Persistent Critical Illness
Theodore J. Iwashyna, MD, PhD University of Michigan Ann Arbor VA Center for Clinical Management Research while on sabbatical at ANZIC-RC at Monash University 1 November 2016 -- CCCF
This is joint work with: • Carol Hodgson • David Pilcher • Michael Bailey • Allison van Lint • Shaila Chavan • Neil Orford • John Santamaria • Rinaldo Bellomo
• • • •
Liz Viglianti Kyle Kepreos Brenda Vincent Wyndy Wiitala
• Joanne McPeake • Tara Quasim • Martin Shaw
It is our hypothesis that there exists a substantial and growing group of patients
who are ICU-dependent, in the sense that they are are unable to live for more than a few days outside of intensive-care-like services whose current problems are driven by their ongoing cascading critical illnesses rather than their original ICU admitting diagnosis
who account for a substantial portion of our bed-days for whom we have little specific expertise in promoting their recovery (as opposed to continuing their resuscitation) but who are not immutably fated to such limbo, but rather whose care we could improve both via improved ICU patient selection but also by changing care & communication practices in the ICU
Iwashyna, Hodgson, Pilcher, Orford, Santamaria, Bailey, Bellomo (2015) Crit Care & Resusc 17:215.
Persistent Critical Illness: “those patients whose reason for being in the ICU is now more related to their ongoing critical illness than their original reason for admission to the ICU” A novel concept in the family of “Chronic Critical Illness” • Persistent critical illness (as defined here) • Chronic Critical Illness / Medically Complex patients • Diseases with long intrinsic recovery times • Prolonged weaning • Prolonged ICU length of stay
Iwashyna, Hodgson, Pilcher, Orford, Santamaria, Bailey, Bellomo (2015) Crit Care & Resusc 17:215.
Persistent Critical Illness, as Characterized by Australian and New Zealand ICU Clinicians Aim: determine, via websurvey, the perspectives of members of the ANZICS CTG regarding patients with persistent critical illness.
Role ICU Consultant Research Coordinator Nurse Project Manager Dietitian Physiotherapist Other
N=101 59 10 14 1 11 4 2
Relative Distribution 70 % 12 % 17 % 1% 13 % 5% 2%
Time to Onset of Persistent Critical Illness: 10 days (IQR: 7-14) Incidence Estimate: 10% (IQR: 5%-15%) of all ICU Patients Fraction of Prolonged ICU Length of Stay that is Due to Persistent Critical Illness: 50% (IQR: 20% - 60%)
Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation 17:153.
Typical Problems of the Persistently Critically Ill
Percent of Respondents (n=78)
0%
Respiratory Insufficiency Delirium Acquired Neuromuscular… Sepsis Kidney Injury Malnutrition Skin Breakdown and… Traumatic Brain Injury Severe Wounds Pancreatitis Heart Failure Liver Failure Gastrointestinal Bleeding Severe Burns Stroke Endocrinopathies
25%
50%
75%
100%
90% identified ongoing mechanical ventilation as the typical need
Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation 17:153.
Not Persistently Critically Ill: Diseases with Long Intrinsic Recovery Times
Percent of Respondents (n=78)
0%
25%
50%
75%
100%
Neuromuscular Disease Head Trauma Pancreatitis Intracranial Haemorrhage Neurologic Infection Hepatic Failure Multiple Trauma Excluding… Isolated Cervical Spine… Cardiogenic Shock Pneumonia Cardiac Arrest Intestinal Surgery Ischemic Stroke Seizure
Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation 17:153.
Timing of Onset and Burden of Persistent Critical Illness Aim 1: Test the “persistent critical illness” hypothesis that there is a point in the ICU stay beyond which ICU-admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death. Aim 2: Measure the timing of such a population-level transition. Aim 3: Characterize the utilization of such persistently critically ill patients.
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Characteristic
All Patients
Characteristic
Median Age (IQR) – yr
65 (51–75)
Mean Age (SD) – yr
61∙5 (17∙7)
Male sex – no. (%)
602,455 (58∙6)
Discharge to
49∙1 (26∙6)
Home
APACHE III Score on Admission Median risk of death on admission (ANZROD) (IQR) – % Mean risk of death on admission (ANZROD) (SD) – % Median duration of ICU stay (IQR) – days Median duration of hospital stay (IQR) – days Major Diagnostic Category – no. (%)
2∙2 (0∙5–6∙9)
All Patients
Hospital Outcome – no. (%) Death
102,948 (10∙0) 782,520 (76∙1)
Rehabilitation or Long-term Care
77,418 (7∙5)
Other Hospital
65,349 (6∙3)
10∙0 (18∙3%) 1∙7 (0∙9–3∙0) 8∙4 (4∙6–15∙6)
Cardiovascular (CABG/Valve)
162,858 (15∙8)
Other cardiovascular
137,445 (13∙4)
Respiratory
155,376 (15∙1)
Gastrointestinal
180,351 (17∙5)
Neurological
110,270 (10∙7)
Trauma
46,304 (4∙5)
Sepsis
52,066 (5∙1)
Other
183,565 (17∙9)
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Odds Ratio for Death, Comparing Patients who had High Likelihood of Death on Admission to those with Low Likelihood
30
20
10
1 0
10
20
30
ICU Days Completed
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Reason for ICU Admission
Cardiac Surgical Cardiovascular Respiratory Gastrointestinal Neurologic Trauma Sepsis
Number in Validation Cohort
Day on which Acute Characteristics are No Longer More Predictive than Antecedent Characteristics Alone
Day on which Acute Characteristics are No Longer Statistically Significantly More Predictive than Antecedent Characteristics Alone
75,340 64,716 74,213 86,722 51,453 22,108 24,977
22 11 9 12 9 17 7
6 9 7 8 7 9 6
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Hospital Outcome Death Discharge to home to Rehabilitation or Long-term Care to Other Hospital
10 or Fewer Days 90,323 (9∙2)
More Than 10 Days 12,625 (24∙4)
758,552 (77∙7) 68,584 (7∙0)
23,698 (49∙9) 8,834 (17∙2)
59,627 (6∙1)
6,082 (11∙8)
The 51,509 patients who stayed 10 days or more accounted for: 5.0% of all ICU patients in Australia and New Zealand; 32.8% of all ICU bed-days (1,029,354 ICU bed days); and 14.6% of all hospital-bed-days by ICU patients (2,197,108 hospital bed days).
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Resp Med 4:566.
Interim Conclusions • Persistent critical illness can be defined and is probably not just relabelling currently described syndromes of chronic critical illness. • Many ANZ clinicians identify consistent features of persistent critical illness and have concerns about these patients. • The “persistent critical illness” hypothesis that there is a point in the ICU stay beyond which ICU-admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death is supported, with onset somewhere during the second week.
Interim Conclusions
• The “persistent critical illness” hypothesis that there is a point in the ICU stay beyond which ICU-admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death is supported, with onset somewhere during the second week in both ANZ and VA2014. • Next steps include:
• Patterns post-discharge mortality and healthcare utilization • Detailed examination of the evolution of ICU patients in this time frame • Understanding the relative importance of non-resolution; cascading new problems; complications of care; and iatrogenesis in mechanisms
Please email me at
[email protected] or tweet me @iwashyna for copies of slides or to continue the conversation
Articulate the Concept
Critical Care & Resuscitation “Point of View” published Presentations to Assorted Bodies done
Exploratory Empirical Work
Survey of ANZ Clinicians published Timing of Onset and Burden under review
Consensus Conference
Workable Case Definition & Admin Operationalization
Validation
Measure Burden
Prognostication & Risk Stratification
Goal: Define a clear, clinically relevant case definition First round convened, consensus 2/3 drafted Second round February - March 2016
Criterion Validation 1: Do case def pts meet clinician judgement gold standar d? Predictive Validation 2: Do case def pts have higher subsequent mortality , readmits? Replications of Timing Analysis: VA and ICNARC Cascades of Primary Problems possible VA MERIT ANZ Time Course of Complications & Hospital-Acquir ed Conditions data being obtained
Interventions
Survey respondents offered 188 recommendations for possible interventions to improve care.
Articulate the Concept
Critical Care & Resuscitation “Point of View” published Presentations to Assorted Bodies done
Exploratory Empirical Work
Survey of ANZ Clinicians published Timing of Onset and Burden under review
Consensus Conference
Workable Case Definition & Admin Operationalization
Validation
Measure Burden
Prognostication & Risk Stratification
Goal: Define a clear, clinically relevant case definition First round convened, consensus 2/3 drafted Second round February - March 2016
Criterion Validation 1: Do case def pts meet clinician judgement gold standar d? Predictive Validation 2: Do case def pts have higher subsequent mortality , readmits? Replications of Timing Analysis: VA and ICNARC Cascades of Primary Problems possible VA MERIT ANZ Time Course of Complications & Hospital-Acquir ed Conditions data being obtained
Interventions
Survey respondents offered 188 recommendations for possible interventions to improve care.
Thank you for your attention. Email me at
[email protected] or tweet me @iwashyna for copies of slides or to continue the conversation.
Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2015) under review
Van den Berge (1998) Verhandelingen - Koninklijke Academie voor Geneeskunde van Belgie 60:487.
http://innovation.cms.gov/Files/reports/ChronicallyCriticallyIllPopulation-Report.pdf; Kahn et al (2010) JAMA 303:2253.; Kahn et al (2015) Crit Care Med 43:282.
0
Persistently Critically Ill:
10
20
30
40
10
20
30
40
Die before leaving the hospital? Die in the 6 months after discharge from hospital? Survive 6 months after discharge with high level support in a… Survive 6 months after discharge with significant assistance at… Be alive and well at 6 months after discharge?
Prolonged ICU Length of Stay
0
Die before leaving the hospital? Die in the 6 months after discharge from hospital? Survive 6 months after discharge with high level support in a…
Survive 6 months after discharge with significant assistance at… Be alive and well at 6 months after discharge?
Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation forthcoming.
Quality of Care for Persistently Critically Ill Frequency
15
10
5
0
Excellent Care
Poor Care
Care is Stressful for Team
Frequency
15
10
5
0
Very Stressful
Not Stressful
Care is Cost Effective
Frequency
20 15 10 5 0
Not At All
Very Cost Effective
Iwashyna, Hodgson, Pilcher, Bailey, Bellomo (2015) Critical Care & Resuscitation forthcoming.