Matt Anstey is an intensivist from Sir Charles Gardiner hospital in Perth, Australia. He gave this talk on outcomes after intensive care at an ICN WA meeting in Perth last year.

1. What are the outcomes that matter in the
ICU?
Dr Matthew Anstey
MBBS, MPH, FACEM, FCICM, PGDipEcho
Intensive Care Consultant, Sir Charles Gairdner Hospital

2. Disclosures
• Atlas Advisory Group Australian
Commission on Safety and
Quality in Health Care
• Chair Advisory Board, Choosing
Wisely Australia
• No competing interests.

3. NEJM 1976
• In 226 consecutive critically ill primarily postoperative patients, we determined
survival and quality of life, hospitalization charges, and consumption of blood and
blood products. The patients were physiologically unstable and required intensive
physician and nursing care. By one month, 123 patients had died (54 per cent), 70
were still hospitalized, and 31 were home; only one of 103 survivors had fully
recovered. By 12 months, 164 patients (73 per cent) had died, 10 were still
hospitalized, and 51 were home. Twenty-seven of 62 survivors had fully recovered.
• Hospitalization charges averaged $14,304 per patient. The total charge for blood and
blood fractions was $617,710 — 21 per cent of the total hospitalization charge;
$515,711 (83 per cent) of the blood charge went to 164 nonsurvivors, whereas
$101,939 (17 per cent) went to the 62 survivors.
• These data document the use of increasingly limited resources in the management of
critically ill patients. The medical profession must make difficult decisions to allocate
these resources effectively

8. Choose your own adventure outcomes
• A NEW LIFE
• YOU RETURN HOME
• DEATH

9. 1. Death

11. Is everything we do in the ICU what we think we should
do?

13. Appropriate care in the ICU
• Appropricus study
In 9 European countries: ‘inappropriate care’ in at least
1 patient on that day perceived by 27% nurses/doctors –
mainly ‘too much care’. JAMA 2011
• 46% US ICU directors – “too much care” provided “sometimes or frequently” ,
10% perceived rationing CCM 2008
• In Canada: 90+% nurses/physicians have provided “futile” therapy in the last
year. J of CC 2005
• In California, 38% of ICU nurses/doctors identified at least 1 patient receiving
‘inappropriate care’

14. Appropriate care in Australia
• 70% of Australians would prefer to die at home and yet
70% die in an acute hospital
• Advance care planning rates low (estimated 1-29%).
• Advanced care planning improves patient satisfaction,
reduces family members stress & depression.
• Australian ICU physicians are commonly involved in
triaging ‘appropriateness’ of admissions. Refusals (74%)
are common due to patients either “too sick” or “too well”
14

15. Australian ICU data
These are preliminary unpublished results.
Surveyed doctors & nurses @ 24 ANZ ICUs
• Availability of advanced directives 8%
• As a healthcare worker do you feel that you are providing
treatments that are mismatched with patient’s
wishes/expected prognosis?
21% (doctors & nurses)

16. Australian data
• For the patients identified: only 10% of clinicians felt that the prognosis was
uncertain
• The intensity of treatment was appropriate at admission to ICU, but is no
longer appropriate: 64% agree
• Has there been a family meeting during the patient stay? Yes 78%

17. Why do you think the treatment is inappropriate?

18. Potential solutions
Positive impact We already do this
Use triggers at hospital admission (significant co-
morbidity, poor functioning) to ensure advance
directives are known
82% 17%
For patients with poor pre-hospital functioning and
multiple co-morbidities, offer a limited trial of
treatment
66% 25%
Routine (mandatory) family meetings at 72 hours with
the intensivist and primary team
67% 19%
Formal training for nurses & doctors in talking with
families about end-of-life decisions
89% 8%

19. Follow up work in Australia
• Advance directives in the ICU
• Current issue of AIC
• Using point prevalence program data
• 46 hospitals. <9% patients had an advance directive available.

20. 2. YOU RETURN HOME

21. What happens to people who survive the ICU?

22. Study Design
• Secondary analyses of two RCTs (Eritoran versus placebo &
PROWESS-SHOCK).
• Patients in ICUs from Americas, Europe, Africa, Asia, Australia.
Had severe sepsis.
• Analysis confined to patients who were functional and living at
home without help before hospitalization with sepsis.

23. Results
• Average age patients living at home independently was 63
and 61 years.
• Eritoran cohort – 34.9% died by 6 months.
• Of survivors only 58% were at home and fully functional,
23% home needing help, 5% n/h, 5% in hospital.
• PROWESS cohort – 30.2% died by 6 months.
• Of survivors: 61% at home fully functional, 26% needed
help, 4% in n/h, 4% in hospital.

24. Copyright © by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Published by Lippincott Williams &
Wilkins, Inc.
2
Figure 1
One third of survivors reported problems with mobility and performing self care or usual activities

25. Copyright © by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Published by Lippincott Williams &
Wilkins, Inc.
4
Figure 2

26. Results
• Predictors of problems with mobility and self care at 6
months
- Age
- Mechanical ventilation or dialysis for 14 + days
- NOT duration of vasopressors or chronic disease before
sepsis.

27. Implications
• Severe sepsis survivors – significant morbidity – need
further understanding early rehab / f/u clinics.
• Improve use of functional outcomes, not just 28 day
mortality in sepsis trials.
• QOL at 6 months did not really change at 1 year.
• One third of sepsis survivors need assistance – societal
implications for caring for these patients.

28. BRAIN-ICU study
• Patients with respiratory failure, cardiogenic failure or septic shock.
• Delirium developed in-hospital in 74%.
• At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below
the population means (similar to scores for patients with moderate traumatic brain
injury), and 26% had scores 2 SD below the population means (similar to scores for
patients with mild Alzheimer’s disease). Deficits occurred in both older and younger
patients and persisted, with 34% and 24% of all patients with assessments at 12
months that were similar to scores for patients with moderate traumatic brain injury
and scores for patients with mild Alzheimer’s disease, respectively. A longer duration
of delirium was in- dependently associated with worse global cognition at 3 and 12
months (P=0.001 and P = 0.04, respectively) and worse executive function at 3 and
12 months (P = 0.004 and P=0.007, respectively). Use of sedative or analgesic
medications was not con- sistently associated with cognitive impairment at 3 and 12
months.

29. ARDS survivors
• Pre-illness the median age of the patients was 44 years, 83% had no or one
coexisting condition, and 83% were working full time.
• At 1 year. 109 survivors. Lost 18% baseline body weight. Muscle weakness and
fatigue the reasons for functional limitation. 6 min walk test 281 at 3 months, 422 at
12 months. Lung volume and spirometry normal by 6 months.
• Returned to work 48%
• At 5 years: Pulmonary function near normal.
• Physical function: SF 36 physical component 1 SD below mean age matched.
• 51% had 1+ episode diagnosed depression/anxiety.
• Family mental health problems in 27%
• Returned to work 77%

30. Long term cognitive impairment in survivors
• Mechanically ventilated patients (within the ABC trial)
• 84% had delirium
• Nearly 80% of patients at 3 months had cognitive impairment.
• Over 70% patients remained impaired 1 year after critical illness (1/3 severely
impaired)
• Duration of delirium an independent predictor of cognitive impairment. A change from
1 day to 5 days of delirium : a ‘typical’ patient in our cohort) who was delirious for one
day in the ICU would be able to function cognitively on the lower boundary of ‘normal’
3 months after their critical illness (performing all instrumental activities of daily living),
a ‘typical’ patient who was delirious for five days in the ICU would characteristically
demonstrate deficits 3 months later when performing complex tasks (such as those
required to manage money, follow detailed instructions, read maps, etc).
• Duration of ventilation did not predict cognitive impairment.

31. Current project
• Dr Ed Heydon
• Post intensive care survivors
• Looking at medical/health needs and interactions
• SCGH and Rockingham

32. Long term QOL for ICU survivors

34. 3. A NEW LIFE…

35. Study Design
• Surgical intensive care patients in Austria, Germany and USA.
• Patients mechanically ventilated < 48hrs, expected to remain ventilated for >
24 rs, randomly assigned to standard care or early goal directed mobilisation.
• Standard care included daily waking trials, goal directed sedation, daily SBT,
weaning.

36. Intervention
• Early goal directed mobilisation
• Interprofessional approach - Each unit had a facilitator who worked with the
clinical teams to assign a daily mobility goal. At end of day, achieved mobility
goal recorded and barriers discussed.
• Uses SICU optimal mobilisation score (from 0 – no mobilisation to 4
ambulation).

37. mSOMS study

38. Outcome
• Mean SOMS level achieved during SICU stay
• SICU LOS
• Mini modified functional independence measure score (mmFIM) at hospital
discharge (specifically locomotion and transfers domains).

39. Vote – this led to…

40. Results
• 200 patients randomised.
• Mobilisation level (mean achieved mSOMS) 2.2 in intervention group, 1.5 in
control (p<0.0001).
• Decreased SICU length of stay (7 versus 10 days p=0.0054)
• More adverse events in intervention group (2.8% versus 0.8%) but NO serious
adverse events
• mmFIM improved at hospital discharge 8 versus 5 p=0.0002

41. Clinical Implications
• First SICU mobilisation trial.
• This nominated a facilitator to ensure teamwork.
• No changes to ventilator free days or sedation free days (therefore not due to
improved sedation practices in intervention group).
• Started early (within 3 days of intubation)
• Generalisability? No new staff. Multiple sites.

42. Vote – do you have an early mobilisation team in your
unit?

43. Reocvery from critical illness
• Growth and anabolism in intensive care survivors (GAINS
trial)
• Nandrolone versus placebo (minimal androgenic side
effects compared with testosterone)
• Pilot study, 20 patients
• Weekly IMI for 3 weeks.

44. Outcome variables
• Weight gain
• Muscle strength (MRC, ultrasound thickness)
• Grip strength
• Length of mechanical ventilation
• Length of hospital stay
• haemoglobin

45. • Inclusion: Long stay ICU patients
• Deconditioning (weight loss or weakness)
• Receiving goal nutrition and able to interact with physio
• Exclusions – no ongoing critical illness, active cardiac
disease or cancer.

46. This individualised eight-week home-based physical rehabilitation program did not
increase the underlying rate of recovery in this sample, with both groups of critically ill
survivors improving their physical function over the 26 weeks of follow-up.

47. Intervention: Nurse led intensive care follow-up programmes versus standard care.
Result: At 12 months, there was no evidence of a difference in the SF-36 physical
component score or the SF-36 mental component score

48. matthew.anstey@health.wa.gov.au