Development of an ICU discharge instrument predicting psychological morbidity: a multinational study

A Milton, A Schandl, I W Soliman, K Meijers, M van den Boogaard, I M Larsson, C Brorsson, U Östberg, M Oxenbøll-Collet, J Savilampi, S Paskins, M Bottai, P V Sackey, A Milton, A Schandl, I W Soliman, K Meijers, M van den Boogaard, I M Larsson, C Brorsson, U Östberg, M Oxenbøll-Collet, J Savilampi, S Paskins, M Bottai, P V Sackey

Abstract

Purpose: To develop an instrument for use at ICU discharge for prediction of psychological problems in ICU survivors.

Methods: Multinational, prospective cohort study in ten general ICUs in secondary and tertiary care hospitals in Sweden, Denmark and the Netherlands. Adult patients with an ICU stay ≥ 12 h were eligible for inclusion. Patients in need of neurointensive care, with documented cognitive impairment, unable to communicate in the local language, without a home address or with more than one limitation of therapy were excluded. Primary outcome was psychological morbidity 3 months after ICU discharge, defined as Hospital Anxiety and Depression Scale (HADS) subscale score ≥ 11 or Post-traumatic Stress Symptoms Checklist-14 (PTSS-14) part B score > 45.

Results: A total of 572 patients were included and 78% of patients alive at follow-up responded to questionnaires. Twenty percent were classified as having psychological problems post-ICU. Of 18 potential risk factors, four were included in the final prediction model after multivariable logistic regression analysis: symptoms of depression [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.10-1.50], traumatic memories (OR 1.44, 95% CI 1.13-1.82), lack of social support (OR 3.28, 95% CI 1.47-7.32) and age (age-dependent OR, peak risk at age 49-65 years). The area under the receiver operating characteristics curve (AUC) for the instrument was 0.76 (95% CI 0.70-0.81).

Conclusions: We developed an instrument to predict individual patients' risk for psychological problems 3 months post-ICU, http://www.imm.ki.se/biostatistics/calculators/psychmorb/ . The instrument can be used for triage of patients for psychological ICU follow-up.

Trial registration: The study was registered at clinicaltrials.gov, NCT02679157.

Keywords: Anxiety; Depression; Follow-up; Intensive care; PICS; Post-traumatic stress.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Flow chart of inclusion and exclusion
Fig. 2
Fig. 2
The psychological risk prediction instrument for use at ICU discharge

References

    1. Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36(10):pp. 2787–93, e1–9. doi: 10.1097/CCM.0b013e318186aec8.
    1. Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bienvenu OJ, Needham DM. Posttraumatic stress disorder in critical illness survivors: a metaanalysis. Crit Care Med. 2015;43(5):1121–1129. doi: 10.1097/CCM.0000000000000882.
    1. Rabiee A, Nikayin S, Hashem MD, Huang M, Dinglas VD, Bienvenu OJ, et al. Depressive symptoms after critical illness: a systematic review and meta-analysis. Crit Care Med. 2016;44(9):1744–1753. doi: 10.1097/CCM.0000000000001811.
    1. Nikayin S, Rabiee A, Hashem MD, Huang M, Bienvenu OJ, Turnbull AE, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–29. doi: 10.1016/j.genhosppsych.2016.08.005.
    1. Schandl A, Bottai M, Holdar U, Hellgren E, Sackey P. Early prediction of new-onset physical disability after intensive care unit stay: a preliminary instrument. Crit Care. 2014;18(4):455. doi: 10.1186/s13054-014-0455-7.
    1. van der Schaaf M, Beelen A, Dongelmans DA, Vroom MB, Nollet F. Functional status after intensive care: a challenge for rehabilitation professionals to improve outcome. J Rehabil Med. 2009;41(5):360–366. doi: 10.2340/16501977-0333.
    1. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40(2):502–509. doi: 10.1097/CCM.0b013e318232da75.
    1. Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme JF., Jr Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2005;171(4):340–347. doi: 10.1164/rccm.200406-763OC.
    1. Myhren H, Ekeberg O, Toien K, Karlsson S, Stokland O. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge. Crit Care. 2010;14(1):R14. doi: 10.1186/cc8870.
    1. NICE (2017) Rehabilitation after critical illness in adults NICE Clinical guideline (CG83) 2017.
    1. Griffiths JA, Barber VS, Cuthbertson BH, Young JD. A national survey of intensive care follow-up clinics. Anaesthesia. 2006;61(10):950–955. doi: 10.1111/j.1365-2044.2006.04792.x.
    1. Jubran A, Lawm G, Duffner LA, Collins EG, Lanuza DM, Hoffman LA, et al. Post-traumatic stress disorder after weaning from prolonged mechanical ventilation. Intensive Care Med. 2010;36(12):2030–2037. doi: 10.1007/s00134-010-1972-8.
    1. Orwelius L (2016) Riktlinje för PostIVA uppföljning [cited 2016-02-02].
    1. Milton A, Schandl A, Meijers K, Larsson IM, Savilampi J, Brorsson C et al (2018) Development of a multivariable prediction instrument for psychological morbidity in ICU survivors. In: 38th international symposium of intensive care and emergency medicine, 20–23 Mar 2018, Brussels
    1. Moons KG, Altman DG, Reitsma JB, Ioannidis JP, Macaskill P, Steyerberg EW, et al. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med. 2015;162(1):W1–W73. doi: 10.7326/M14-0698.
    1. Jutte JE, Needham DM, Pfoh ER, Bienvenu OJ. Psychometric evaluation of the Hospital Anxiety and Depression Scale 3 months after acute lung injury. J Crit Care. 2015;30(4):793–798. doi: 10.1016/j.jcrc.2015.04.006.
    1. Brennan C, Worrall-Davies A, McMillan D, Gilbody S, House A. The Hospital Anxiety and Depression Scale: a diagnostic meta-analysis of case-finding ability. J Psychosom Res. 2010;69(4):371–378. doi: 10.1016/j.jpsychores.2010.04.006.
    1. Twigg E, Humphris G, Jones C, Bramwell R, Griffiths RD. Use of a screening questionnaire for post-traumatic stress disorder (PTSD) on a sample of UK ICU patients. Acta Anaesthesiol Scand. 2008;52(2):202–208. doi: 10.1111/j.1399-6576.2007.01531.x.
    1. Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med. 2001;33(5):350–357. doi: 10.3109/07853890109002089.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383. doi: 10.1016/0021-9681(87)90171-8.
    1. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284–1292. doi: 10.1097/01.MLR.0000093487.78664.3C.
    1. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol. 2007;165(6):710–718. doi: 10.1093/aje/kwk052.
    1. Narduzzi S, Golini MN, Porta D, Stafoggia M, Forastiere F. Inverse probability weighting (IPW) for evaluating and “correcting” selection bias. Epidemiol Prev. 2014;38(5):335–341.
    1. Kjer CKW, Estrup S, Poulsen LM, Mathiesen O. Follow-up after intensive care treatment: a questionnaire survey of intensive care aftercare in Denmark. Acta Anaesthesiol Scand. 2017;61(8):925–934. doi: 10.1111/aas.12938.
    1. Van Der Schaaf M, Bakhshi-Raiez F, Van Der Steen M, Dongelmans DA, De Keizer NF. Recommendations for intensive care follow-up clinics; report from a survey and conference of Dutch intensive cares. Minerva Anestesiol. 2015;81(2):135–144.
    1. Elliott D, Davidson JE, Harvey MA, Bemis-Dougherty A, Hopkins RO, Iwashyna TJ, et al. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting. Crit Care Med. 2014;42(12):2518–2526. doi: 10.1097/CCM.0000000000000525.
    1. Warlan H, Howland L, Connelly C. Detection of posttraumatic stress symptoms in patients after discharge from intensive care. Am J Crit Care. 2016;25(6):509–515. doi: 10.4037/ajcc2016573.
    1. Wade DM, Hankins M, Smyth DA, Rhone EE, Mythen MG, Howell DC, et al. Detecting acute distress and risk of future psychological morbidity in critically ill patients: validation of the intensive care psychological assessment tool. Crit Care. 2014;18(5):519. doi: 10.1186/s13054-014-0519-8.
    1. Blanchflower DG, Oswald AJ. Is well-being U-shaped over the life cycle? Soc Sci Med. 2008;66(8):1733–1749. doi: 10.1016/j.socscimed.2008.01.030.
    1. Deja M, Denke C, Weber-Carstens S, Schroder J, Pille CE, Hokema F, et al. Social support during intensive care unit stay might improve mental impairment and consequently health-related quality of life in survivors of severe acute respiratory distress syndrome. Crit Care. 2006;10(5):R147. doi: 10.1186/cc5070.
    1. Schandl A, Bottai M, Hellgren E, Sundin O, Sackey PV. Developing an early screening instrument for predicting psychological morbidity after critical illness. Crit Care. 2013;17(5):R210. doi: 10.1186/cc13018.
    1. Wade DM, Howell DC, Weinman JA, Hardy RJ, Mythen MG, Brewin CR, et al. Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study. Crit Care. 2012;16(5):R192. doi: 10.1186/cc11677.
    1. Tilburgs B, Nijkamp MD, Bakker EC, van der Hoeven H. The influence of social support on patients’ quality of life after an intensive care unit discharge: a cross-sectional survey. Intensive Crit Care Nurs. 2015;31(6):336–342. doi: 10.1016/j.iccn.2015.07.002.
    1. Bienvenu OJ, Friedman LA, Colantuoni E, Dinglas VD, Sepulveda KA, Mendez-Tellez P, et al. Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study. Intensive Care Med. 2018;44(1):38–47. doi: 10.1007/s00134-017-5009-4.
    1. Cuthbertson BH, Rattray J, Campbell MK, Gager M, Roughton S, Smith A, et al. The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial. BMJ. 2009;339:b3723. doi: 10.1136/bmj.b3723.
    1. Jones C, Backman C, Capuzzo M, Egerod I, Flaatten H, Granja C, et al. Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Crit Care. 2010;14(5):R168. doi: 10.1186/cc9260.
    1. Jones C, Skirrow P, Griffiths RD, Humphris GH, Ingleby S, Eddleston J, et al. Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med. 2003;31(10):2456–2461. doi: 10.1097/01.CCM.0000089938.56725.33.
    1. Knowles RE, Tarrier N. Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: a randomized controlled trial. Crit Care Med. 2009;37(1):184–191. doi: 10.1097/CCM.0b013e31819287f7.
    1. Elliott D, McKinley S, Alison J, Aitken LM, King M, Leslie GD, et al. Health-related quality of life and physical recovery after a critical illness: a multi-centre randomised controlled trial of a home-based physical rehabilitation program. Crit Care. 2011;15(3):R142. doi: 10.1186/cc10265.
    1. Schandl A, Bottai M, Hellgren E, Sundin O, Sackey P. Gender differences in psychological morbidity and treatment in intensive care survivors—a cohort study. Crit Care. 2012;16(3):R80. doi: 10.1186/cc11338.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren