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Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study
Abstract Background Over 138,000 patients are discharged to hospital wards from intensive care units (ICUs) in England, Wales and Northern Ireland annually. More than 8000 die before leaving hospital. In hospital-wide populations, 6.7–18% of deaths have some degree of avoidability. For patients discharged from ICU, neither the proportion of avoidable deaths nor the reasons underlying avoidability have been determined. We undertook a retrospective case record review within the REFLECT study, examining how post-ICU ward care might be improved. Methods A multi-centre retrospective case record review of 300 consecutive post-ICU in-hospital deaths, between January 2015 and March 2018, in 3 English hospitals. Trained multi-professional researchers assessed the degree to which each death was avoidable and determined care problems using the established Structured Judgement Review method. Results Agreement between reviewers was good (weighted Kappa 0.77, 95% CI 0.64–0.88). Discharge from an ICU for end-of-life care occurred in 50/300 patients. Of the remaining 250 patients, death was probably avoidable in 20 (8%, 95% CI 5.0–12.1) and had some degree of avoidability in 65 (26%, 95% CI 20.7–31.9). Common problems included out-of-hours discharge from ICU (168/250, 67.2%), suboptimal rehabilitation (167/241, 69.3%), absent nutritional planning (76/185, 41.1%) and incomplete sepsis management (50/150, 33.3%). Conclusions The proportion of deaths in hospital with some degree of avoidability is higher in patients discharged from an ICU than reported in hospital-wide populations. Extrapolating our findings suggests around 550 probably avoidable deaths occur annually in hospital following ICU discharge in England, Wales and Northern Ireland. This avoidability occurs in an elderly frail population with complex needs that current strategies struggle to meet. Problems in post-ICU care are rectifiable but multi-disciplinary. Trial Registration: ISRCTN14658054.
Physiotherapy and Optimised Enteral Nutrition In the post-acute phase of critical illness (PHOENIX): protocol for a mixed methods feasibility randomised controlled trial
IntroductionEach year in the UK, 140 000 patients are discharged from intensive care units (ICUs) to general hospital wards, almost all with complex rehabilitation needs. 84% of patients still require nutritional support and 98% are not physically independent. Despite this, many are discharged from ICU without a nutrition plan, and failure to recognise malnutrition is common. Consequently, malnutrition persists in the ward environment, leading to poor outcomes and acting as a barrier to successful physical rehabilitation. This transition from intensive care to the ward represents a key stage in the recovery journey, and a window for optimising physical independence prior to hospital discharge, decreasing the need for support in the community. However, uncertainty as to how best to provide ongoing rehabilitation which combines adequate nutrition and exercise on the general ward has driven widespread variation in practice.We have previously shown the benefits of delivering a structured rehabilitation strategy in the ICU. However, the ward environment poses different challenges to the development of an integrated rehabilitation pathway. There is a need to evaluate the clinical and cost-effectiveness of structured rehabilitation strategies when delivered outside the ICU.Methods and analysisPhysiotherapy and Optimised Enteral Nutrition In the post-acute phase of critical illness is a bi-centre, mixed methods feasibility randomised controlled trial (RCT). 60 patients will be recruited from ICUs at two acute National Health Service Trusts and randomised on a 1:1 basis to receive either individualised physiotherapy and optimised nutrition post discharge from ICU (intervention) or standard care. The primary objective is to assess the acceptability of the intervention and feasibility of a future, multicentre RCT. The primary outcome measures, which will determine feasibility, are recruitment and retention rates, and intervention fidelity. Acceptability of the intervention will be evaluated through semistructured interviews of participants and staff. Secondary outcome measures include collecting baseline, clinical and outcome data to inform the power calculations of a future definitive trial.Ethics and disseminationEthical approval has been obtained through the Wales Research and Ethics Committee 2 (24/WA/0050). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.Trial registration numberNCT06159868. Prospectively registered on 28 November 2023.
Digital health interventions in adult intensive care and recovery after critical illness to promote survivorship care
Digital health refers to the field of using and developing technology to improve health outcomes. Digital health and digital health interventions (DHIs) within the area of intensive care and critical illness survivorship are rapidly evolving. Digital health interventions refer to technologies in clinical interventional format. A DHI could support clinicians with increasing clinical demands to have improved oversight of their patients’ recovery trajectory or potential for deterioration, improve efficiency of healthcare delivery, and/or predict patient outcomes. In this narrative review, DHIs are explored across the continuum from in the ICU (recognising and managing clinical deterioration, identifying individuals at risk of poor recovery outcomes, tailoring care of the ICU patient and supporting the emotional needs of their family) through to integration in the primary care setting (adjuncts to ICU follow-up clinics and tracking, coaching and remote monitoring). Some of the DHIs discussed in this narrative review (to name a few) include interventions delivered via: Telehealth, artificial intelligence, wearable devices, virtual reality, and mobile phone applications (apps). Additionally, exploration of DHIs used successfully in other health fields are discussed to highlight potential opportunities for adaptation to the ICU context. Finally, the review provides an overview of considerations needed in the development of new DHIs. Development should consider the intended user, barriers to technology engagement and design. In the implementation of a new DHI, the World Health Organization (WHO) Global Strategy on Digital Health and appropriate evaluation should be considered prior to scaling up. Optimal implementation of DHIs could help address the key challenges of the ICU field.
The impact of musculoskeletal ill health on quality of life and function after critical care: a multicentre prospective cohort study
SummaryPhysical disability is a common component of post‐intensive care syndrome, but the importance of musculoskeletal health in this population is currently unknown. We aimed to determine the musculoskeletal health state of intensive care unit survivors and assess its relationship with health‐related quality of life; employment; and psychological and physical function. We conducted a multicentre prospective cohort study of adults admitted to intensive care for > 48 h without musculoskeletal trauma or neurological insult. Patients were followed up 6 months after admission where musculoskeletal health state was measured using the validated Musculoskeletal Health Questionnaire score. Of the 254 participants, 150 (59%) had a musculoskeletal problem and only 60 (24%) had received physiotherapy after discharge. Functional Comorbidity Index, Clinical Frailty Scale, duration of intensive care unit stay and prone positioning were all independently associated with worse musculoskeletal health. Musculoskeletal health state moderately correlated with quality of life, rs = 0.499 (95%CI 0.392–0.589); anxiety, rs = ‐0.433 (95%CI ‐0.538 to ‐0.315); and depression, rs = ‐0.537 (95%CI ‐0.631 to ‐0.434) (all p < 0.001). Patients with a musculoskeletal problem were less physically active than those without a problem (median (IQR [range]) number of 30 min physical activity sessions per week 1 (0–3.25 [0–7]) vs. 4 (1–7 [0–7]), p < 0.001, respectively). This study found that musculoskeletal health problems were common after intensive care unit stay. However, we observed that < 25% of patients received physical rehabilitation after discharge home. Our work has identified potential high‐risk groups to target in future interventional studies.
Allied health professionals’ research capacity: open to interpretation?
AbstractAllied health professional research capacity and culture has been the focus of growing research interest of late. The recent study by Comer et al. represents the largest survey of allied health research capacity and culture to date. We congratulate the authors on this work and would like to raise some discussion points in relation to their study.The authors have interpreted their research capacity and culture survey results using cut-off values to indicate a degree of adequacy in relation to perceived research success and/or skill level. To our knowledge, the constructs of the research capacity and culture tool have not been validated to an extent that would enable such an inference to be made.Comer et al. describe perceived individual research success and/or skill as adequate, but the rating of skills in areas necessary for the conduct of original research, such as writing research protocols, ethics submissions, securing funding, and writing for publication range from median scores one to three, which is considered ‘less than adequate’ on the interpretation scale used by the authors.The survey results for the individual and organisational domains reported in Comer et al. are comparable to other similar studies. However, they uniquely conclude research success and/or skill to be adequate in both domains, which is contrary to the interpretation of the other studies.The interpretation of allied health professional research success and skill offered by Cromer et al. differs from studies with similar results and is contrary to previous reports of insufficient research capacity in terms of research trained and active practitioners within these professions in the UK.
Musculoskeletal health state and physical function of intensive care unit survivors: protocol for a UK multicentre prospective cohort study (the MSK-ICU study)
IntroductionSurvivors of critical illness frequently experience long-term physical impairment, decreased health-related quality of life and low rates of return to employment. There has been limited investigation of the underlying problems affecting physical function post-intensive care unit (ICU) admission. Musculoskeletal (MSK) conditions may be complex in presentation, with ICU survivors potentially at greater risk of their development due to the rapid muscle mass loss seen in ICU. The MSK health state of ICU survivors and its impact on physical function remain largely unknown. The aim of the MSK-ICU study is to determine and characterise the MSK health state of ICU survivors 6 months following admission to ICU, in order to inform development of targeted rehabilitation interventions.Methods and analysisThe MSK-ICU study is a multicentre prospective longitudinal cohort study, evaluating the MSK health state of ICU survivors 6 months after admission to ICU. The study consists of a primary study and two substudies. The primary study will be a telephone follow-up of adults admitted to ICU for more than 48 hours, collecting data on MSK health state, quality of life, employment, anxiety and depression and symptoms of post-traumatic stress disorder. The planned sample size is 334 participants. Multivariable regression will be used to identify prognostic factors for a worse MSK health state, as measured by the MSK-Health Questionnaire. In substudy 1, participants who self-report any MSK problem will undergo a detailed, in-person MSK physical assessment of pain, peripheral joint range of movement and strength. In substudy 2, participants reporting a severe MSK problem will undergo a detailed physical assessment of mobility, function and muscle architecture.Ethics and disseminationEthical approval has been obtained through the North of Scotland Research Ethics Committee 2 (21/NS/0143). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.Trial registration numberISRCTN24998809.
Exploring research capacity and culture of allied health professionals: a mixed methods evaluation
Abstract Background Despite the myriad benefits of research to patients, professionals, and organisations, fewer than 0.1% of the Allied Health Professions workforce are employed in clinical academic roles. Identified barriers include a lack of role modelling, management support, funding, and availability of clinical academic roles. Research capacity building is critical to improving Allied Health Professional research capability. The aim of this evaluation was to explore the current research capacity and culture of Allied Health Professionals to inform future tailored research capacity building strategies at a local level. Methods A mixed methods evaluation of research capacity and culture was conducted within the Allied Health Professions department of a large National Health Service Foundation Trust using an online research capacity and culture questionnaire, followed by focus groups. Staff were recruited using a purposive method with the questionnaire and subsequent focus groups completed between July and September 2020. Data from the questionnaire was analysed using simple descriptive statistics and after inductive coding, focus group data was analysed thematically. Results 93 out of 278 staff completed the questionnaire and 60 staff members attended seven focus groups. The research capacity and culture survey reported the department’s key strength as promoting clinical practice based on evidence (median=8, range=6-9). A key reported weakness of the department was insufficient resources to support staff research training (med=4, 3-6). Respondents considered themselves most skilled in finding relevant literature (med=6, 5-8) and least skilled at securing research funding (med=1, 1-2). Greater than half of the respondents (n=50) reported not currently being involved with research. Five themes were identified from the focus groups: empowerment; building research infrastructure; fostering research skills; access for all; and positive research culture. Conclusions Allied Health Professionals recognise the benefits of research at teams and departmental level, but marginally at an individual level. Local research capacity building strategies should aim to address the role, responsibilities and barriers to Allied Health Profession research development at an individual level. To ensure all staff can engage, research infrastructure and empowerment are essential.
Early-Onset Cone Photoreceptor Degeneration Is Associated With High Myopia in RPGR-Related Retinal Dystrophy.
Purpose: High myopia is a feature of several inherited retinal diseases, including X-linked retinitis pigmentosa (XLRP) which is characterized by childhood onset, centripetal photoreceptor degeneration, and rapid progression to blindness by the fourth decade. Mutations in the retinitis pigmentosa GTPase regulator (RPGR) gene cause over 90% of XLRP cases. It presents with a varied clinical phenotype, categorized into the predominant rod-cone, cone-rod, and cone dystrophy. This case-series study examines the clinical characteristics of patients with RPGR-related retinal dystrophy to identify associations with refractive error. Methods: Data collected between October 2023 and April 2024 from retinal imaging, clinical ophthalmic examination, and genetic analysis were retrospectively analyzed. Results: Twenty-four male patients were identified, with a mean age of 30 years (range 7-57). The median (IQR) best-corrected visual acuity was 60 (55-66) letters in the cone-rod/cone phenotype and 65 (49-73) letters in the rod-cone phenotype. High axial myopia showed preponderance in cone-dominated degenerations. Estimated mean refractive error was -7.92DS (95% CI: [-11.39, -4.44]) in the cone-rod phenotype and -3.52DS (95% CI: [-5.87, -1.17]) in the rod-cone phenotype, adjusting for age and genetic mutation. This difference between phenotype was significant (p=0.041). In a subanalysis, no significant association was found between refractive error and nucleotide position. Evaluation of disease progression found that all patients with a fast-progressing, rod-cone phenotype had high myopia. Conversely, one patient who presented with a slow-progressing, cone-rod phenotype did not have high myopia. Conclusions: Refractive trends in this cohort suggest that cone photoreceptor degeneration occurring during early childhood is associated with high myopia. Image degradation primarily due to cone photoreceptor dysfunction may act as a stimulus to drive myopia development in early childhood. These observations advocate for the earlier treatment of myopia in cone-dominated RPGR-related retinal dystrophy to preserve retinal function and minimize the risks of retinal gene therapy surgery for patients enrolling in clinical trials. Trial Registration: ClinicalTrials.gov identifier: NCT03116113.
A cognitive map for value-guided choice in the ventromedial prefrontal cortex.
The prefrontal cortex (PFC) is crucial for economic decision-making. However, how PFC value representations facilitate flexible decisions remains unknown. We reframe economic decision-making as a navigation process through a cognitive map of choice values. We found rhesus macaques represented choices as navigation trajectories in a value space using a grid-like code. This occurred in ventromedial PFC (vmPFC) local field potential theta frequency across two datasets. vmPFC neurons deployed the same grid-like code and encoded chosen value. However, both signals depended on theta phase: occurring on theta troughs but on separate theta cycles. Finally, we found sharp-wave ripples-a key signature of planning and flexible behavior-in vmPFC. Thus, vmPFC utilizes cognitive map-based computations to organize and compare values, suggesting an alternative architecture for economic choice in PFC.
Neural mechanisms of credit assignment for delayed outcomes during contingent learning.
Adaptive behavior in complex environments critically relies on the ability to appropriately link specific choices or actions to their outcomes. However, the neural mechanisms that support the ability to credit only those past choices believed to have caused the observed outcomes remain unclear. Here, we leverage multivariate pattern analyses of functional magnetic resonance imaging (fMRI) data and an adaptive learning task to shed light on the underlying neural mechanisms of such specific credit assignment. We find that the lateral orbitofrontal cortex (lOFC) and hippocampus (HC) code for the causal choice identity when credit needs to be assigned for choices that are separated from outcomes by a long delay, even when this delayed transition is punctuated by interim decisions. Further, we show when interim decisions must be made, learning is additionally supported by lateral frontopolar cortex (lFPC). Our results indicate that lFPC holds previous causal choices in a 'pending' state until a relevant outcome is observed, and the fidelity of these representations predicts the fidelity of subsequent causal choice representations in lOFC and HC during credit assignment. Together, these results highlight the importance of the timely reinstatement of specific causes in lOFC and HC in learning choice-outcome relationships when delays and choices intervene, a critical component of real-world learning and decision making.