A scoping review of use of wearable devices to evaluate outcomes in survivors of critical illness

Objective: Wearable devices using new technology may be a cost-effective method to assess functional outcomes in survivors of critical illness. Our primary objective was to review the extent to which wearable devices such as smartphones, pedometers, accelerometers and global positioning systems have been used to evaluate outcomes in survivors of an intensive care unit admission. Design: We included studies of patients surviving an ICU admission and which measured outcomes using wearable devices. We performed a scoping review of studies found by searching the CINAHL, Embase, MEDLINE and PubMed databases. Results: The seven studies we identifi ed were published in or after 2012 and were predominantly descriptive (n = 6) with one randomised controlled trial. All studies described outcomes in cohorts of relatively few participants (range, 11–51 participants). Duration to follow-up was mostly short, at a median time of 3 months after ICU discharge (range, in-hospital to 27 years). All studies used accelerometers to monitor patient movement: physical activity (n = 5), sleep quality (n = 1), and infant movement (n = 1). The accelerometers were bi-axial (n = 3), uni-axial (n = 2) combined uni-axial (n = 1) and tri-axial (n = 1). Common outcomes evaluated were the number of participants walking for < 30 min/day, mean daily step count and walking speed. Conclusions: Wearable devices have infrequently been used to measure physical activity in survivors of critical illness and all identifi ed studies were published recently, which suggests that the use of wearable devices for research may be increasing. To date, only accelerometry has been reported, and the wide variation in methodologies used and the outcomes measured limits synthesis of these data.Samuel Gluck, Lee-anne S Chapple, Marianne J Chapman, Theodore J Iwashyna and Adam M Dean

Models of peer support to remediate post-intensive care syndrome: A report developed by the SCCM Thrive International Peer Support Collaborative

Objective: Patients and caregivers can experience a range of physical, psychological, 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: 17 Thrive sites from the USA, UK, and Australia were represented by a range of healthcare professionals. Interventions: 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. Results: 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. Conclusion: A number of different models of peer support are currently being developed to help patients and families recover and grow in the post-critical care setting

Assessment of Clinical Criteria for Sepsis:For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

IMPORTANCE: The Third International Consensus Definitions Task Force defined sepsis as “life-threatening organ dysfunction due to a dysregulated host response to infection.” The performance of clinical criteria for this sepsis definition is unknown. OBJECTIVE: To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis. DESIGN, SETTINGS AND POPULATION: Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706 399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013. EXPOSURES: Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤100 mm Hg], tachypnea [≥22/min], or altered mentation). MAIN OUTCOMES AND MEASURES: For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay ≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC). RESULTS: In the primary cohort, 148 907 encounters had suspected infection (n = 74 453 derivation; n = 74 454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome. CONCLUSIONS AND RELEVANCE: Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis

An observational study investigating the use of patient-owned technology to quantify physical activity in survivors of critical illness

BACKGROUND:Physical activity after intensive care unit (ICU) discharge is challenging to measure but could inform research and practice. A patient's smartphone may provide a novel method to quantify physical activity. OBJECTIVES:We aimed to evaluate the feasibility and accuracy of using smartphone step counts among survivors of critical illness. METHODS:We performed a prospective observational cohort study in 50 patients who had an ICU length of stay>48 h, owned a smartphone, were ambulatory before admission, and were likely to attend follow-up at 3 and 6 months after discharge. At follow-up, daily step counts were extracted from participants' smartphones and two FitBit pedometers, and exercise capacity (6-min walk test) and quality of life (European Quality of Life-5 Dimensions) were measured. RESULTS:Thirty-nine (78%) patients returned at 3 months and 33 (66%) at 6 months, the median [interquartile range] smartphone step counts being 3372 [1688-5899] and 2716 [1717-5994], respectively. There was a strong linear relationship, with smartphone approximating 0.71 (0.58, 0.84) of FitBit step counts, P < 0.0001, R-squared = 0.87. There were weak relationships between step counts and the 6-min walk test distance. CONCLUSION:Although smartphone ownership and data acquisition limit the viability of using extracted smartphone steps at this time, mean daily step counts recorded using a smartphone may act as a surrogate for a dedicated pedometer; however, the relationship between step counts and other measures of physical recovery remains unclear.Samuel Gluck, Matthew James Summers, Mark Edward Finnis, Alice Andrawos, Thomas Paul Goddard, Carol Lynette Hodgson, Theodore John Iwashyna, Adam Michael Dean

A study to explore patient goals in the ICU Rehabilitation setting

Background: The number of patients surviving critical care is increasing. Quality of life after critical care is known to be poor for some patients. The evidence base for effective rehabilitation interventions in the period following a stay in an intensive care unit is limited. Objectives: To understand what rehabilitation goals are important to patients after critical care discharge. Methods: This prospective study, which was undertaken during an intensive care unit recovery program, explored the recovery goals of 43 patients. Framework analysis was used to extract prevalent themes and identify the important components of recovery from the patients’ perspective. Results: Participants described diverse goals for their post–intensive care unit recovery. Most goals were about health-related quality of life, including physical goals and rehabilitation. Although health was central to many of the participants’ individual recovery aims, themes of family and social engagement and adopting appropriate goal trajectories also emerged within patient goals. Individual strategies for reaching these goals varied, and patients had different aspirations about what they could achieve. Conclusions: Patients’ aspirations for their intensive care unit recovery are diverse. Design of postdischarge care can be informed by this greater understanding of the heterogeneous starting points and goal trajectories of survivors of critical illness

Hospital re-admission after critical care survival: a systematic review and meta-analysis

Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to English language. Two reviewers independently applied pre-defined eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. Primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 individual patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3–21.2%) at 30 days; 31.0% (95%CI: 24.3–38.6%) at 90 days; 29.6% (95%CI: 24.5–35.2%) at six months; and 53.3% (95%CI: 44.4–62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factor contributed to excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection during the post-hospital discharge period. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation

A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators

Purpose: To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. Methods: Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. Results: From 2395 initially eligible abstracts, five randomised clinical trials (n\ua0=\ua04735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2\ua0% [495/2134] versus control: 22.4\ua0% [582/2601]; pooled OR 1.01 [95\ua0% CI 0.88–1.16], P\ua0=\ua00.9, with heterogeneity [I\ua0=\ua057\ua0%; P\ua0=\ua00.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n\ua0=\ua04063) also showed no difference [pooled OR 0.99 (95\ua0% CI 0.86–1.15), P\ua0=\ua00.93] with no heterogeneity (I\ua0=\ua00.0\ua0%; P\ua0=\ua00.97). EGDT increased vasopressor use (OR 1.25 [95\ua0% CI 1.10–1.41]; P\ua

Understanding and Enhancing Sepsis Survivorship. Priorities for Research and Practice.

An estimated 14.1 million patients survive sepsis each year. Many survivors experience poor long-term outcomes, including new or worsened neuropsychological impairment; physical disability; and vulnerability to further health deterioration, including recurrent infection, cardiovascular events, and acute renal failure. However, clinical trials and guidelines have focused on shorter-term survival, so there are few data on promoting longer-term recovery. To address this unmet need, the International Sepsis Forum convened a colloquium in February 2018 titled "Understanding and Enhancing Sepsis Survivorship." The goals were to identify gaps and limitations of current research and shorter- and longer-term priorities for understanding and enhancing sepsis survivorship. Twenty-six experts from eight countries participated. The top short-term priorities identified by nominal group technique culminating in formal voting were to better leverage existing databases for research, develop and disseminate educational resources on postsepsis morbidity, and partner with sepsis survivors to define and achieve research priorities. The top longer-term priorities were to study mechanisms of long-term morbidity through large cohort studies with deep phenotyping, build a harmonized global sepsis registry to facilitate enrollment in cohorts and trials, and complete detailed longitudinal follow-up to characterize the diversity of recovery experiences. This perspective reviews colloquium discussions, the identified priorities, and current initiatives to address them