Study (Azoulay)

Post-ICU syndrome and the burden of care on relatives. Hence the need to develop a tool to assess this.

A high CAESAR score represents higher family satisfaction with care

Conclusion – CAESAR instrument

  • new instrument based on family experience that will help develop family centred care
  • lower scores associated with higher burden
  • clinically, may be useful to identify vulnerable families

 

FLUID-TRIPS (Hammond)

Albumin studies – SAFE, VISEP, CRYSTMAS, CHEST, 6S, ALBIOS

Inter-country variation in types of fluid prescribed

Conclusion

  • signification variation in fluid use remains
  • significant secular changes in patterns of fluid resuscitation between 2007-2014
  • crytalloids still predominate
  • increased use of balanced salt solutions
  • pattern of colloid use consistent with recent RCT

SAFE TRIP study

Fluid-TRIPS protocol

 

CHECKLIST-ICU (Cavalanti)

Checklist and daily goals read out during round

No difference in mortality!

CHECKLIST ICU Trial protocol

Trial statistical analysis plan

Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

 

Very high volume hemofiltration with the Cascade system in septic shock patients

Cascade trial

 

 

Let’s talk about Post Intensive Care Unit Syndrome – Hannah Wunsch (presented 4th October)

In this presentation, Dr Wuncsh highlights some important key points:-

There are some significant negative consequences for our patients after discharge from the ICU.  Not only is QOL decreased for at least two years after hospital discharge, but patients can also suffer psychological and physical consequences such as anxiety and mood disorders, extreme fatigue, sleep disturbance, weakness, foot drip and more.

Some general tips for improving the patient experience and decreasing the impact of PICS include:-

  • Minimising sedation
  • Tailoring the environment to reduce noise and night disturbance
  • Early physical and cognitive therapy
  • Screening for psychiatric disease
  • ICU diaries

By

Dr Melissa Bloomer